Community health is the cornerstone of health care in many countries, reaching beyond formal health care settings into communities to deliver a range of care to people who may not have access otherwise. As a result, community health is increasingly acknowledged as essential for achieving universal health coverage (UHC).
At the forefront are community health workers who serve as a vital link between communities and wider health care systems, often traveling door to door in hard-to-reach communities. Their work improves access to care, community participation, health outcomes, and health care efficiency — particularly in reproductive, maternal and child health, and prevention, detection and treatment of communicable diseases like COVID-19.
Despite the important role of community health workers, they face multiple challenges, including poor remuneration, inadequate training and weak supervision. In many places, community health workers do not reflect the communities they serve, which can lead to mistrust and misunderstandings. Addressing these challenges is essential for unlocking the full potential of community health workers, integrating them into the formal health system, paying them adequate salaries for their services, and achieving equitable, high quality health care.
R4D is working on many of these issues, and we’re excited to be seeing an important shift in how country leaders, community organizations and advocates, and donors are thinking about community health. These are the 8 trends we’re observing right now:
1. Greater integration of community health into primary health care
Integrating community health into primary health care improves accessibility, reduces fragmentation, improves trust, guarantees a comprehensive approach to well-being, and gives communities the power to actively engage in their own health care, all of which contribute to the development of a more resilient and efficient health care system.
For example, The Community Health Influencers, Promoters and Services (CHIPS) Programme is a national program in Nigeria that aims to enhance access to health care and strengthen the community aspect of primary health care. The CHIPS Program stimulates and supports households to seek primary care services through various delivery platforms, namely the health facility and outreach. The program also enables clients to obtain essential primary care services, by bringing these services closer to households through home visits by CHIPS Agents, especially in underserved rural communities.
R4D, through The Health Systems Strengthening Accelerator, is currently working with the Nigerian government to co-create a comprehensive plan to improve the CHIPS Program. This has been a welcome approach, as explained by Dr. Nana Sandah-Abubakar, CHIPS National Program Manager: “We are excited to have the HSSA team from Results for Development support us in a co-creation approach in strengthening the governance and coordination of the CHIPS Programme. For better outcomes, this is an area that needs to be built up, especially at the sub-national levels.”
2. A movement to professionalize community health work
Recognizing the critical role that community health workers play, many countries are moving toward paying, supporting, and formally integrating these workers into the public sector. There is also a growing focus on enhancing the recruitment process to be more diverse and formalized, fostering gender equity, improving training initiatives, promoting career development, and incorporating digital innovations.
For example, Guinea recently adopted a new law mandating that community health workers and mobilizers are recruited and paid by the government as civil servants. This was the culmination of an advocacy campaign led civil society organizations (CSOs) in Guinea who have been championing community health worker compensation. R4D and local partner Comité Jeunes, Mon Avenir D’Abord (CJMAD), provided coaching, mentoring, and training for CSOs, enhancing their advocacy capacity. This included developing an advocacy strategy, crafting effective messaging, mobilizing media coverage, and providing guidance on engaging with the Ministry of Health, Ministry of Finance, Ministry of Territories and Decentralization, and the National Transitional Council.
3. More focus on country-led costing and financing of community health plans
During our engagement in the 3rd International Community Health Workers Symposium in Liberia, a central theme resonated across various sessions, underscoring the imperative need to enhance sustainable funding, in particular domestic funding, for the expansive growth of community health programs. The success of integrating community health into the broader health care system hinges critically upon securing sustained financial backing for policies and operational plans that champion community health workers.
For this to happen, it is important that community health funding aligns with broader health system objectives. Countries undertaking the task of scaling and integrating community health programs must ensure the availability of adequate funding, human resources, and infrastructure support. This is particularly crucial given that many community health programs initially concentrate on discrete, disease-specific tasks.
A pivotal strategy in garnering support for community health programs involves costing out and strengthening community health investment cases to bolster political will and attract funding. These investment cases can highlight how the scaling of community health programs not only delivers immediate benefits but also generates long-term cost savings in various segments of the health system. By emphasizing the substantial return on investment, including determination of lives saved, advocates can further solidify the importance of prioritizing and sustaining funding for community health plans, thereby fortifying the foundation for a healthier and more resilient society.
4. Focusing more on the community level, where health care takes place and where equity is enhanced
There is growing recognition that health care must be heavily concentrated at the community level to ensure equity, close access gaps and secure the needed buy-in from community leaders and to address any cultural issues to enhance uptake of services. For example, Tanzania, along with several other countries, now mandates that community health workers should be selected and recruited from the communities they serve, so that they have a deeper understanding of the communities they serve and be effective liaisons to health centers. This strategic shift enhances the effectiveness of health care interventions and fosters a sense of community engagement and trust. CHWs can also reach the most marginalized, underserved communities where access to care is limited. In addition, there is growing evidence that community health workers can effectively provide basic curative services and vaccinations with adequate training, commodities and support.
Cote d’Ivoire’s national community health policy, developed in 2021 with R4D’s support, and its National Strategic Plan for Community Health finalized in 2022 lay out a vision to provide quality health services, by fostering greater collaboration between communities and local government. The plan emphasizes the importance of decentralized levels of the government, particularly at the district level, taking ownership of their community health activities and harmonizing their decentralized plans with the overarching strategy to foster smooth integration of community health workers into the formal health care system. Community-based management committees (comités des gestion or COGES) are supposed to be initiated or strengthened to play an oversight and accountability role, to ensure that community health services are responsive to community needs and demands. R4D, working in collaboration with the USAID Mission, is supporting the Ivorian government to develop a communications plan and a strategy for adoption of policies on community health to ensure that all stakeholders within the health system understand the community health approach outlined in the National Strategic Plan and ultimately implement the policies appropriately.
5. In response to calls from country leaders and advocates, donors are coordinating more to reduce fragmentation
As outlined in the Monrovia Call to Action, it is critical for partners and donors to align community health investments with country-led strategies following a One Plan, One Budget, and One Monitoring and Evaluation Plan approach. Instead of having multiple community health initiatives in a country financed by different donors, each with their goals, reporting systems, and financing — there should be a commitment to have one community health strategy, developed by country stakeholders that everyone invests in, follows and adheres to.
Country leaders, advocates, and other stakeholders advocated for this approach and are working with funding and development partners to streamline programs to align with their identified needs and priorities. These efforts are helping to minimize the fragmentation of donor funding and verticalization of community health programs.
For example, both Ethiopia and Zambia have brought together donors and implementing partners to mobilize the financing for integrated community health platforms. Ethiopia and Zambia both benefited from technical assistance from the Community Health Roadmap, a global platform which supports countries to coordinate investments aligned with national community health priorities.
6. Integrating vertical programs into more comprehensive, horizontal health services, including Essential Health Service Packages
To date, most donors have channeled funding and support to community health workers and community health programs through vertical health programs, such as HIV, TB, malaria, and immunization programs. There are multiple challenges with this approach, including fragmented management and service delivery, demotivation of staff, undermining local leadership, a focus on short-term targets versus longer-term health systems strengthening, and lack of alignment with or distortion of national and local priorities.
However, there is growing recognition that countries can achieve more with limited resources by integrating community health into primary health care and the broader health system, integrating across vertical disease programs, reducing fragmentation and facilitating multi-sectoral collaboration. Integration into the broader health system will also enhance governance of community health workers, build their capacity, improve logistics management, and lead to strengthened and resilient health systems for delivery of Essential Health Services Packages. Fortunately, many donors and partners are now making significant shifts towards more integrated funding models. For example, the Global Fund is committing $900 million over the next three years to support community health workers.
7. Improved health information systems
Another area of focus is the development of more robust community health information systems, which can support evidence-based program improvement, policy, decision-making and feedback to the community.
Many countries are focused on integrating community health reporting into one system, directly tied to national health management information systems, and using electronic platforms such as DHIS2, rather than maintaining duplicate or parallel M&E data and reporting systems. The use of digital health tools and digitizing data collection at the point of care is also being emphasized as key to having more real-time, reliable, and high-quality data. Ensuring that data are disaggregated by gender and other characteristics is critical for ensuring that inequities in health care access and quality are being tracked and equity gaps are reduced.
R4D supported the government of Ghana to equip and train frontline health workers to use digital tablets during the country’s COVID-19 vaccination campaigns. The tablets allowed health workers to capture critical case-based information during outreach visits across the country. The data also provided valuable insights into where vaccination rates were high or where they lagged, informing decision making about where to focus efforts. The tablets are now being used to collect, analyze, and share data for routine immunizations and other primary health services.
8. Promoting monitoring, accountability and advocacy
Community health advocates and stakeholders are emphasizing the importance of setting and tracking shared targets, milestones, indicators, and investments as a way to increase accountability for achieving shared commitments in community health.
However, there are myriad community health and primary health care measurement initiatives and frameworks, and work must be done to identify promising examples and decide on the indicators of highest priority.
Global advocacy campaigns, including the Community Health Impact Coalition among others, are elevating the voices and demands of community health workers, highlighting that there should be: “nothing about us, without us.”
Community health workers are essential to improving healthcare access and outcomes, particularly in remote areas. However, persistent challenges such as institutionalization issues, program fragmentation, financial constraints, and insufficient training impede their effectiveness.
The positive trends highlighted in this blog, including greater integration of community health into primary health care, strengthened government leadership and commitment, and more aligned donor support based on countries’ needs are collectively contributing to the potential of community health workers, and in turn, fostering more resilient, efficient health care systems — and ultimately, advancing universal health coverage.
Photo © Health Systems Strengthening Accelerator/Guinea