Strengthening Community-Led Health Systems

On September 28, 2021, The Movement for Community-Led Development (MCLD) in partnership with the Canadian Partnership for Women and Children’s Health (CANWACH), organized a special dialogue on Strengthening Community-Led Development Health Systems. This was part of an ongoing series of Sector Dialogues being organized by MCLD in order to engage with sector experts to promote the adoption of CLD. In this call, we explored the role of community-led approaches to attain SDG 3 on health and well-being for all. Speakers and participants delved into the importance of community-led approaches in achieving universal health coverage and ensuring adequate finance for community health and support for community health workers. The dialogue was facilitated by Jessica Ferne, Director of Global Health Impact at CanWaCH and Gunjan Veda, Senior Advisor, Global Collaborative Research and Public Policy, MCLD.

Watch the event recording here:

The event began with a panel discussion with Angela Nguku, Executive Director of White Ribbon Alliance Kenya and Chris Collins, President and CEO of Friends of the Global Fight Against AIDS, Tuberculosis, and Malaria.

Decolonizing Health in Community Led Development

In a discussion on the role of decolonizing health in community-led development, panelist Angela Nguku outlined how her professional experience with White Ribbon Alliance and midwifery training has shaped her understanding of how decolonization can strengthen existing health structures. In order to design sustainable local health systems, Angela emphasized the value of placing communities at the center of the decision-making process. “Communities are integral to what we do, yet they are not part and parcel of decision-making,” she explained.
As a trained midwife, Angela noted the absence of community input in designing local health systems. “I was trained first and foremost with the thinking that healthcare should only be foreign…anything that comes from that indigenous or traditional systems is not supposed to be part of the formal healthcare system,” she explained. 
Recounting her experience of providing care to mothers at a community health care facility, Angela noted, “From the colonial days, healthcare was supposed to be: you go to the facility, everything has to happen in the morning. But coming from communities where most people have informal jobs, we understand that you have to get to work in the morning or drop your children to school or fetch water. Where is the time to visit a health centre for a check-up?” While designing the schedule of healthcare facilities, it is important to organize hours of operation and health system practices around the needs of the community rather than the needs of the healthcare system. “When it comes to decision making, when it comes to the way healthcare is organized, I feel like communities are always turned into backbenchers. They are never consulted. Their voices are not on the table,” she explained.
The “What Women Want Campaign” designed by White Ribbon Alliance seeks to determine what women and girls perceive as quality healthcare practices, and to improve maternal and reproductive health practices for them. This campaign was based on the 2018 survey “Confidential Inquiry into Maternal Deaths in Kenya” that identified poor quality of care as a leading driver of maternal death in Kenya. The results of the “What Women Want Campaign” determined a discrepancy between donor and government perceptions of quality healthcare and the healthcare practices demanded by women and girls in communities surveyed. Women and girls interviewed identified water, sanitation, and hygiene as important considerations of healthcare practices and described the need for clean toilets, clean linens, clean floors, and culturally acceptable food available in healthcare facilities.
Global Finance with a focus on CLD
The international community faces a critical moment in the global health sector that calls for strengthening community-led health systems to alleviate the burden that global diseases place on international health systems. Now, more than ever, it is important to acknowledge and fund the role of communities in healthcare provision, and to create a global health architecture and funding system to prepare for future pandemics.
According to Chris Collins, community is a “game changer at every single level of the health food chain.” The COVID-19 pandemic has generated interest among policy-makers in laying the groundwork to address future pandemic preparedness and response with community inputs.
The HIV movement exemplifies the value of community input in strengthening health systems through advocacy, research and planning for health care delivery. According to Chris, the HIV Movement is “all about the community in multiple different roles at the table, from planning healthcare delivery, to advocacy for resources”. During the COVID-19 pandemic, while governments struggled to reach marginalized community networks during the COVID-19 pandemic, they relied on existing HIV community networks that had already established these relationships. Moving forward, it will be important to recognize these community networks and secure funding and adequate support for them.

As Chief of the Community Mobilization Division at UNAIDS several years ago, Chris sought to raise awareness of the critical role of community input in AIDS response. He noted a lack of existing data on the types of funding available for communities. To support effective global finance practices in community-led development, donors must participate in advocacy initiatives with national governments to strengthen their understanding of the value of community input in global health practices. Countries need to set up legal structures that allow for more social contracting and direct financing from national governments to communities.
CLD in Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCHA)

This discussion focussed on the importance of strengthening community health systems for expanding local access to RMNCHA programs.“CLD is best when communities are involved in the design phase to the implementation phase, to the monitoring phase,” noted Tariah Abrams, Communications & Advocacy Officer, White Ribbon Alliance Nigeria. A critical component of achieving this is to decolonize existing RMNCHA practices and to evaluate their inclusiveness by questioning what we assume are the best practices for implementing effective health systems. It is important to challenge remaining colonial institutions that are ingrained in cultural healthcare practices, such as those in Sub-Saharan Africa, and value the role of indigenous practices and medicine in existing health systems.

Structural weaknesses exposed in health systems during the pandemic demonstrate that adequate financing of community health systems by governments is a critical component of expanding local access to health programs (such as programs with a focus on RMNCHA). Participants shared many examples. In Liberia, the government needs to expand its support for community health centers as healthcare centers require payment for care practices before treatment which leads to patients developing complications or dying before they receive care. Larger hospitals that are well-equipped are only accessible for the rich, while local community health centers lack facilities and equipment such as ambulances.
Facilitated by Tariah Abrams, Communications & Advocacy Officer, White Ribbon Alliance, Nigeria and Jessica Ferne, Director of Global Health Impact, CanWaCH
CLD in HIV/AIDS & Vaccinations and Immunizations

This discussion focused on the value of  incorporating a bottom-up approach to structuring health systems and decolonizing health practices. Key considerations to improving the accessibility and effectiveness of HIV/AIDS and Vaccinations and Immunizations programs may include:
●      Investing time to engage communities and receive their input while designing community-led health systems.
●      Tailor health programming to meet the needs of the communities involved.
●      Engage in community learning about the COVID-19 virus and include cultural and religious leaders in these conversations.
Another important consideration of strengthening practices of HIV/AIDS and Vaccinations & Immunizations in community-led health systems is fostering the co-ownership of existing health systems with communities to open up local access to community-led health practices. According to Vashti Rebong, Member of the Youth Coalition for Sexual and Reproductive Rights, “…co-ownership of our ownership in communities in leading development has been helpful, has been successful, in ensuring access to vaccinations”. While decolonizing health practices to improve the effectiveness of HIV and Immunization & Vaccination focused programs, volunteers should understand the leadership role of community members in supporting effective local health systems and practices. “Include the discussion on volunteers. How do we ensure that they are also mindful of the work that they’re doing?” concluded Vashti.
Facilitated by Vashti Rebong, Member, Youth Coalition for Sexual and Reproductive Rights.
Community Health Workers (CHWs)

The COVID-19 pandemic generated public recognition of the critical role that community health workers (CHW) play in strengthening community-led health systems, and demonstrated the importance of constructing the architecture, legal and financial instruments in the health sector to support their work. “In the pandemic, we have obviously seen the role that health workers play in their communities in the broader COVID response and the critical role that health workers play in health systems in order for them to function”, explained Kiki Kalkstein, Director of Advocacy & Engagement for the Global Health Council.

CHWs face many challenges while seeking to provide adequate care to existing community health systems. According to Dr. Stella Kanyerere, a Senior Health Advisor for Living Goods, the COVID-19 pandemic had a large impact on CHWs, and “some of them were the only contact that communities had. But if you look at the planning that went around different countries, they were among the last people to receive PPE, to qualify for vaccine rollout.” In many cases CHWs are volunteers, despite serving as critical links between communities and existing local health systems. They often lack access to PPEs (Personal Protective Equipment), necessary drugs, and digital tools to capture pertinent data for health systems, which often requires them to enter data manually. A lack of resources increases their risk of contracting COVID-19, and over-stretches their ability to strengthen community health systems.
This group discussed the best practices to support the work of CHWs. A participant noted that there were 14,000 community clinics in Bangladesh. Community health systems and community service providers in rural areas provide care to expectant mothers and other local community members. During the COVID-19 pandemic, rural communities with CHWs received a better quality of healthcare provision than communities in cities. Moving forward, a critical focus of supporting CHWs should be equipping them with skills and essential commodities, ensuring that they are adequately supported and supervised, their efforts are compensated for and their data collection systems are digitalized. Another critical consideration of strengthening networks of CHWs should be a focus placed on capacity strengthening to train CHWs for operation under pertinent government and country health guidelines. This process should involve consultation from local communities at every stage on how to develop effective health systems.

Facilitated by Dr. Stella Kanyerere, Senior Health Advisor, Living Goods and Kiki Kalkstein, Director of Advocacy & Engagement, Global Health Council.
Call to Action

The event concluded with a Call to Action issued by Angela Nguku.

Angela urged participants to recognize the innate local knowledge and unique contexts that guide community health systems, and the ability of communities to self-organize and self-advocate to govern their own health systems. “Communities have systems to self-organize, self-advocate, and self-care as a whole..It is not about other people coming to organize them. They know how to do that, they have done it over and over again,” she explained.

In order to support the sustainability of community-led health systems, it is important to recognize, support, and fund the integration of community-led initiatives into national health systems. In order to achieve the goal of universal healthcare and strengthen local health systems, governments, funders, and academics should acknowledge the importance of incorporating communities into decision-making processes to strengthen existing health systems.

Moving forward, a critical consideration of strengthening community-led health systems should be to empower communities by harnessing local skills and knowledge to construct sustainable health practices. “Communities therefore have a stake in decision-making because they know the ground realities, they have the knowledge, they have the skills, the know-how to take it forward. So going forward, community-led initiatives must and should be recognized, supported, funded and integrated into the main health system,” Angela concluded.