Figures & Tables
Tables
- TABLE 1.
Country Self-Grading of Health System Domains as Severe/Very Severea Bottlenecks to Strengthen Community Health Systems (N=22 Countriesb)
Legislation, Policies, Governance, Coordination Health Financing Essential Medical Technology and Products Human Resources Service Delivery and Integration; Quality of Services Information System/ Monitoring and Evaluation Community Ownership andPartnership Benin * * * Burkina Faso * * * * * Cameroon * * * * * * Cabo Verde * Central African Republic * * * * * * * Chad * * Congo * * * * * Cote d'Ivoire * * * * * Democratic Republic of the Congo * * * * Equatorial Guinea * * * * Gambia * * * * * Ghana Guinea * * * * * * Guinea-Bissau * * Liberia * * * Mali * Mauritania * * * * * * Niger * * * * * Nigeria * * * * * Senegal * * * * Sierra Leone * * * * * Togo * * * Total number of countries 10/22 19/22 16/22 7/22 14/22 9/22 14/22 - TABLE 2.
Country Self-Grading of Health System Domains as Severe/Very Severea Bottlenecks to Strengthen Community Health Systems by Under-5 Mortality Rate Category (N=21 Countriesb)
Countries/Domains Legislation, Policies, Governance, Coordination Health Financing Essential Medical Technology and Products Human Resources Service Delivery and Integration; Quality of Services Information System/ Monitoring and Evaluation Community Ownership and Partnership Countries with under-5 mortality rate = 25 to 75 deaths/1,000 live births (6 countries) Congo * * * * * Gambia * * * * * Ghana Liberia * * * * Senegal * * * * Togo * * * Total number of countries 2/6 5/6 5/6 3/6 2/6 0/6 4/6 Countries with under-5 mortality rate > 75 deaths/1,000 live births (15 countries) Benin * * * Burkina Faso * * * * * Cameroon * * * * * * Central African Republic * * * * * * * Chad * * Cote d'Ivoire * * * * * Democratic Republic of the Congo * * * * * Equatorial Guinea * * * * Guinea * * * * * * Guinea-Bissau * * Mali * Mauritania * * * * * * Niger * * * * * Nigeria * * * * * Sierra Leone * * * * * Total number of countries 8/15 13/15 11 /15 4/15 12/15 9/15 10/15 - TABLE 3.
Grouping of 22 West and Central African Countries According to Under-5 Mortality Rates Showing Selected Health System Tracer Indicators (Financing, Supply, Health Workforce, and Service Delivery) and Child Indicators
Group 1, U5MR <25 Deaths per 1,000 Live Births (N=1)a Group 2, U5MR 25 to 75 Deaths per 1,000 Live Births (N=6)b Group 3, U5MR >75 Deaths per 1,000 Live Births (N=15)c Countries With Data,No. Mortality/demographicsd Under-5 mortality rate (Median, deaths per 1,000 live births) 19.5 54.2 88.1 22 Annual rate of reduction (2000–2018) 3.3% 4.2% 3.3% 22 Health financinge Median primary health care expenditure as % current health expenditure (2016–2017) 63.3% 67.7% 73.5% 14 Median primary health care expenditure per capita (2016–2017) US$94.5 US$34.9 US$24.7 13 Median domestic general government health expenditure per capita, PPP (2017) US$215.1 US$34.5 US$25.7 22 Median government expenditure on health, percentage of gross domestic product (2018) 3.1% 1.5% 1.0% 22 Median out-of-pocket expenditure, percentage of current health expenditure (2017) 28.9% 48.5% 43.5% 22 Supplyf Median essential drug availability - 37.1% 29.0% 9 Median vaccine availability - 83.9% 76.5% 8 Median basic equipment availability - 87.0% 82.0% 9 Median facilities with clean water, electricity, & sanitation (% of health facilities) - 54.2% 69.2% 8 Health workforce Median community and traditional health worker density (per 1,000 population) - 0.1 0.1 10 Median health center density (per 100,000 population) 3.8 5.1 4.4 15 Health facility service deliveryg At least 1 antenatal visit, median 97.6% 92.0% 83.2% 22 At least 4 antenatal visits, median 72.3% 77.9% 51.3% 22 Skilled attendance at birth, median 92.3% 64.8% 67.3% 22 Institutional delivery, median 75.6% 72.8% 66.8% 22 Child health tracer indicatorsh Diphtheria-tetanus-pertussis immunization coverage, median 98.0% 86.0% 79.0% 22 Children with diarrhea treated with oral rehydration salts, median - 36.0% 34.3% 21 Children with malaria with first-line treatment (artemisinin-based combination therapy) for under-5, median - 57.8% 17.5% 21 Children with symptoms of acute respiratory infection who received antibiotics, median - 40.2% 27.8% 21 Other child health-related tracer indicators (multisectoral)h Children (0–14) living with HIV, median no. - 6,100 10,000 21 Children (0–14) living with HIV receiving antiretroviral therapy, median - 27.5% 23.4% 21 Children under 5 years who are stunted (moderate and severe), median 21.0% 23.0% 32.0% 22 Children under 5 years who are wasted (severe), median - 1.5% 2.0% 21 Children under 5 years who have their births registered, median 91.4% 74.7% 65.6% 22 Households with at least basic drinking water services, median 87.1% 75.6% 63.3% 21 Households with at least basic sanitation services, median 73.9% 19.3% 21.6% 21 Households with at least basic hygiene facilities, median - 17.3% 14.7% 18 Abbreviation: U5MR, under-5 mortality rate.
↵a Cabo Verde.
↵b Senegal, Ghana, Congo, Gambia, Togo, Liberia.
↵c Mauritania, Cameroon, Burkina Faso, Cote d'Ivoire, Guinea-Bissau, Niger, Equatorial Guinea, Democratic Republic of the Congo, Benin, Mali, Guinea, Sierra-Leone, Central African Republic, Chad, Nigeria.
↵d Mortality/Demographics Source: 2019 United Nations Inter-agency Group for Child Mortality Estimation (United Nations Children's Fund, World Health Organization, United Nations Population Division and the World Bank Group).
↵e Health Financing Sources: Databank from The World Bank, Global Health Expenditure Database from World Health Organization, and Primary Health Care Performance Initiative.
↵f Supply Source: Based on country's latest results from the Service Availability and Readiness Assessment, if available.
↵g Health Workforce Source: Primary Health Care Performance Initiative.
↵h Health Service Delivery, Child Health, Multi-sectoral Child Needs: Based on latest Demographic and Health Survey or MICS Country Survey Results and 2019 State of the World's Children Report.
- TABLE 4.
Examples of Country Achievements and Proposed Strategies to Strengthen Community Health Systems
Highlights of Recent Achievements Key Strategies to Enhance Current Efforts Group 1 and 2: Countries with U5MR < to 75 deaths / 1,000 live births Senegal High-level commitment and government leadership to scale up PHC: national health financing strategy developed; National UHC program defined; PHC review completed (2018–2019)
National community health program 2019–2023
National health investment case developed; including community health component
Various CHW cadres in place, mostly funded by external resources
Engagement of local authorities for the management of health posts (case de santé) through local health development committee
Ongoing resource mobilization efforts conducted, with a great focus on external resources
CHW package of services defined; scale up of integrated services in most regions, including health and nutrition at the community level
CHIS developed and integrated into DHIS2
Increase domestic resources mobilization for community-based PHC by leveraging investments from local governments or other ministers (education, youth); Leverage innovative funding mechanisms: education and economic growth programs; co-financing/matching funds, trust funds with private sector
Implement performance-based financing based on lessons learned from the pilot program and local contexts
Work toward professionalizing CHWs to strengthen health systems
Strengthen community-based logistic management system (forecasting, procurement, quality control) as well as last-mile distribution of essential drugs
Scale up innovative technologies for better health management system, including information and logistics management systems
Enhance social accountability mechanisms (community scorecards, observatories) and citizen engagement for better planning and monitoring with local communities
Invest in the building and equipping health posts (case de santé) close to the communities in the deprived regions of the country
Liberia High-level presidential engagement to scale to community health post Ebola virus disease-crisis (2016)
Community health investment case completed; National community health policy developed
Financing gap analysis and resource mobilization, with a main focus on external funding – international aid
Roll-out of the national community health assistant program: training modules and tools developed; community health assistants and supervisors recruited and trained in selected regions
CHIS is integrated into DHIS2; Ongoing digitalization of the system to strengthen CHW performance
Strengthen the functionality of national coordination and governance mechanisms for PHC including community health
Review of national community health policy as per WHO recent guidelines
Build a pathway toward financial sustainability: develop clear gap analyses and financing pathways for the CHA program by leveraging domestic/ international resources, new funding sources including matching grants, co-investment with local governments as well as the private sector
Work with local governments and other line ministries (decentralization, social welfare, youth, education) to ensure long-term availability of community health assistant (remote and rural areas)
Fully integrate community-based LMIS into national LMIS and improve last-mile distribution of drugs
Generate evidence on innovative approaches and best financing models for the national CHW program
Develop referral systems with local governments and communities
Enhance community governance and oversight mechanisms for the community health assistant program; establish community-based monitoring and social accountability systems
Group 3: Countries with U5MR Over 75 deaths/1,000 live births Guinea National health investment case developed; National community health policy developed (CHA profile harmonized)
National intersectoral coordination mechanism established, under the leadership of the Ministry of Territorial Administration and Decentralization to support implementation of the national community health policy
Resource mobilization through the National Financing Agency for local collectivities; financial contribution of local collectivities through their annual investment plan
Implementation of the national CHA program in selected districts (mainly funded by donors): development of tools, training of CHAs
Engagement of community leaders and networks in decision making and monitoring enhanced through local government structures and local committees
Development of the CHIS (tools and modules)
Raise awareness on specific community health policy issues (parliament, champions)
Implement and expand pro-poor legislation and strategies (e.g., vouchers, community-based health insurance schemes)
Develop clear gap analyses and financing pathways for costed CHW programs by leveraging domestic/international resources, new funding sources including matching grants, co-investment with local governments, disease surveillance and preparedness
Leverage/strengthen innovative partnerships, especially with the private sector to scale up community health services
Work toward integrating CHWs as part of the PHC multidisciplinary team and expand quality improvement mechanisms to increase CHW performance
Develop and implement innovative and digital approaches to strengthen data collection and use at the community level
Fully integrate community needs into the logistics management systems and ensure last-mile distribution of products
Strengthen referral system between communities and health posts/facilities
Sierra Leone High-level commitment at the presidential level for the UHC program; Review of PHC services completed
CHW governance structure in place; Community health investment case developed (2017)
Community health program review completed (2019); ongoing review and development of PHC model of care (2019-2020)
Free Health Care initiative with essential commodities (includes amoxicillin, oral rehydration solution-zinc)
Harmonization of CHW service delivery package, including the expansion of services to be provided by CHWs
Deployment of a large number of more than 15,000 various CHW cadres under the leadership of the government, with the support of partners
Review of the CHIS modules and integration into the DHIS2
National health financing strategies should consider CHW systems within a broader framework of financing for UHC
Mobilize domestic resource to support PHC services, including community health; Leverage/strengthen innovative partnerships, especially with the private sector to scale up community health services
Review and harmonization of the CHW profile/cadre according to recent WHO guidelines; Mapping and redeployment of CHW as per recent needs assessment and equity analyses
Work toward integrating CHWs as part of the PHC multidisciplinary team and expand quality improvement mechanisms
Better integrated community needs into national logistics management information system and strengthen local system to ensure last mile distribution of drugs
Develop digital approaches to strengthen data collection, analyses and use at the community level; roll out standard operating procedures for data quality
Establish social accountability (scorecards, observatories) and citizen engagement mechanisms with communities
Abbreviations: CHA, community health agent; CHIS, community health information system; CHW, community health worker; DHIS, district health information system; PHC, primary health care; U5MR, under-5 mortality rate; UHC, universal health coverage; WHO, World Health Organization.
- TABLE 5.
Community Health Roadmap Initiative: Selected 2020 Country Priorities to Move Forward
The Community Health Roadmap is an innovative collaboration between multilateral and bilateral donors; private funders; and global health leaders, including USAID, the World Bank, WHO, Bill & Melinda Gates Foundation, The Rockefeller Foundation, UNICEF, and Office of the WHO Ambassador for Global Strategy, to better align existing resources and to attract new resources to community health and support countries in achieving their goals for PHC, UHC, and SDG3. The Roadmap aims to elevate national priorities and create a common agenda for investments in community health to strengthen primary health care.
In West and Central Africa, 7 of 15 countries have been selected for initial inclusion in the Roadmap.
The selected 2020 key priorities to move forward with community health systems strengthening efforts are listed below.Burkina Faso Develop a clearly defined pathway to mobilize domestic resources for community health (financial gaps, potential sources of funding, and actions)
Establish sustainable mechanism for the contextualization and remuneration of CHWs with the support of local governments and community leaders
Expand community health posts as part of the PHC/UHC initiative
Central African Republic Develop a community health investment case and return on investment analysis
Review the community health policy as per 2018 WHO guidelines, taking into consideration the humanitarian-nexus development context
Establish functional community health information and supply chain systems that will sustain the community health program (integrated into the national PHC system)
Côte d'Ivoire Finalize the National Community Health Policy
Operationalize the National Strategic Plan for Community Health
Develop a clearly defined pathway to mobilize domestic resources for sustainable financing for CHW remuneration, in close collaboration with local municipalities and private sector
Develop community health standards and procedures to harmonize implementation
Demographic Republic of Congo Provide high-level advocacy to close financial gaps identified in the national community health investment case and resource mobilization plan
Improve the coverage and functionality of community care sites (e.g., for iCCM) to cover at least 50% of needs and adding at least 3,484 community care sites across the country by 2022
Strengthen managerial and resilience capacities of community outreach units to contribute to national health security priorities, taking into consideration the gender dimension
Integrate community health information system into the DHIS2
Mali Revise the community health strategic plan, in line with the 2018 WHO guidelines, taking into consideration the humanitarian-nexus development context
Support the free care-costing analysis to advocate for resource mobilization and improve equity access of the vulnerable population to quality care, in close collaboration with local municipalities and private sector
Expand the community platform model to strengthen community partnerships and leadership in the implementation of the CHW program, taking into consideration the gender dimension
Establish a functional community health information system integrated into the DHIS2, and capitalize on use of digital tools to improve program performance
Niger Develop an investment case and financing gap analysis to guide resource mobilization efforts
Conduct a detailed partner mapping to support financing and operationalization of the strategic plan
Support ongoing efforts to strengthen procurement systems to include the community dimension and eliminate parallel structures
Integrate community health information system into the DHIS2
Abbreviations: CHW, community health worker; DHIS, district health information system; iCCM, integrated community case management of childhood diseases; PHC, primary health care; UHC, universal health care; UNICEF, United Nations Children's Fund; USAID, U.S. Agency for International Development; WHO, World Health Organization.
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