Conference Summary & Action Points

1. Conference Summary & Action Points

2. Conference Overview #HealthForAll | ichc2017.org

3. Hosted by In collaboration with With support from

4. Participation 363total participants 44countries 20 priority EPCMD countries 22 country delegations 70% country level 30%global level

5. Context • Approaching the 40thanniversary of the Alma Ata Declaration adopted at the 1978 International Conference on Primary Health Care (PHC); with its goal of “Health for All,” it put PHC and community-level interventions on the global agenda • Community engagement, accountability, and resilience are key action areas to accelerate progress of the Global Strategy for Women’s, Children’s, and Adolescents’ Health • Mounting evidence for a range of community approaches for health and community-led processes of planning and implementation, such as women’s groups • Paradigm shift towards a systems approach for community health • Political commitment and financing for implementation of effective and sustainable intervention models at scale are still lacking in many countries • ICHC provided a forum to bring together stakeholders from multiple sectors to frame, debate, and build commitment for community health systems strengthening (evidence, scale, and sustainability in primary health care)

6. ICHC Areas of Focus • Sharing state-of-the-art lessons and experience • Enabling country stakeholders to share progress and identify solutions to persistent challenges • Informing national policies and plans though evidence, success, and adaptive learning • Engaging communities as dynamic resources and agents within national and local systems

7. Conference Agenda Day 1: • Community Health Systems • Implementation at Scale Day 2: • Sustainable Financing for Community Health • Multi-Stakeholder and Multi-Sectoral Partnerships Day 4: Country Planning and Learning Discussion to Action Day 3: • Equity & Accountability • Research & Innovations

8. Conference Outcomes • Advanced understanding of the opportunities and challenges for institutionalizing community health, including community health systems strengthening as an emerging concept • Learned from community health programs in diverse contexts with documented processes and impact on RMNCAH issues • Strengthened dialogue and collaboration between governments, civil society, private sector, and other development partners, to achieve results • Developed country-specific action and learning plans that country delegations will advance with a broader group of stakeholders at country level over the next year • Prioritized learning themes within and across countries to inform community health policies and programs and an emerging global learning agenda for community health systems • Agreed on 10 Critical Principles for institutionalizing community health

9. Knowledge Sharing and Action Planning #HealthForAll | ichc2017.org

10. Setting the Stage: Community Health in a Systems Perspective Why community health systems? • Shift needed from primary focus on service delivery to systems requirements for sustainability and scale • Community health systems include traditional components that may not be formally recognized in policies and strategies • Opportunity to enhance the roles and capacity of communities and local actors to collaborate in systems as agents of change • Opportunity for stronger collaboration at the community level, between communities and health systems, and among sectors for joint benefits for health with a focus on communities to drive social change and address social determinants of health

11. Setting the Stage: Community Health in a Systems Perspective Community health from a systems perspective takes into consideration the interrelationships between: • Household level caregivers • Community, community groups, and social institutions • Frontline health workers • Formal primary care systems, including supervision, supply chain, and the like • Other government sectors: housing, education, social development, agriculture, etc. • Representative local health and political structures Question for reflection: What systems changes are missing or needed in your country context? Community empowerment, defined as making people stronger and more confident to take control of their lives (agency + changes in the social environment), is essential to building resilient health systems and achieving the Sustainable Development Goals

12. Community Empowerment Drives Stronger Community Health Systems Diagram credit: UNICEF

13. Setting the Stage: Community Health in a Systems Perspective Community roles in health systems Communities are valued, essential, and empowered actors of the health system for: • Delivering services • Providing oversight for health services at all levels • Improving health literacy and advancing social norms that promote good health • Enhancing the accountability of health systems to the people they serve • Giving voice to those who are currently voiceless

14. Key Evidence for Community Interventions Strengthening and scaling up community and primary health care platforms could prevent 77% of preventable maternal, newborn, and child deaths and stillbirths 2.4 million 0.9 million 0.8 million SOURCE: Black RE, Walker N, Laxminarayan R, Temmerman M. Chapter 1: Reproductive, Maternal, Newborn, and Child Health: Key Messages of this Volume. DCP3 RMNCH 2016.

15. Key Evidence for Community Interventions Community-Based Primary Health Care (CBPHC) • Encompasses a range of interventions delivered outside facilities • Common implementation approaches included home visits, participatory women’s groups, community case management (CCM), and outreach from peripheral health facilities Key findings from the comprehensive review of CBPHC programs • Evidence that CBPHC is effective in improving MNCH is extensive • Evidence that investing in facilities alone will improve MNCH in geographically defined populations is lacking • Evidence is strong that CBPHC has a pro-equity effect and that facility use is inequitable Selected recommendations • CBPHC needs to become a more important part of health programs, the foundation of health systems strengthening, and a priority for health sector funding. • A rigorous implementation research agenda is also needed to inform the effectiveness of packages of interventions under routine conditions at scale for longer periods of time

16. Key Evidence for Community Interventions Evidence and recommendations for advancing community health systems • WHO-led Community Based Practitioner (CBP) Guidelines Review(ongoing) • Effectiveness of CBPHC in Improving Maternal, Neonatal, and Child Health Outcomes (forthcoming: 8 publications in Journal of Global Health, June 2017) • WHO-led mapping of evidence gaps for social, behavioral, and community engagement interventions for RMNCAH(forthcoming, 2017) • Synergies, strengths, and challenges: findings on community capability from a systematic health systems research literature review(2016) • WHO recommendations on health promotion interventions for maternal and newborn health 2015

17. Key Evidence for Community Interventions Additional evidence reviews • Community participation in health systems research: a systematic assessing the state of research, the nature of interventions involved, and the features of engagement with communities(2015) • Anchoring contextual analysis in health policy and system research: A narrative review of contextual factors influencing health committees in low- and middle-income countries (2015) • Examining the links between community participation and health outcomes: a review of the literature(2014) • Community accountability at peripheral health facilities: a review of the empirical literature and development of a conceptual framework(2012) • A systematic review of the literature for evidence on health facility committees in low- and middle-income countries (2012)

18. Implementation at Scale Implementation of community health policies and strategies Discussion of community health policy implementation and persisting policy issues demonstrated that countries are grappling with similar questions, including: • Evolving roles of community volunteers in mature CHW programs, with urbanization, increasing education of women, and differing needs in urban vs. rural areas (Nepal) • The need for coordination/harmonization at both national and sub-national levels in devolved contexts and quality standards focusing on functionality of community units to support rapid scale-up (Kenya) • Strengthening of community health integration into health systems and community health harmonization (CHW profile and roles, standardized retention system, behavior change communication tools, motivation system, commodities, equipment, and materials (Madagascar)

19. Implementation at Scale ) Critical CHW policy issues There are critical policy questions and challenges that countries must ask to rationalize, sustain, and scale up CHW policies and programs, including: • Classification and nomenclature • Lack of or inconsistent systems support that impedes full realization of CHW potential to contribute to the PHC context • Coordinated planning at the national and sub-national levels (e.g. motivation of volunteers, financing, etc.)

20. Implementation at Scale CHW integration: what does it mean? • Include CHWs in HRH planning • Have a budget line/resource • allocation • Clear/transparent selection system, involving and responding to needs of communities • Curriculum to include scientific • knowledgeon basic • preventative and curative • care • Adapt contents to health system needs Production/ Education Planning • Ensure supplies/ • equipment • Effective referral systems • Regular monitoring & supervision • Community preparedness • Regular and sustainable remuneration package • Opportunities for career and professional development Deployment/ Retention Performance Sources: Bhutta et al., GHWA, 2010; Kok, Dielman, et al., 2015; Campbell & Scott, 2011; Darmstadt, Lee, et al., 2009; Jaskie & Tulenko, 2012; Zulu et al., 2014; Pallas et al., 2013; McCollum, et al., 2016; Bosch-Capblanch, 2011.

21. Implementation at Scale • Defining the optimal population ratio per CHW in line with their scope of work and geographic coverage is required for institutionalizing community health systems • To achieve adequate coverage, consideration should be given to models that comprise two “tiers” of community workers – a formal full-time CHW with requisite qualifications and training and a “lower” level of part-time/voluntary operatives with fewer technical tasks and demands • CHWs and referral systems function best in an environment in which their roles are well defined and they are seen as the “first-line workers” in a well-articulated system, not “competition” for facility-based workers

22. Implementation at Scale • Determinants of successful referral, include access to facilities not being impeded by barriers (such as transport, permission from others, cultural and language differences, etc), use of a written referral slip, and the quality of referral messaging between the CHW and the client • In a facilitated referral, the CHW counsels the client on the reason for referral, fills out a written referral slip, records the referral in a register, and inquires about and addresses any barriers to following through for the client; the referral is then tracked in the HMIS, and the CHW receives counter-referral information • Key factors to consider for scale-up of community engagement and community capacity development interventions include developing solid partnerships with existing organizations at multiple levels, working with influential leaders, and strengthening systems and organizational capacity

23. “Communities can and should participate in the design of interventions, assure timely implementation, and contribute to CHW supervision and motivation.” “Integration of community health into the national health system requires political will and is cost effective.” “Community health is broader than CHW programs focused on service delivery.”

24. Sustainable Financing • Strengthening community health systems can be cost-effective and is a smart investment in social capital and human resources, but it is not cheap • Financing remains one of the biggest challenges for countries as they scale up community health and transition from donor dependency to greater government ownership • Countries had many questions and comments about private sector financing models for CHWs; better understanding of these models and opportunities is needed

25. Sustainable Financing • Investing $1 in CHWs can return up to $10 in the long-term (productivity, insurance, employment). A high return on investment (ROI) (10:1) can only be achieved in high-performing systems. This ROI focuses on CHWs and does not include other components of the community health system and therefore could be higher. • Making a case for community health systems will become increasingly important, and all CHS costing and investment plans have to be done in full alignment with the total health system and national strategies as subsets rather than standalones • More attention is needed on finance levels and mechanisms as well as effective processes focusing on political advocacy and consensus building within ministries around “best buys” • Community health can be included as a priority in Global Financing Facility (GFF) investment cases, and World Bank country offices can provide additional support

26. Sustainable Financing • Countries expressed the need for MOH capacity-building to develop costed investment plans for resource advocacy • There is interest in calculating cost savings from CHW programs to advocate for funding • Toolsexist for community health planning and costing that can help determine the cost of community health packages in order to: • Prepare investment cases • Compare cost-effectiveness of community- vs. facility-based services • Plan and prioritize services within the likely funding envelope • Prepare detailed budgets

27. Multi-Stakeholder and Multi-Sectoral Partnerships • Multi-stakeholder and multi-sectoral partnerships that are inclusive and data-driven are essential for achieving effective coverage at scale in global and national acceleration plans in health and country-led community health systems strengthening agendas • Partnerships should encompass a range of actors, including representatives of governments, civil society, local and international NGOs, academia, professional associations, media, private sector, and underserved populations themselves, with clearly defined roles to improve equitable outcomes and promote mutual accountability • Partnerships should leverage expertise and resources from communities and partners from other relevant sectors (e.g. agriculture, education, youth) in a coordinated manner • Who has a seat at the table and how that is determined requires attention • Capacity building of local partners to participate and collaborate is needed to amplify the voice of communities in policies and systems

28. Multi-Stakeholder and Multi-Sectoral Partnerships • Partnerships are most effective when responding to national leadership and supporting activities harmonized within national strategies • Government stewardship should support dialogue around roles and coordination of efforts to improve sustainability and scale • New thinking about inclusive partnerships is needed in the SDG era as countries grapple with decreasing donor resources; governments will increasingly need to leverage partner (civil society, private sector) and community expertise and resources to harmonize action and learning • Greater emphasis is needed on harmonizing partners at national and sub-national levels and building evidence for inclusive partnership models • Successful models of multi-stakeholder and multi-sector partnerships shared at the ICHC provide insights for improving delivery, demand, and accountability in the community health systems context

29. Multi-Stakeholder and Multi-Sectoral Partnerships • Country-level partnerships for community health systems include BRAC, Living Goods, Aspen Management for Health, Integrating Community Health, SHOPS, WRA, CORE Polio, Restless Development, Digital Green/SPRING, and N’Weti • Evidence and scale for partnership models varies, and it is important to ensure that documentation and learning focusing on partnerships are included in the learning agenda for community health systems, with clearly delineated partner roles and measures of successes as well as “failures” • A roadmap for partnerships that engages partners, including civil society and the private sector, at the outset to clarify, harmonize, and build ownership around roles and contributions is critical

30. “To achieve universal health coverage, community health systems need to be strengthened and should be integrated in to health plans and financed as an integral part of country health systems.” “Sustainability of CHWs cannot be achieved with government alone. It will require looking at resources within the country to create partnerships with the private sector.” “Community health is cost-effective but not cheap.” “If we want to give voice to local organizations, we need to build their capacity and press for their participation.”

31. Equity and Accountability • EQUIST is a data-driven tool that helps policymakers and managers identify equitable strategies to save lives and reduce health inequities, including partnering with communities to optimize available resources • Community empowerment is a critical process for improved equity and accountability • Creates environments where the powerless have the opportunity to gain skills, knowledge, and confidence to make choices about their own lives • Gender-transformative approaches can lead to: • Better community health programming and service provision • Equitable leadership and governance • More effective health promotion and prevention • Empowered communities • Better health outcomes • Providing opportunities to women for training as CHWs/CHVs and space to discuss issues together can be emancipating – but social norms that underpin division of labor at home and gender equality more broadly also need addressing • Compensation and incentives (a source of debate among countries for CHWs in general) may perpetuate gender inequality if not aligned with the demands of the CHW/volunteer role

32. Equity and Accountability • Key principles of social accountability approaches • Build the capacity of community members to understand their rights, how to collect data and evidence, and how to organize and demand action effectively • Address underlying power dynamics • Empower governments to take corrective action • Country experiences with social accountability approaches included among others • Citizen use of cameras to show lack of health center commodities and disrespect from facility staff • Community scorecards • National task force on social accountability to bring together key stakeholders, including district and national governments, to explore how social accountability can improve RMNCH services and outcomes • Evidence from conflict and fragile settings shows that CHWs can continue providing services and access displaced and hard-to-reach populations

33. Research, Innovations, and M&E • Approaches to community capacity development include • Focusing primarily on developing the capacity of communities to work together effectively (e.g., strengthening leadership, management, governance, resource mobilization, etc.) • Focusing primarily on developing technical knowledge and skills (e.g., health practices, service delivery, etc.) • A combination of the two approaches to achieve a particular goal (e.g., reduce maternal and newborn mortality, improve nutritional status, etc.) • Countries (e.g., Tanzania) are taking advantage of high coverage of child immunization to integrate and scale up birth registration • Birth registration is a critical piece of information for assessing the reach of health programming • Mobile technology is useful for data collection as well as clinical decision support, supervision, and health promotion • Need to work on sustainable, interoperable systems that integrate into the overall health system

34. Research, Innovations, and M&E • One comprehensive health information system and budget, including community health, is needed to avoid fragmentation • Lack of measuring and reporting what happens at community level impedes advocacy for community health • Community health M&E systems that are sustainable at scale within country health systems have indicators that: • Are small in number • Cover service delivery, strength of community platforms, and competencies needed for sustainably delivering community-based interventions • Real-time implementation research, monitoring, evaluation, and learning are needed to identify, sustain, and scale up effective community interventions with a practical focus on how to: • Adapt and support proven community interventions to fit context, sustain, and scale up effective approaches for engaging and empowering communities in diverse systems • Improve coverage, quality, and equity of community health services at scale • Implementation research saves money in the long-term, should be budgeted, and should not substitute for M&E resources

35. “We need to be realistic about what paid and volunteer CHWs can actually physically do and not expect too much from them, which only leads to unsustainable and poor quality programming.” “More evidence is needed on the impact and delivery of community health interventions in emergencies and fragile settings.”

36. Country Planning and Learning Example country action and learning plan • Develop a harmonized, government-led implementation framework for community health • Develop an investment case for community health systems, clearly mapping resources and resource gaps • Develop an advocacy and communication strategy for community health with a focus on a community health worker strategy • Finalize key tools for a sustainable program • Receive approval from the relevant government ministries • Submit the policy to the cabinet • Evaluate community health programs at the county level to determine why some counties have more effective implementation than others Countries submitted detailed action and learning plans for the 12 months following the conference that will inform dialogue with countries post-ICHC

37. Country Planning and Learning Country-to-country learning • Many dimensions to community-level programs • Individual countries may be well advanced along one dimension, yet have considerable work remaining to do along another dimension • Enabled country delegations to approach other country delegations to learn from their successes • Uganda and Rwanda teams met to exchange lessons learned with their respective systems • Allowed sharing of experiences and lessons among countries that normally have only limited contact • Among English-, French-, and Portuguese-speaking African countries • Among Africa, Asia, and the Caribbean

38. Country Planning and Learning Illustrative knowledge gaps from evidence reviews to inform learning agendas • Lack of evidence of comprehensive CBPHC at scale for longer period of time (5 or more years) • CHW roles and performance; cost-effectiveness of CHWs; adaptation of lessons from low-and middle-income countries to high-income countries • Cross-cutting enabling factors for CHWs (education, accreditation and regulation, management and supervision, effective linkage to professional cadres, motivation and remuneration, and provision of essential drugs and commodities) • How to ensure the sustainability of CHW programs through national planning, governance, legal, and financial mechanisms

39. Country Planning and Learning Illustrative knowledge gaps from evidence reviews to inform learning agendas (cont.) • Effective indicators of community health system interface • Community participation and its role in holding services accountable • Sustainability, cost, and scale of community participation • Gender dynamics in community participation • Measuring changes in community capacity and links to health outcomes • Community participation and its role in holding services accountable • Evidence gap map review and prioritized research agenda forthcoming from a WHO-led process focusing on social and behavioral and community-engagement interventions

40. “This country commits to maintaining the country delegation to serve as advisory group on community health to the MOH.” “We will review the existing CHW strategy to align it with lessons learned from ICHC and ensure it takes a community health systems approach.” “With a view to strong community involvement in achieving the Sustainable Development Goals, this country is committed to an integrated community health system with strong leadership.”

41. Extending the Reach of the Conference #HealthForAll | ichc2017.org

42. Communications and Knowledge Management • Expanded the reach of the conference via online engagement • Leveraged the partnership of co-hosts, collaborators, and potential sponsors and their various communications platforms • Targeted media engagement at local levels to further communicate the importance of community health issues discussed • Captured the knowledge and learning from the conference to make available on the conference website • Building on post-ICHC conferences and meetings to further elevate conference outcomes and the importance of community health

43. Blog Series Website • 27 blogs • 16 organization represented • Blogs featured on The Huffington Post, ICHC website, and MCSP’s website • http://www.ichc2017.org/ • Find conference resources, including livestreamed videos, blogs, presentations, the conference program, and social media links Social Media Livestream • 10 sessions (25 hours) livestreamed • Over 500 views and 15,000 minutes watched • Viewed in 35 countries with viewing parties in 7 countries • Reach: 3,415,599 • Impressions: 9,432,785 • Tweets: 1,631 • Contributors: 636 • #HealthForAll trended on Twitter

44. Looking Forward   • Community of practice for those working in community health to continue the conversation • Implementation of country action plans • Dissemination of the conference principles (presentation, short version, long version) • Present and discuss results at upcoming conferences

45. #HealthForAll ichc2017.org

46. Additional Slides for Reference

47. Community Health Systems Defined • “A community health system is a set of local actors, relationships, and processes engaged in producing, advocating for, and supporting health in communities and households outside of, but existing in relationship to, formal health structures.” • The local actors in this system who engage in health action include some or all of the following (context specific): • Household level caregivers • The array of formal, volunteer, and informal health providers working in communities • Organizational intermediaries: nongovernmental organizations and other forms (religious, sport, youth, etc.) of associational life; workplaces • Other government sectors: housing, education, social development, etc. • Representative local health and political structures”

48. USAID Community Health System Framework Link to Framework Here!

49. The Community Health System Strengthening Model Example of a model for community health system strengthening