The race is on…how Community Health is being integrated into Primary Health Care systems across countries…update from ICHC 2021

From Afghanistan to Zimbabwe, Community Health Worker (CHW) programmes that are connecting people with various needs to the health services they require, close to where they live, are being implemented – combining trust, expertise, action, and impact. 

Throughout the four-day (April 19 – 22, 2021) second Institutionalising Community Health Conference (ICHC 2021), four heads of global health agencies (UNICEF, WHO, UNAIDS, and USAID), various Ministers of Health, several panellists and participants overwhelming agreed that Community Health (CH) is the foundation for primary care/primary health care and the main pathway towards achieving universal health coverage (UHC). 

As Dr Shannon Hader, Deputy Executive Director of UNAIDS said at the opening plenary: “This has to be a new model of systems for health…it can’t just be adding on community health workers and community-led components, after the formal or facility health is perfected or funded”

The vital role of CHWs in emergency situations was also highlighted as COVID-19 disrupted essential health services and continues to cast a dark shadow on health systems, unravelling their inherent weaknesses. 

During the pandemic, CHWs helped to sustain treatment in the homes of those with HIV, Tuberculosis, and Malaria; and kept primary health care services like immunisation and pre-natal care going. They assisted people to wear masks and maintain hand hygiene, and now mobilising them to get vaccinated against the virus. 

“They’ve carried out case-finding, contact tracing and help hunt down the virus in an attempt to stop it in its tracks”, observed Raj Panjabi, US Global Malaria Coordinator for the President’s Malaria Initiative. 

Furthermore, ICHC 2021 was informed that Health Ministers from over 190 countries came together at the 2019 World Health Assembly (WHA) to adopt a historic resolution on CHWs. This resolution called for greater investments, not just in community health services, but in community health systems, including systems to strengthen skills, supervision, supplies and salaries. 

And later that year Heads of States committed to community-based health care, at the first UN high-level declaration on UHC. However, such paper proclamations and verbal rhetoric are not enough. 

Notwithstanding, based on reports from the pre-conference scorecards, many countries have made tremendous progress in investing in systems to strengthen PHC in communities since the previous ICHC in 2017. Community clinics have been built, CHWs, Nurses and Midwives have been trained, they have been equipped with point-of-care tests, medicines and smartphones, systems to strengthen the quality of data and quality of care have been enhanced. 

What has been the impetus instigating countries to develop roadmaps in order to optimise CHW programmes? 

For Ethiopia, the revitalisation of the health extension programme that has already shown big impact in reducing maternal and child mortality, was a major driver in configuring the CH roadmap. Besides, with a huge population (117 million), addressing the huge burden of communicable diseases, along with maternal and child health, will not be possible without a strong disease prevention and health promotion programme. 

Moreover, there has been a shift in epidemiology arising from non-communicable diseases, as the needs of communities have also increased requiring more packages of health intervention at the community level. Furthermore, “the need to engage communities more….and the lessons learnt during the pandemic of COVID and the role health extension workers played …has also contributed to a stronger roadmap design that we are now having”, Dr Liya Tadesse Gebremedhin, the Ethiopian Minister of Health stated. 

In Afghanistan, improving services at community level and developing the systems for CH on a sustainable basis, remain central to the country’s community health policy and strategy.  Other than putting in place systems for strong supervision and monitoring, data quality, reporting and feedback and multisectoral coordination, as well as increasing the number of CHWs in urban areas; the main concern of the Ministry of Public Health is on incentivising about 30,000 CHWs currently working as volunteers. 

At the cost of $63 million over 5 years, this war-torn country is looking up to donors to foot the bill. Though Afghan government officials are not unaware that reliance on external support to pay CHWs salaries is not a viable option in the long-term, the reality on ground is dire, as domestic funding for health has been an ongoing issue. “…we have a lot of challenges…health is in competition with other sectors”, noted one of them. 

Besides developing and maintaining the community health workforce and strengthening systems for community-based health care, some countries have also engaged communities and expanding their collective or group roles in addressing issues that affect their lives. 

Zambia has revamped the Neighbourhood Health Committees (NHCs) that previously existed and now prioritised by the National Strategic Health Development Plan. These are non-partisan, multisectoral bodies composed of local residents in a certain catchment area. Apart from local planning and selection of community-based volunteers, they are also the platforms for multisectoral action and accountability at the community level. Dr Slvia Chila, Assistant Director, Community Health at the Ministry of Health reports that NHCs also take the lead in community health budgeting and financing, which has been integrated into the health sector, where at least 10% of national budget goes into community activities. 

Ghana has introduced the ‘community scorecard’, aimed at empowering communities, strengthening accountability and improving healthcare quality at PHC level. It consists of two components: a scoring session during which community members provide feedback on 9 indicators related to quality of health services; and the development of Community Health Action Plans (CHAPS) to address the issues identified during the scoring session. There are reports that through the community scorecard, critical challenges deterring health facilities from providing quality services, including inadequate power and water supplies have been resolved. 

“I think the community scorecard has come to stay; we don’t have a choice. it is a crucial tool if we truly want to make sure that the voice of the patient, the communities and our families are actually at the center of health care, which is what the national health care quality strategy launched in 2016 seeks to achieve”. ~ Dr Mary Eyram Ashinyo, Deputy Director Quality Assurance, Ghana Health Service 

Using disease-specific and/or programme-specific resources, Haiti has been able to strengthen organised community groups to be more involved in addressing root causes of ill health, including poverty. This approach has not only helped CHWs to connect community members to many different types of essential health services, but also improved the general health and well-being of community members. 

Along the same lines, Dr Jocelyne B. Pierre-Louis, Haiti’s Director responsible for the Directorate of Health Promotion and Environmental Protection (La Direction de la Promotion de la Santé et de la Protection de l’Environnement – DPSPE) at the Ministry of Public Health and Population (Ministère de la Santé Publique et de la Population – MSPP) ; mentioned that the country is experimenting with digitisation of the community health information system and linking it to the District Health Information System version 2 (DHIS2) platform. 

Talking about Improving access to and use of community health data:

Liberia adheres to “a clear decentralisation policy that outlines how data should be shared and used for decision making from the community to the national level”, said Olasford Wiah, Director, National Community Health Programme at the Ministry of Health. 

As reported, Liberia’s community-based information system has service-based tools to optimise workflow management for Community Health Assistants (CHAs) – used in a logical format starting with case detection, classification, treatment and referral. While these tools are kept at the community level to maintain an accurate record of CHAs’ work in their communities, this information can later be used by the CHAs and their supervisors, as well as community health committees for decision-making around health education and interventions, as needed.

Uganda, which currently pays a monthly allowance to community health workers who are called Village Health Teams (VHTs) are being provided with the right tools and supervision to collect good quality data that creates accountability. With a vision for a digitally empowered community health workforce, one of the community health reporting tools is being reviewed to facilitate a more streamlined process of data collection, and data transfer (following VHT home visits) into the national health information management system. 

Remarking, Dr Upenytho George DuGuMm, Commissioner Health Services, Community Health in the Ministry of Health: “We embrace innovation in Uganda… rural connectivity is a challenge…we are using smart-paper technology to augment our data…we believe in a digitally enabled village health team…we will deploy a digital solution to coordinate care and household data that will feed into our national information system”.

Malawi has developed and rolling out the community health register, which is an integrated community health data collection tool for all community health interventions. Used in monitoring of essential care package, access and coverage, it supports the delivery of integrated community health services and serves as an accountability tool – as all sectors now accept the community health register as data for decision-making. 

The importance of understanding community engagement for this process was emphasised. “We started with development of the community health indicators through engagement meetings with all our stakeholders “, Doreen Namagetsi Ali – Deputy Director for Preventive Health Services (Community Health) – recalled. In addition to harmonising the framework for community health information management system, Malawi’s Ministry of Health has identified some community health indicators that has now been integrated into the DHIS2.  

In terms of financing community health services, ICHC 2021 was informed that beyond doing the math, financing community health is a political choice and requires political will, planning, and coordination.

However, costing countries’ community health strategy proved useful in providing evidence for engaging governments and other stakeholders, including the private sector – as an investment case for funding national community health services.  

Using the ‘Community Health Planning and Costing Tool’, experiences from Burkina Faso, Zimbabwe and Afghanistandemonstrated that expanded access to community health services have direct impact in reducing maternal and under five mortality rates. Other than providing evidence for knowing the cost to achieve population coverage and impact, community health costing exercises also provided useful information on how efficiencies could be implemented. 

Moreover, costing data also revealed that financing community health is not limited to financial incentives (allowances and salaries) of CHWs and supplies and equipment for service delivery. Fiscal resources for capacity building and other operational and recurring costs need to be considered also. As such, innovative funding (catalytic and coordinated investments) needed to support and sustain these other fundamental cost drivers is critical. 

And as the ‘community’ becomes the central unit for health planning, tactical shift around financing is needed. 

At the ICHC 2021, the call for multi-sectoral engagement at the community level was very loud. As Dr Wilson Were of WHO mentioned, “health is made from home and community and not from hospitals and clinics”. Therefore, the community must be the unit for intersection – multisectoral action: service provision across various domains (healthcare, education, agriculture, livelihood etc.), accountability and learning. 

However, multi-sectoral action requires multi-sectoral planning and financing. Though many countries lay claim to understanding community-level multisectoral action, there is a sense that there is a huge know-do gap. This may not be unrelated to the ways and means of undertaking multisectoral action but also the capacity of doing so. If one may then ask: What are the competencies required to undertake multi-sectoral approaches at the community level? 

The Age of Abundance and the African mind-set

Empowered by exponential technologies

A whole new mind-set 

“Today, the defining feature of social, economic, and cultural life in much of the world is abundance”, says Daniel Pink in his book, A Whole New Mind: Why Right-Brainers Will Rule The Future. And there is a sense that despite economic disparities among nations and between the well-to-do and those at the bottom of the income pyramid within each country, technological progress of the past 200 years has continued to create material abundance and improved well being for all. How true is this? In their book, Abundance – the future is better than you think published in 2014, Peter Diamandis and Steven Kotler observed: “Compared to fifty years ago, today the Chinese are ten times as rich, have one-third fewer babies, and live twenty-eight years longer. In the same half-century span, Nigerians are twice as well off, with 25 percent fewer children and nine-year boost in life span. All told, according to the United Nations, poverty was reduced more in the past fifty years than the previous five hundred.”

Even with such data, it is hard to believe that mankind has made much progress given our level of cynicism and the media’s predilection for bad news, especially in Africa. But those who envision the age of abundance are certain about a period of radical transformation in which technology has the potential to significantly raise the basic standards of living for every man, woman, and child on the planet. The question is whether; this abundance perspective can free the African mind from the day-to-day struggles and allow millions of people in the continent to pursue significant desires – purpose, transcendence and/or spiritual fulfilment.

Vijay Mahaja’s Africa Rising narrative seems to allude to this, where more than 900 million consumers with daily basic necessities for food, clean water, shelter, clothing, medicines; as well as additional amenities such as cell phones, computers, automobiles and education for their children presents huge opportunities for everyone to create markets to meet these needs. Moreover, Africa currently has at its disposal, disruptive technological innovations that were not evident or even possible for developed nations. As Diamandis and Kotler aptly put it: “Right now a Masai warrior with a cell phone has better mobile phone capabilities than the president of the United States did twenty-five years ago.” The possibility for abundance in Africa therefore could be ways of re-imagining how things can be done in the face of present and future capabilities to provide goods and services once reserved for the wealthy few, to everyone who may need or desire them. And who is better placed than ‘young African minds’ to take up this challenge? As James Martin in his blueprint for ensuring humanity’s future – The Meaning of the 21st Century, proposed: it is possible to pluck youngsters from shantytowns and boot-camped for a startlingly new human game. “The goal is to demonstrate that we can take children of no hope and put them into a world of great hope”, he said.

~ Tarry Asoka, 09/03/18

A Vision for Nigeria Health System in 2030

Frog_leapfrogging

Consolidating its position as Africa’s largest economy, and 10 years after it has been admitted into the Global 20 Club – Nigeria’s place as a significant economic power house is no longer in doubt.

The economy is now more diversified and the tax base is healthy, although government still relies heavily on oil and gas revenues. Like Agriculture that fully transformed itself from subsistence level to a growth sector in the decade that ended in 2020, the Health sector has also emerged from its ‘cocoon’ where it has undergone metamorphosis from its ‘pupal’ social service status to become one of the ‘real’ sectors of the economy. The key drivers are (i) the over USD 10 Billion annual spend on pharmaceuticals (drugs and medicines); (ii) commoditisation of healthcare that is no longer differentiated from personal care, as several medical goods and services loose their unique medical function and become readily available at the marketplace; and (iii) a massive middle class that demand for quality care and are willing to pay for better services.

And while there has been no rational re-design of the delivery system – health services are delivered through diverse approaches. Ranging from home-based care, mobile clinics, and provision from the regular government owned and operated primary health care centres and General Hospitals, to privately run specialist medical centres – there is near universal access to a broad-range of healthcare services. But the vast majority are ‘Stand-alone Facilities’ and Independent Practitioners using very basic to high-end specialised equipment that are responding to consumer demand for quick and reliable diagnosis and treatment of common and not too common health problems. In the rural and semi-urban areas, many of these are health extenders – not the conventional Community Health Extension Workers (CHEWs) usually employed by the LGAs, but ‘Paid Volunteer Health Workers’ linked to specific health programmes such as immunisation, maternal and child health, malaria, nutrition, TB, HIV/AIDS etc. And the PHC health facilities from where these cadres of health workers are supervised have taken on a new role – that of coordinators of inputs of these health interventions and the expected health outcomes for a given population.

There is still some bit of medical tourism as the proportion of citizens that is older (with associated chronic medical conditions) and richer (with huge disposable incomes) accounts for about a fifth of the population. But the destinations are now more widespread. Rather than India, the United Arab Emirates, Dubai in particular now receives the largest number of medical tourists from Nigeria. The United Kingdom and South Africa with strong historical and continental trading ties respectively also have reasonable share of this extended Nigeria healthcare market. Interestingly, these external medical suppliers are linked to local network of providers that feed the international markets, as well as maintain some level of continuity of care when the medical visitors return home.

In terms of financial access and funding for health services, the so called National Health Insurance Scheme is still faltering. Due to ‘vested interests’ the programme fails to take on a national outlook, as it has not been reformed within the context of a federal country; and thus not able to expand beyond its initial coverage of workers in the employment of the Federal government. Several State governments also attempted to institute state-based health insurance or similar pre-payment schemes, but these too have ran into similar difficulties as they were prone to capture by entrenched interests – politicians, civil servants and professional groups. And there has been serious tensions between State Primary Health Care Development Agencies (or Boards) on one hand, and the National Health Insurance Scheme, alongside the National Primary Health Care Development Agency and the Federal Ministry of Health, with respect to control of the Primary Health Care Fund that is incorporated with the National Health Act. Consequently, PHC Agencies in several States are only in name as they have not been funded by their State governments and the hope of accessing the national PHC Fund has not materialised. Only in States such as Zamfara and others that have adopted a ‘basket-fund’ arrangement where ‘pooled funding’ for PHC activities from State, LGAs and Donors exist – are State PHC Agencies or Boards seen to be viable with related improvement in access to services and health outcomes.

Notwithstanding, as a market for health care emerges, driven by high consumer demand and spending power, individuals and households still account for the largest proportion (over 70%) of total health expenditure in the country. But curiously, direct out-of pocket payments are now very low (about 10 to 15% of total health expenditure), due to the myriads of private pre-payment medical schemes and innovative market-based health care payment mechanisms that facilitate financial access to health care across the country. Learning from how multi-national companies – from manufactures of household goods to mobile telephone operators and digital television service providers – have converted the millions at the bottom of the income pyramid into effective consumers, smart healthcare enterprises are offering ‘financial access packages’ to healthcare tailored to the needs and aspirations of each and every segment of the population.

In this health care scenario, Donors or Development Partners as they prefer to be called, struggle to find a new role for themselves. Government officials still make the right noises about being committed to the Post-2015 Agenda, but it is business as usual as donors especially those with global mandates continue to carry out their small projects in limited number of LGAs while pretending to be supporting national programmes for this and that disease or strengthening national health systems. Nevertheless, donor-supported programmes, more like ‘research pilots’ provide good evidence for continuously improving health care service delivery and the management systems that support it in Nigeria. For example, our knowledge about the effectiveness of Community Health Volunteers as health extenders came from experience gathered from two donor-funded projects: an Australia Aid (AUSAID) funded Community Mental Health Programme in South East Nigeria that was managed by CBM Australia; and a Nutrition Programme in Northern Nigeria, which was jointly overseen by Unicef, Save the Children, and Action Against Hunger, but funded by UK Department for International Development (DFID). However, we also learnt from these projects that to be sustainable, Community Health Volunteers have to be paid – no matter how small.

And as per Health Care Professional Unions – the Doctors, Nurses, Pharmacists and the rest – they have become very unpopular with the average consumer of healthcare services. Tired of their constant bickering over professional supremacy, and their collective neglect of the interests and concerns of the consumer over the years – Nigeria healthcare consumers have used their new found influence expressed in ‘healthcare purchasing power ‘ to set new measures for healthcare delivery performance, partly based on mutual accountability among healthcare professionals. Although cost of care is important, consumers now value choice and trusting relationships with doctors and provider-teams who routinely spend considerable time learning about each consumer’s medical history and needs and provide each consumer with a feeling of empathy, security and respect.

With respect to the overall performance of the health system, there have been fundamental changes that are more aligned with the overall economic growth and development agenda of the country as an advancing economy, than with technically perceived unproven ideals. While the United Nations (UN) and its agencies fret about lack of progress by Africa’s largest economy in meeting the Post-2015 Agenda targets, the ‘leapfrogged’ changes at both macro and micro levels have set Nigeria’s health system on a path to sustainable development. And this transformation has started to lead to: (i) better health outcomes – for all demographic and socio-economic groups; (ii) improved individual satisfaction and experience – with health activities and interventions; and (iii) enhanced financial sustainability – for both individuals and the economy as a whole.

Nigeria Health Sector in 2015

Healthcare Nigeria

With the singing of the National Health Bill at the twilight of 2014, stakeholders in the Nigeria health sector naturally appear to be gearing up to actively participate in what they anticipate would be the beginning of a ‘new dawn’ for health care delivery in the country.

Theoretically, the National Health Bill now an Act of the National Assembly (Parliament) creates a huge opportunity that would help the country chart a path towards achieving Universal Health Coverage (UHC) in the very near future. Specifically, as this law makes provision for financing Primary Health Care (PHC) from the Federation Account, outside the regular monthly allocations to the 36 States (that is not mandated for any goods or services); it is expected that the in-built mechanism of using this as a ‘challenge fund’ would leverage additional resources from the States for PHC. And there is therefore the assumption that the potential increased funding for PHC would by and large provide vital health services at the community level, as well as secure financial risk protection for ordinary Nigerians when they use such services.

But this futuristic glance of the coming year – 2015, advise the exercise of caution in balancing optimism with a tinge realism.

Here is why ‘fundamental health system change’ that leads to: (i) better health outcomes – for all demographic and socio-economic groups; (ii) improved individual satisfaction and experience – with health activities and interventions; and (iii) enhanced financial sustainability – for both individuals and the economy as a whole – may not happen (or begin to happen) in 2015.

First – 2015 is election year in Nigeria. Though the elections will definitely come and go, and there will be winners and losers for sure. But as most things in Nigeria depend on government, the period of electioneering and the outcome of this significant national event will influence what happens generally in the country for the whole year. The May 29th ‘transition date’ somewhat divides the year into two halves. The first part of the year, overshadowed by ‘election fever’ will create uncertainly as stakeholders within the health sector may not fully engage with government as they are not sure of who they may be dealing with after the elections. The second half, the transition period will be equally unsettling as political officer holders – who are either new to office or consolidating their mandates – would either be finding their bearing or trying new approaches to doing things based on their previous experience.

Second – as technical capacity at all levels of government (Local, State and Federal) within the health sector remains weak; 2015 is not the year when suddenly technocrats in Nigeria are able to translate policies into plans and get them implemented. Moreover, as they are known to be territorial and clandestine in their dealings; this may not be the year when they become more transparent and agree to openly work collaboratively with all stakeholders in the health sector.

Third – Nigeria is an emerging economy (despite income inequalities) with all the trappings of affluence, and a growing middle class. But the International Donor Community (aka Development Partners) remain pretentious about delivering International Aid in the health sector based on conventional ideas of helping a poor country. In 2015, Development Aid to Nigeria in the health sector will continue to be ineffective as the interventions of Donor organisations will continue to be seen as projects of the respective agencies (including those with global mandates); and not national health programmes since they will fail to make the connection of engaging with a country in transition.

However, all hope is not lost for the Nigeria health sector in 2015. Based on the ‘drivers of change’ analysis – we are aware that while actors make outcomes possible their capacity to act is ultimately set by the structural context which they find themselves. Notwithstanding, in 2015, change may still come through collective action by actors who are able to overcome such structural obstacles by re-making of institutions – modifying the way actors relate with each other and with the structures. As previously demonstrated by the ‘Nollywood Paradigm’, the group that got the National Health Bill passed and signed through sustained advocacy – the Health Sector Coalition of Nigeria – will continue to ensure that the National Health Act begin to provide benefits for all Nigerians as intended and not hijacked by vested interests. But fundamentally, as the market-based Nigerian economy powers on (irrespective of low oil prices, which will only affect government revenue), the health sector will most likely follow the approach of the multi-national companies serving Nigerians (even the very poor) with good and services – by converting them into effective consumers rather than being patronising in their dealings.

On this note, stakeholders in the Nigeria health sector should look forward to a 2015 that will not only engage their energies, but also their mental faculties as they ‘navigate’ the ‘treacherous waters’ of re-vitalising the health system, especially primary health care delivery.