The Community Health Systems Reform Cycle: Strengthening the Integration of Community Health Worker Programs Through an Institutional Reform Perspective

Nan Chen; Mallika Raghavan; Joshua Albert; Abigail McDaniel; Lilian Otiso; Richard Kintu; Melissa West; David Jacobstein

doi:10.9745/GHSP-D-20-00429

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Jerome Gardiner, a community health assistant in Liberia, displays his COVID-19 job aid. Liberia's community health assistants are a cadre of government-formalized community health workers that are paid, supervised, trained, equipped, and integrated into the public health system. © 2020 Rachel Larson/Last Mile Health.
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FIGURE
The Community Health Systems Reform Cycle

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TABLE.

Key Country Actions by Community Health Systems Reform Cycle Stage

Problem Prioritization	Actors diagnose and frame a compelling problem or opportunity that sets the foundation for the rest of the cycle. A meaningful and relevant problem has been identified, pain points and unmet needs have been defined and, where possible, these are connected to priority areas for reform. Relevant actors acknowledge the need for reform within the community health system, while committing towards a joint vision for addressing gaps.
Coalition Building	A group is formed around a compelling problem or vision. Members understand the group and individual roles and goals. Group size and composition is fit for purpose. Diverse membership is established that can fill critical roles for reform (e.g., leaders, connectors, gatekeepers, donors, enablers, change champions, and links to key players outside the coalition).
Solution Gathering	Criteria or priorities are developed to determine how to assess solutions. Potential solutions are gathered, drawing from existing, local, and international ideas and where possible, specific ideas for reform are tested/piloted for effectiveness. Promising solutions are prioritized for integration into the health system.
Design	Key decision makers, contributors, and authorizers of the reform are identified. These may be a small group, or large multi-sectoral group. Key informants and designers map and understand the different design choices. Where possible, evidence about the different design options and expected cost, impact, and feasibility are identified. Through consultations, workshops, and other forums, groups recommend design choices and decision makers are able to validate these choices. This stage includes the design of training materials, operational plans, job descriptions, management tools, data collection systems, supply chain processes, and planning documents which are all necessary for planning.
Readiness	Coalition actors and champions generate buy-in from actors who will need to play key roles in the launch, rollout, and maintenance of the program, including sharing of key information and knowledge. Stakeholders also translate program design into costed operational plans and implementation guidance. These plans should include a clear “launch” plan, accompanied by strong planning and management tools to ensure smooth rollout. Orienting and resourcing stakeholders to fulfill new roles and responsibilities is key. Costed plans inform financing mechanisms to ensure that needed funds are mobilized and can readily flow to the right actors for implementation. Additionally, investment plans for sustainable financing are put in place. Stakeholders identify and address policy/protocol conflicts and integration needs across the health system.
Launch	Key actors are able to access relevant skills, knowledge, and resources to execute their new roles. New processes and organizational structures are identified, socialized, and then implemented. As these shifts progress, the program reform is implemented in target areas. From implementation, learning is gathered to demonstrate momentum and identify challenges to achieving scale. Particular attention should be paid to roll out challenges to make shifts in design quickly.
Governance	During this stage, stakeholders establish a project governance framework, which includes key leadership and decision-making bodies, clear roles and responsibilities, and explicit decision rights. It is also critical to establish processes for risk and issue management; stakeholder engagement; and cross-functional communication. As the program evolves, actors monitor and assess progress to advance clear decision making and address critical issues or challenges.
Management and Learning	Key stakeholders regularly review data to inform joint problem solving (e.g., regular program reviews at national and subnational level). These reviews serve to identify and institutionalize reflection points. Continuous improvement within existing program design is a key feature of this stage, in which challenges and changes to program design and other systems bottlenecks are identified.