Transformative approaches to strengthening primary health care and community health

Access to quality affordable primary health care is critical to resilient and responsive health systems. Despite considerable progress, many countries still face significant challenges in strengthening their primary health care (PHC) systems. Common obstacles include insufficient and unsustainable funding, inadequate training for community health workers (CHWs), and weak integration of community health programs into broader health systems.

To address these challenges, the Health Systems Strengthening Accelerator applied transformative approaches to strengthen primary care networks (PCNs) and community-based primary health care services in multiple countries and generated global evidence for knowledge exchange. These efforts have supported local governments in redesigning service delivery systems, promoting sustainable financing, and strengthening civil society’s capacity to hold governments accountable to their universal health coverage (UHC) commitments.

Strengthening primary health care delivery through networks of practice

Evidence shows that a well-organized network of primary care practices enables countries to deliver a wide range of services on a large scale. PCNs can improve the quality of health services, enhance resource sharing, enable comprehensive care, and improve efficiency by leveraging shared technology for streamlined information exchange. PCNs also facilitate collaboration between public and private primary care facilities.

Ghana is one of several leading countries in developing, scaling up, and sharing globally-relevant lessons for PCNs. The Accelerator partnered with the Ministry of Health (MOH) and Ghana Health Service (GHS) to generate and use evidence to inform the design, pilot, roll-out, and scale-up of primary care provider networks as a critical reform to strengthen PHC service delivery. In an initial pilot, networks enabled lower-capacity facilities to pool and more effectively manage resources and deliver a broader package of services. Based on the pilot’s results, Ghana launched a nationwide rollout that has improved equity in coverage, healthcare delivery quality, service access, referral coordination, and capacity building across more than 400 facilities and over 90 networks, proving pivotal in Ghana’s journey toward UHC.

Key lessons from this experience were captured in a learning exchange supported by Results for Development (R4D) in partnership with the Joint Learning Network for Universal Health Coverage (JLN) and the Primary Health Care Performance Initiative (PHCPI). The learning community reviewed implementation cases from Colombia, Ghana and Kenya and produced a paper, “Transforming PHC Delivery and Financing through Primary Care Networks.”

Several ingredients for success and essential tools were identified for successfully implementing a PCN, including:

1. Developing and using causal chains to map action steps and outcomes and regularly assess progress;
2. Consulting and aligning with the key stakeholders throughout the health system — from local to national levels — to ensure appropriate funding, participation, and both government and community support; and
3. Using systematic learning and continuous feedback processes to ensure responsiveness and adapt and improve the implementation process.

Strengthening community health strategy and workforce

There is increasing global recognition of the role of community health workers in achieving UHC and other health equity goals. There has also been momentum toward ensuring community health programs are appropriately integrated and sustainably financed within the broader health system and that community health workers are adequately compensated and formally recognized within the health workforce — notably through the Community Health Roadmap partnership.

Advancing this community heath agenda requires a systems approach—that is, moving from siloed training of CHWs in certain areas to broader government-led strategies to improve financing, governance, capacity, and other systematic changes needed for professional CHWs to be a core part of primary health care and the broader national health system. The Accelerator took such an approach, supporting systems-wide strategies to advance community health policies in Guinea, Nigeria and Tanzania.

Engaging civil society in primary health care-centered UHC policies

Civil society organizations (CSOs) are vital in holding governments accountable and ensuring health policies are relevant, inclusive and equitable. Long proven to advance agendas and improve impact for disease-specific challenges, such as the prevention and treatment of HIV/AIDS, CSOs can help policymakers hear from diverse voices in health prioritization processes, fine-tune implementation of health programs to reach vulnerable communities, and call policymakers’ attention to what is and is not working well at the community level of health systems.

In Togo, the Accelerator supported strengthening CSOs’ capacity to engage effectively in UHC policy and decision-making processes as the country designed and rolled out its new national health insurance program. The Accelerator co-created a capacity-building plan with local CSOs, providing face-to-face training sessions, ongoing coaching, and support in developing and implementing advocacy activities. This approach has enhanced CSOs’ understanding of UHC, improved their ability to conduct community dialogue, and fostered a new perception of civil society by government actors.

In Benin, where the government launched its ambitious national health insurance program, AM-ARCH, the Accelerator facilitated a platform called the “consultative committee” for inclusive policy dialogue to enable civil society to give feedback to the government on the program’s scale-up. The Accelerator supported CSOs to increase community awareness, enrollment, and use of the new national health insurance program, since early evaluations demonstrated low participation, especially in rural, remote communities. Civil society was also responsible for a new complaints management system for users to provide feedback on the program, further enhancing patients’ rights and promoting accountability.

Key Lessons

Continued investment to strengthen community-based primary health care is essential. Donors and implementing partners should focus on learning from and scaling successful models for service delivery and workforce within community and primary care programs.

• Investments in implementation research and other learning efforts should guide community health and PHC program design and implementation.
• Partners must support country decision-makers to lead in articulating community health investment priorities and to integrate and institutionalize community health programs into existing health system structures.
• CSOs, especially at the sub-national level, should be supported so they can contribute to developing and monitoring policies.
• Applying systems thinking to community health program design and supporting collaborative learning among countries will be crucial for health systems’ quality, resilience, and sustainability and attaining UHC.