Conference Summary & Action Points - PowerPoint Presentation

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Conference Summary & Action Points

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Conference Overview

#

HealthForAll

| ichc2017.org

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Hosted

by

In collaboration with

With support from

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Participation

363 total participants

70%

country level

30%

global level

44

countries

20

priority EPCMD countries

22

country delegations

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Context

Approaching the 40

th anniversary of the Alma Ata

Declaration adopted at the 1978 International Conference on Primary Health Care (PHC); with its goal of “Health for All,” it put PHC and community-level interventions on the global agenda

Community engagement, accountability, and resilience are key action areas to accelerate progress of the Global Strategy for Women’s, Children’s, and Adolescents’ Health

Mounting evidence for a range of community approaches for health and community-led processes of planning and

implementation,

such as women’s

groups

Paradigm shift towards a systems approach for community health

Political

commitment and financing for implementation of effective and sustainable intervention models at scale are still lacking in many countries

ICHC provided a forum to bring together stakeholders from multiple sectors to

frame, debate, and build commitment for

community health systems strengthening (evidence, scale,

and sustainability

in primary health care)

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ICHC Areas of Focus

Sharing state-of-the-art lessons and experience

Enabling country stakeholders to share progress and identify solutions to persistent challenges

Informing national policies and plans though evidence, success, and adaptive learning

Engaging communities as dynamic resources and agents within national and local systems

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Conference Agenda

Day 1:

Community Health SystemsImplementation at Scale

Day 2:

Sustainable Financing for Community Health

Multi-Stakeholder and Multi-Sectoral Partnerships

Day 3:

Equity

&

Accountability

Research & Innovations

Day 4:

Country Planning and Learning

Discussion to

Action

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Conference Outcomes

Advanced understanding of the opportunities and challenges for institutionalizing community health, including community health systems strengthening as an emerging concept

Learned from community health programs in diverse contexts with documented processes and impact on RMNCAH issues

Strengthened dialogue and collaboration between governments, civil society, private sector, and other development partners, to achieve results

Developed country-specific action and learning plans that country delegations will advance with a broader group of stakeholders at country level over the next year

Prioritized learning themes within and across countries to inform community health policies and programs and an emerging global learning agenda for community health systems

Agreed on 10 Critical Principles for institutionalizing community health

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Knowledge Sharing and Action Planning

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Why community health systems?

Shift needed from primary focus on service delivery to systems requirements for sustainability and

scaleCommunity health systems include traditional components that may not be formally recognized in policies and

strategies

Opportunity to enhance the roles and capacity of communities and local actors to collaborate in systems as agents of

change

Opportunity for stronger collaboration at the community level, between communities and health systems, and among sectors for joint benefits for health with a focus on communities to drive social change and address social determinants of

health

Setting the Stage:

Community Health in a Systems Perspective

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Household level caregivers

Community, community groups, and social institutions

Frontline health workers

Formal primary care systems, including supervision, supply chain, and the like

Other government sectors: housing, education, social development, agriculture, etc.

Representative local health and political structures

Question for reflection:

What systems changes are missing or needed in your country

context?

Setting the Stage:

Community Health in a Systems Perspective

Community health from a systems perspective

takes into consideration the interrelationships between:

Community

empowerment,

defined

as

making people stronger and more confident to take control of their lives (agency + changes in the social environment), is

essential to building resilient health systems and

achieving the Sustainable Development Goals

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Diagram credit:

UNICEF

Community Empowerment Drives

S

tronger

C

ommunity

H

ealth

S

ystems

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Community roles in health systems

Communities

are valued, essential, and empowered actors of the health system for:Delivering services

Providing oversight for

health

services at all

levels

Improving health literacy and advancing social norms that promote good health

Enhancing the accountability of health systems to the people they serve

Giving voice to those who are currently voiceless

Setting the Stage:

Community Health in a Systems Perspective

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Strengthening and scaling up community and primary health care platforms could prevent 77% of preventable maternal, newborn, and child deaths and stillbirths

SOURCE: Black RE, Walker N,

Laxminarayan R, Temmerman M. Chapter 1: Reproductive, Maternal, Newborn, and Child Health: Key Messages of this Volume. DCP3 RMNCH 2016

.

2.4 million

0.8 million

0.9 million

Key Evidence for Community Interventions

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Community-Based Primary Health Care (CBPHC)

Encompasses a range of interventions delivered outside facilities

Common implementation approaches included home visits, participatory women’s groups, community case management (CCM), and outreach from peripheral health facilitiesKey findings from the

comprehensive

r

eview

of CBPHC p

rograms

Evidence that CBPHC is effective in improving MNCH is extensive

Evidence that investing in facilities alone will improve MNCH in geographically defined populations is lacking

Evidence is strong that CBPHC has a pro-equity effect and that facility use is inequitable

Selected recommendations

CBPHC needs to become a more important part of health programs, the foundation of health systems strengthening, and a priority for health sector funding.

A rigorous implementation research agenda is also needed to inform the effectiveness of packages of interventions under routine conditions at scale for longer periods of time

Key Evidence for Community Interventions

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WHO-led Community Based Practitioner (CBP) Guidelines Review

(ongoing)

Effectiveness of CBPHC in Improving Maternal, Neonatal, and Child Health Outcomes (forthcoming: 8 publications in Journal of Global Health, June 2017)

WHO-led

mapping of evidence gaps for social, behavioral, and community engagement interventions for RMNCAH

(forthcoming, 2017

)

Synergies,

strengths,

and challenges: findings on community capability from a systematic health systems research literature review

(2016) WHO recommendations on health promotion interventions for maternal and newborn health

2015

Key Evidence for Community Interventions

Evidence and

recommendations for advancing community health systems

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Additional evidence reviews

Community participation in health systems research: a systematic assessing the state of research, the nature of interventions involved,

and the features of engagement with communities (2015)Anchoring contextual analysis in health policy and system research:

A

narrative review of contextual factors influencing health committees in

low-

and

middle-income

countries (2015

)Examining the links between community participation and health outcomes: a review of the literature (2014

)Community accountability at peripheral health facilities: a review of the empirical literature and development of a conceptual framework

(2012)

A

 systematic review of the literature for evidence on health facility committees in low- and middle-income

countries

(2012)

Key Evidence for Community Interventions

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Implementation of community health policies and strategies

Discussion of community health policy implementation and persisting policy issues demonstrated that countries are grappling with similar questions, including:

Evolving roles of community volunteers in mature CHW programs, with urbanization, increasing education of women, and differing needs in urban vs. rural areas (Nepal)

The need for coordination/harmonization at both national and sub-national levels in devolved contexts and quality standards focusing on functionality of community units to support rapid scale-up (

Kenya)

Strengthening

of community health integration into health systems and community health harmonization (CHW profile and roles, standardized retention system, behavior change communication tools, motivation system, commodities, equipment, and materials (Madagascar)

Implementation at Scale

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)

Implementation at Scale

Critical CHW

policy issues

There are critical policy questions and challenges that countries must ask to rationalize, sustain, and scale up CHW policies and programs, including

:

Classification and

nomenclature

Lack of or inconsistent systems support that impedes full realization of CHW potential to contribute to the PHC

context

Coordinated planning at the national and sub-national levels (e.g. motivation of volunteers, financing, etc.)

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Community preparedness

Regular and sustainable

remuneration packageOpportunities for career and

professional development

Clear/transparent

selection

system, involving and responding to needs of

communities

Curriculum to include

scientific

knowledge

on basic

preventative

and

curative

care

Adapt

contents to health system

needs

Ensure

supplies

/equipmentEffective

referral systemsRegular

monitoring & supervision

Include CHWs in

HRH planningHave a

budget line/resource allocation

Implementation at Scale

Planning

Production/ Education

Performance

Deployment/ Retention

Sources:

Bhutta

et al., GHWA, 2010;

Kok

,

Dielman

, et al., 2015; Campbell & Scott, 2011; Darmstadt, Lee, et al., 2009;

Jaskie

&

Tulenko

, 2012; Zulu et al., 2014; Pallas et al., 2013; McCollum, et al., 2016; Bosch-

Capblanch

, 2011.

CHW

integration: what does it mean?

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Defining the optimal population ratio per CHW in line with their scope of work and geographic coverage is required for institutionalizing community health systems

To achieve adequate coverage, consideration should be given to models

that comprise two “tiers” of community workers – a formal full-time CHW with requisite qualifications and training and a “lower” level of part-time/voluntary operatives with

fewer

technical tasks and

demands

CHWs and referral systems function best in an environment in which their roles are well defined and they are seen as the “first-line workers” in a well-articulated system, not “competition” for facility-based workers

Implementation at Scale

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Determinants of successful referral, include access to facilities not being impeded by barriers (such as transport, permission from others, cultural and language differences,

etc), use of a written referral slip, and the quality of referral messaging between the CHW and the client

In a facilitated referral, the CHW counsels the client on the reason for referral, fills out a written referral slip, records the referral in a register, and inquires about and addresses any barriers to following through for the client; the referral is then tracked in the HMIS, and the CHW receives counter-referral

information

Key factors to consider for scale-up of community engagement and community capacity development interventions include developing solid partnerships with existing organizations at multiple levels, working with influential leaders, and strengthening systems and organizational capacity

Implementation at Scale

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“

Community health is broader than CHW programs

focused on service delivery.”

“

Integration of community health into the national health system

requires political will and is cost effective

.”

“Communities

can and should participate

in the design of interventions, assure timely

implementation,

and contribute to CHW supervision and motivation

.”

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Sustainable Financing

Strengthening community health systems can be cost-effective and is a smart investment in social capital and human resources, but it is not

cheap

Financing remains one of the biggest challenges for countries as they scale up community health and transition from donor dependency to greater government

ownership

Countries had many questions and comments about private sector financing models for CHWs; better understanding of these models and opportunities is needed

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Sustainable Financing

Investing $1 in CHWs can return up to $10 in the long-term (productivity, insurance, employment). A high return on investment (ROI) (10:1) can only be achieved in high-performing systems. This ROI focuses on CHWs and does not include other components of the community health system and therefore could be higher

.

Making a case for community health systems will become increasingly important, and all CHS costing and investment plans have to be done in full alignment with the total health system and national strategies as subsets rather than

standalones

More

attention is needed on finance levels and mechanisms as well as effective processes focusing on political advocacy and consensus building within ministries around “best buys

”

Community health can be included as a priority in Global Financing Facility (GFF) investment cases, and World Bank country offices can provide additional support

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Sustainable

Financing

Countries expressed the need for MOH capacity-building to develop costed investment plans for resource

advocacy

There

is interest in calculating cost savings from CHW programs to advocate for funding

Tools

exist for community health planning and costing that can help determine the cost of community health packages in order to:

P

repare

investment

cases

C

ompare

cost-effectiveness of

community-

vs.

facility-based services

P

lan

and prioritize services within the likely funding

envelope

P

repare

detailed budgets

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Multi-Stakeholder and Multi-Sectoral

Partnerships

Multi-stakeholder and multi-sectoral partnerships that are inclusive and data-driven are essential for achieving effective coverage at scale in global and national acceleration plans in health and country-led community health systems strengthening

agendas

Partnerships should encompass a range of actors, including representatives of governments, civil society, local and international NGOs, academia, professional associations, media, private sector, and underserved populations themselves, with clearly defined roles to improve equitable outcomes and promote mutual

accountability

Partnerships should leverage expertise and resources from communities and partners from other relevant sectors (e.g. agriculture, education, youth) in a coordinated manner

Who has a seat at the table and how that is determined requires

attention

Capacity building of local partners to participate and collaborate is needed to amplify the voice of communities in policies and systems

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Partnerships are most effective when responding to national leadership and supporting activities harmonized within national

strategies

Government stewardship should support dialogue around roles and coordination of efforts to improve sustainability and scale

New thinking about inclusive partnerships is needed in the SDG era as countries grapple with decreasing donor resources; governments will increasingly need to leverage partner (civil society, private sector) and community expertise and resources to harmonize action and

learning

Greater emphasis is needed on harmonizing partners at national and sub-national levels and building evidence for inclusive partnership

models

Successful models of multi-stakeholder and multi-sector partnerships shared at the ICHC provide insights for improving delivery, demand, and accountability in the community health systems context

Multi-Stakeholder

and Multi-Sectoral

Partnerships

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Country-level partnerships for community health systems include BRAC, Living Goods, Aspen Management for Health, Integrating Community Health, SHOPS, WRA, CORE Polio, Restless Development, Digital Green/SPRING, and

N’Weti

Evidence and scale for partnership models varies, and it is important to ensure that documentation and learning focusing on partnerships are included in the learning agenda for community health systems, with clearly delineated partner roles and measures of successes as well as “failures

”

A roadmap for partnerships that engages partners, including civil society and the private sector, at the outset to clarify, harmonize, and build ownership around roles and contributions is critical

Multi-Stakeholder and Multi-Sectoral

Partnerships

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“

To achieve

universal health coverage,

c

ommunity

health systems need to be strengthened

and should be integrated in to

health

plans and financed as an integral

part

of country health systems

.”

“If we want to give voice to local organizations, we need to build their capacity and press for their participation.”

“

Sustainability

of CHWs cannot be achieved with government

alone.

It

will require looking at resources within the country to create partnerships with the private sector

.”

“Community health is cost-effective but not cheap.”

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EQUIST

is a data-driven tool that helps policymakers and managers identify equitable strategies to save lives and reduce health inequities, including partnering with communities to optimize available resources

Community empowerment is a critical process for improved equity and accountabilityCreates environments where the powerless have the opportunity to gain skills, knowledge, and confidence to make choices about their own lives

Gender-transformative approaches can lead to:

Better community health programming and service provision

Equitable leadership and governance

More effective health promotion and prevention

Empowered communities

Better health outcomes

Providing opportunities to women for training as CHWs/CHVs and space to discuss issues together can be emancipating – but social norms that underpin division of labor at home and gender equality more broadly also need addressing

Compensation and incentives (a source of debate among countries for CHWs in general) may perpetuate gender inequality if not aligned with the demands of the CHW/volunteer role

Equity and Accountability

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Key

principles of social accountability approaches

Build the capacity of community members to understand their rights, how to collect data and evidence, and how to organize and demand action effectivelyAddress underlying power dynamics

Empower governments to take corrective action

Country experiences with social accountability approaches included among

others

Citizen use of cameras to show lack of health center commodities and disrespect from facility staff

Community scorecards

National task force on social accountability to bring together key stakeholders, including district and national governments, to explore how social accountability can improve RMNCH services and outcomes

Evidence from conflict and fragile settings shows that CHWs can continue providing services and access displaced and hard-to-reach

populations

Equity and Accountability

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Approaches to community capacity development

include

Focusing primarily on developing the capacity of communities to work together effectively (e.g., strengthening leadership, management, governance, resource mobilization, etc.)Focusing primarily on developing technical knowledge and skills (e.g., health practices, service delivery, etc.)

A combination of the two approaches to achieve a particular goal (e.g., reduce maternal and newborn mortality, improve nutritional status, etc

.)

Countries (e.g., Tanzania) are taking advantage of high coverage of child immunization to integrate and scale up birth

registration

Birth registration is a critical piece of information for assessing the reach of health programming

Mobile

technology is useful for data collection as well as clinical decision support, supervision, and health promotion

Need to work on sustainable, interoperable systems that integrate into the overall health system

Research, Innovations, and M&E

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One comprehensive health information system and budget, including community health, is needed to avoid fragmentation

Lack of measuring and reporting what happens at community level impedes advocacy for community health

Community health M&E systems that are sustainable at scale within country health systems have indicators that:Are small in number

Cover service delivery, strength of community platforms, and competencies needed for sustainably delivering community-based interventions

Real-time implementation research, monitoring, evaluation, and learning are needed to identify, sustain, and scale up effective community interventions with a practical focus on how to:

Adapt and support proven community interventions to fit context, sustain, and scale up effective approaches for engaging and empowering communities in diverse systems

Improve coverage, quality, and equity of community health services at scale

Implementation research saves money in the long-term, should be budgeted, and should not substitute for M&E resources

Research, Innovations, and M&E

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“

More

evidence

is needed on the impact and delivery of community health interventions in emergencies and fragile

settings.”

“We

need to be realistic about what

paid and volunteer CHWs

can actually physically do and not expect too much from them, which only leads to unsustainable and poor quality programming

.”

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Example

country action and learning plan

Develop a harmonized, government-led implementation framework for community health

Develop an investment case for community health systems, clearly mapping resources and resource

gaps

Develop an advocacy and communication strategy for community health with a focus on a community health worker

strategy

Finalize key tools for a sustainable

program

Receive approval from the relevant government

ministries

Submit the policy to the

cabinet

Evaluate community health programs at the county level to determine why some counties have more effective implementation than others

Countries submitted detailed action and learning plans for the 12 months following the conference that will inform dialogue with countries post-ICHC

Country Planning and Learning

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Country-to-country learning

Many dimensions to community-level programs

Individual countries may be well advanced along one dimension, yet have considerable work remaining to do along another dimension

Enabled country delegations to approach other country delegations to learn from their successes

Uganda and Rwanda teams met to exchange lessons learned with their respective systems

Allowed sharing of experiences and lessons among countries that normally have only limited contact

Among English-, French-, and Portuguese-speaking African countries

Among Africa, Asia, and the Caribbean

Country Planning and Learning

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Illustrative knowledge gaps from evidence reviews to inform learning agendas

Lack of evidence of comprehensive CBPHC at scale for longer period of time (5 or more years

)

CHW roles and performance; cost-effectiveness of CHWs; adaptation of lessons from low-and middle-income countries to high-income

countries

Cross-cutting enabling factors for CHWs (education, accreditation and regulation, management and supervision, effective linkage to professional cadres, motivation and remuneration, and provision of essential drugs and commodities

)

How to ensure the sustainability of CHW programs through national planning, governance, legal, and financial mechanisms

Country Planning and Learning

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Illustrative knowledge gaps from evidence reviews to inform learning agendas (cont.)

Effective indicators of community health system

interface

Community participation and its role in holding services

accountable

Sustainability, cost, and scale of community

participation

Gender dynamics in community

participation

Measuring changes in community capacity and links to health

outcomes

Community participation and its role in holding services

accountable

Evidence gap map review and prioritized research agenda forthcoming from a WHO-led process focusing on social and behavioral and community-engagement interventions

Country Planning and Learning

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“We will review the existing CHW strategy to align it with

lessons learned from ICHC

and ensure it takes a community health systems approach.”

“With a view to strong community involvement in achieving the Sustainable Development Goals, this country is committed to an

integrated community health system

with strong leadership.”

“

This country commits

to maintaining the country delegation to serve as advisory group on community health to the MOH.”

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Extending the Reach of the Conference

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Expanded the reach of the conference via online engagement

Leveraged the partnership of co-hosts, collaborators, and potential sponsors and their various communications platforms

Targeted media engagement at local levels to further communicate the importance of community health issues discussed

Captured the knowledge and learning from the conference to make available on the conference website

Building

on post-ICHC conferences and meetings to further elevate conference outcomes and the importance of community health

Communications and Knowledge Management

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Website

http://www.ichc2017.org

/Find conference resources, including livestreamed videos, blogs, presentations, the conference program, and social media links

Blog Series

Livestream

Social Media

27 blogs

16 organization represented

Blogs featured on The Huffington Post, ICHC website, and MCSP’s website

10 sessions (25 hours) livestreamed

Over 500 views and 15,000 minutes watched

Viewed in 35 countries with viewing parties in 7 countries

Reach: 3,415,599

Impressions: 9,432,785

Tweets: 1,631

Contributors: 636

#

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trended on Twitter

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Looking Forward

 

Community of practice for those working in community health to continue the

conversation

Implementation of country action plans

Dissemination of the conference principles (

presentation

,

short version

,

long version

)

Present and discuss results at upcoming conferences

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Additional Slides for Reference

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“A community health system is a set of local actors, relationships, and processes engaged in producing, advocating for, and supporting health in communities and households outside of, but existing in relationship to, formal health structures.”

The local actors in this system who engage in health action include some or all of the following (context specific):

Household level caregivers

The array of formal, volunteer, and informal health providers working in

communities

Organizational intermediaries: nongovernmental organizations and other forms (religious, sport, youth, etc.) of associational life; workplaces

Other government sectors: housing, education, social development, etc.

Representative local health and political structures”

Community Health Systems Defined

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Link to Framework Here!

USAID

Community Health System Framework

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Example of a model for community health system strengthening

The

Community Health System Strengthening Model