The last must become the first: key insights from the Institutionalizing Community Health Conference

Community health programmes are neither cheap nor easy to implement well, but they remain a good and wise investment that can yield important dividends. The latest evidence shows that for every dollar invested in community health there is a 10 dollar return of good health and productivity (Dahn B 2015). Current pressures on health systems in low- and middle-income countries (LMICs) and the difficulties in responding adequately, especially during this COVID-19 pandemic, have overwhelmingly shown the critical importance of the community health system. The second Institutionalizing Community Health Conference (ICHC) that took place between 19-22 April 2021, brought us up-to-date with the gains that have been made in community health systems, the investments currently in place, the gaps that still exist and the investment priorities for low resource and hard-to-reach settings.

Below are some notes and reflections from my participation in the conference.

Remuneration of Community Health Workers (CHWs):  Many LMICs continue to endorse community health strategies, however, with the majority of CHWs working as volunteers, this has raised questions, both about their remuneration and about their professionalisation. Different examples of models that have been put in place to remunerate and to value community work were presented by Ministry of Health representatives from; Afghanistan, Ethiopia, Kenya, Malawi, Pakistan, Liberia, Rwanda, and Uganda. Ministers reinforced the importance and investments in place to include CHWs on the payroll and to professionalize CHWs status. As the majority of CHWs are women, a call to action was made to abolish the gender pay gap, which also recognises that women are generally not only primary health care workers, but also primary caregivers in their families and communities.

Community health must be inclusive: The best place for multisectoral integration is in the household, where we do not think in sectors. Communities need to be the central unit for health. The conference identified that young people and people with disabilities are often left out, but in fact often want to be included in the planning, implementation, and subsequent improvements in community health. Community scorecards, which are community-based social accountability tools that are citizen-driven for the assessment, planning, monitoring, and evaluation of public services, were mentioned to be helpful in tracking this progress.

Digital technology that honours community contexts and builds for and with community health workers: Digital health offers an opportunity to build an ‘intelligent’ health system and can be used for social accountability. It requires the creation of digital solutions with the users in mind, and it positions CHWs at the centre. The country-level best practices presentations from Mali, Uganda and India described how governments are embedding digital technologies within their national health systems.

Sustainable financing beyond the budget of the health ministry: It is not just about sums of money required; adequate financing of community health is a political choice and requires political will, planning and coordination. Successful examples of major scale-up of community health initiatives were presented from Ethiopia’s Health Extension Programme and Pakistan’s Lady Health Workers programme, along with a description of Kenya’s ‘County Community Health Services Bill’ that was passed in subnational parliaments and that provides legal recognition and regulation of community health services. In addition, these countries demonstrated how their leadership are investing domestic resources for the improved health of their people. The ministerial roundtable sessions stressed that governments must commit to primary health care, both in political will and in resources. This session also reinforced that subnational budgets must be structured so that the majority of funds are spent on preventive health care at community level.

So, what did I learn from this conference? As my work is largely focussed on nutrition and the integration of nutrition services within primary health care, the ICHC 2021 helped me to reflect on our collective ability to reach and treat wasted children and to prevent the problem arising in the first place. Both the recent international community management of acute malnutrition, CMAM@20 international conference on the scale up of wasting services and ENN’s report on scale-up of severe wasting management within the health system highlighted the need to revive the community health aspect - putting the ‘C’ back in CMAM. Identification of the critical tasks of generating sufficient financing and high-level commitment while reducing fragmentation and increasing the use of existing opportunities within the health system was also called for by this conference. The ICHC 2.0 approaches and models that were described, including the commitments for institutionalizing and financing community health as part of primary health care, offer avenues to advance some of the adaptations to CMAM programming, such as the family mid-upper-arm circumference (MUAC) and the task-shifting to CHW-led early identification and treatment of wasting. These simplified approaches have been explored as possible scalable community-based solutions, which require more testing and then endorsement by relevant Ministries of Health. They will then require major increases in funding to bring them to scale.  It could be a smart move to consider framing their design, costing and investment priorities around the respective governments and global financing architecture for primary health care and community health, along with the Community Health Roadmap initiative - a global innovative collaboration between traditional multilateral and bilateral donors, private funders and global health leaders, to better align existing resources and to attract new resources to community health and support countries in achieving their goals for primary health care, universal health care (UHC) and sustainable development goal 3 "Good Health and Well-being". This could well require planning and operationalisation for severe wasting services to be accounted for by government-led primary child health programmes, rather than siloed nutrition activities, which could potentially considerably improve the sustainability of wasting financing and services.

In summary, I found the optics of this conference refreshing. Government’s senior leadership took centre stage in each of the specific sessions and plenary sessions. The dedicated sessions for the ministerial roundtable session and investment round table (though an invitation only session) was a great way to focus the outcomes of an international conference like this to governments as duty bearers. In addition, the dedicated session for the ‘Women’s Storytelling Salon’ brought a fresh vibe to the conference, bringing the narrative around women and the work force to life. The stories illustrated positive examples of strong women leaders and their determination to bring primary health care to their countries.

For more information, all session recordings and materials in English and French continue to be accessible on the ICHC conference platform. For a virtual poster hall style space for technical guidance materials, technical tools or resources, peer-reviewed research, new and emerging evidence, and innovations, check out the events page here Events | ICHC 2021 (conference.tc).