The Challenge
Accelerating progress toward universal health coverage and achieving the health targets outlined in the Sustainable Development Goals will require dedicated investments in human resources for health. However, in many countries — particularly low- and middle-income countries — there are deficits in human resources, making it difficult to provide equitable and quality health care especially in hard-to-reach communities. To address this challenge, countries are increasingly finding the role of community health workers critical in the primary care continuum.
There is evidence of the effectiveness — and cost-effectiveness — of community health programs in delivering a wide range of essential health services especially to hard-to-reach communities. Community health workers can deliver a range of preventive, promotive, curative, and rehabilitative services related to reproductive, maternal, newborn, and child health; infectious diseases; HIV; non-communicable diseases; and neglected tropical diseases — and therefore, contribute to the realization of universal health coverage.
Despite their critical role, community health worker programs face many challenges, including inadequate funding and poor engagement with local government and community members in recruiting and selecting community health workers — in addition to inadequate training, poor or no salaries and uncertain career pathways. Increasingly, countries have recognized that to get the best out of community health as an integral part of primary health care, community health workers must be formally employed by governments and institutionalized as part of the national health system. This will increase the trust communities have in them, improve uptake of services, health outcomes and ultimately universal health coverage.
Our Approach
R4D contributes to systems strengthening for delivery of equitable and quality community health by engaging Ministries of Health, civil society, and other partners to diagnose the root causes of challenges in community health. We co-create local solutions for integrating community health workers into primary health care systems and for promoting adequate domestic financing to fund them.
And by strengthening dialogue and partnership between Ministries of Health and civil society, R4D helps to foster accountability to quality health care that is responsive to community needs. R4D’s approach also underscores systems thinking — moving beyond supporting frontline service delivery, such as training and paying community health workers, towards understanding all of the actors and processes that need to be involved in integrating and sustaining community health programs.
And on a global scale, R4D is uniquely positioned to play a connector role, promoting collaborative learning, networking and knowledge translation among countries, while also working with partners and funders to align their support to address country priorities and reduce fragmentation and verticalization of programs.
Our Work
R4D has supported global community health initiatives and several countries to make significant progress in strengthening community health including:
Advancing the Community Health Roadmap at the global and country levels
The global Community Health Roadmap (CHR) initiative is a collaborative platform made up of donors, private funders, and global health leaders. Its primary objective is to mobilize increased and coordinated investments in community health to help countries attain their primary health care and universal health care objectives. So far, sixteen countries have formulated roadmaps outlining their community health investment priorities.
R4D is supporting the Community Health Roadmap through country-specific technical assistance in roadmap countries, and at a global level is strengthening coordination of technical assistance, knowledge management, and development of global goods across countries and partners.
At the country level, R4D supported the United Republic of Tanzania to become the sixteenth country to join the Community Health Roadmap and to develop roadmap profiles for Mainland Tanzania and Zanzibar, which outline the country’s most urgent investment priorities for community health. This is in alignment with the global Community Health Roadmap’s efforts to elevate country-led community health strategies following a one plan, one budget, and one implementation approach so that all donors, partners, and implementers support the country’s community health plan. For example, R4D is currently supporting a community health worker mapping exercise to inform Tanzania’s new CHW training being rolled out in early 2024.
At the global level, R4D supported the 3rd Community Health Worker Symposium in Monrovia, Liberia in March 2023 by contributing to the development and facilitation of five tracks for the symposium. We organized the day 2 pre-conference workshop for 39 countries. During the workshop, countries were supported to review their community health plans, measure their performance, and share challenges and best practice with peers and foster networks for continued knowledge sharing. The symposium led to the development of the Monrovia Call to Action which is guiding the implementation of community health in countries around the world.
R4D also hosted and co-facilitated the 2nd High-Level Partnership meeting of the Community Health Roadmap in August 2023, an opportunity to convene global stakeholders including CHR donors, partners, and Ministers of Health. The purpose of the meeting was to share global progress updates and define collective efforts to support improved alignment, coherence and mutual accountability at global, regional and country levels.
This convening led to a commitment to establish the Community Health Delivery Platform to fast-track implementation of the CHR and, through the Platform, operationalize the Monrovia Call to Action.
Improving community health and immunization outcomes in Guinea
Guinea has developed a National Community Health Policy in response to long-standing health challenges. The R4D-led Health Systems Strengthening Accelerator and local partner Comité Jeunes Mon avenir d’Abord (My Future First Youth Committee or CJMAD) are supporting Guinea to effectively implement the policy and improve community health system performance. The work focuses on improving management and leadership of the community health program, supporting increased and sustained financing for community health and community health workers, integrating routine immunization programming within community health, and facilitating learning for adaptation and decision-making to improve implementation. In 2023, Guinea passed a new law mandating municipal payment of community health workers, this is a great achievement for community health and CHWs, thanks in part to a civil society advocacy campaign.
Strengthening community health governance in Côte d’Ivoire
In Côte d’Ivoire community health services have historically been implemented in an inconsistent and fragmented way by donors and implementing partners. R4D has supported the development of three major activities to strengthen the Ministry of Health’s community health leadership, governance and coordination: the country’s first National Community Health Policy, an operational plan for the policy, and an interactive community health resource mapping tool.
R4D is also supporting Côte d’Ivoire’s efforts to improve equity and resilience of their future community health workforce. Côte d’Ivoire has prioritized expanding its community health workforce from 11,397 CHWs in 2017 to 25,000 in 2025. They have developed the National Strategic Plan for Community Health (2022-2025) and an investment case to strengthen community health activities in Côte d’Ivoire. In collaboration with the Ministry of Health in Côte d’Ivoire, R4D is supporting the Directorate of Community Health to strengthen governance, leadership, and community engagement for their community health workforce. This support includes developing a communication plan for the National Strategic Plan for Community Health (2022-2025) to improve awareness, understanding and support at decentralized levels of government. The communication plan will focus on moving from proposed solutions to policy adoption, building consensus and support, and strategic communication. R4D’s support will also emphasize the financing, sustainability and institutionalization of the policy for long-term success.
Scaling up primary care provider networks in Ghana
The Government of Ghana is expanding access to affordable primary health care services by designing and implementing primary care provider networks, also known as Networks of Practice (NoPs). The Ghana Health Service, the National Health Insurance Authority, the Ministry of Health and the R4D-led Health Systems Strengthening Accelerator are working together to conduct capacity-building activities to equip key stakeholders with the necessary tools and resources to successfully manage the networks. R4D has supported the Ghana Health Service to conduct implementation research and monitoring of the networks. The findings are being applied to improve the design and implementation of the NoPs scale up in Ghana. R4D is supporting the Ghana Health Service to develop a preventive and promotive health benefit package to be integrated into the primary care provider networks with financing flowing to the networks.
Improving equity and resilience of the future community health workforce in Nigeria
In Nigeria, R4D is providing technical assistance to the National Primary Health Care Development Agency (NPHCDA) on community health worker advocacy, capacity strengthening, mentoring, coaching, utilizing opportunities for analytics, and translation of evidence into action. We are supporting the NPHCDA to develop a compelling investment case for prioritization, targeted allocation, release and utilization of resources for establishing an equitably distributed, well-trained and highly motivated community health workforce.
R4D is leading a rapid scan of community health workforce topics in Nigeria to examine community health worker programs and categorizations, institutionalization/formalization, workforce distribution and gender dimensions. The findings from the scan will be used by the NPHCDA to develop plans to strengthen the state-level Community Health Influencers, Promoters and Service Program Implementation Unit (CHIPS PIU) and develop other self-identified tasks such as the establishment of routines for partner/stakeholder coordination, content creation for a proposed interactive CHIPS webpage on the NPHCDA website, a CHIPS program documentary, the development of a CHIPS program advocacy plan, and a Nigeria CHIPS program bulletin.
