Going Universal: How 24 countries are implementing universal health coverage reforms from the bottom up

This World Bank Group book is an overview of how 24 developing countries have embarked on the long journey to Universal Health Coverage (UHC). This Universal Health Coverage Study Series (UNICO) offers knowledge and operational tools to help countries tackle UHC in ways that are fiscally sustainable and that enhance equity and efficiency, by providing examples and lessons learnt from the UNICO countries (individual case studies may be accessed at http://www.worldbank.org/en/topic/health/publication/universal-health-coverage-study-series). In these countries, which together represent one third of the world’s population, efforts to achieve UHC have mainly focused on fiscal expansion, accountability, and community health workers. The study finds that most of these countries, except for success stories such as Costa Rica and Thailand, are still struggling with establishing functional integrated care networks. However, the report recommends that developing countries should continue to empower their primary sector as gatekeepers ...

People-centred health systems, a bottom-up approach: where theory meets empery

BACKGROUND AND METHODS:

Health systems are complex and constantly adapt to changing demands. These complex-adaptive characteristics are rarely considered in the current bureaucratic top-down approaches to health system reforms aimed to constrain demand and expenditure growth. The economic focus fails to address the needs of patients, providers and communities, and ultimately results in declining effectiveness and efficiency of the health care system as well as the health of the wider community. A needs-focused complex-adaptive health system can be represented by the 'healthcare vortex' model; how to build a needs-focused complex-adaptive health system is illustrated by Eastern Deanery AIDS Relief Program approaches in the poor neighbourhoods of Nairobi, Kenya.

FINDINGS AND CONCLUSIONS:

A small group of nurses and community health workers focused on the care of terminally ill HIV/AIDS patients. This work identified additional problems: tuberculosis (TB) was underdiagnosed and undertreated, a local TB-technician was trained to run a local ...

How can health and social care work together effectively?

Let´s consider what an integrated health and social care system might look like. Should the cultural differences between health and social care be preserved within a closer partnership? And what role can technology play in bringing together services that have traditionally worked in parallel? 

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Costs of implementing integrated community case management (iCCM) in six African countries: implications for sustainability

Sub-Saharan Africa still reports the highest rates of under-five mortality. Low cost, high impact interventions exist, however poor access remains a challenge. Integrated community case management (iCCM) was introduce to improve access to essential services for children 2-59 months through diagnosis, treatment and referral services by community health workers for malaria, pneumonia and diarrhea. 

This paper presents the results of an economic analysis of iCCM implementation in regions supported by UNICEF in six countries and assesses country-level sclae-up implications. The paper focuses on costs to provider (healht system andd donors) to inform planning and budgeting, and does not cover cost-effectiveness. 

Perceived mHealth barriers and benefits for home-based HIV testing and counseling and other care: Qualitative findings from health officials, community health workers, and persons living with HIV in South Africa

mHealth has been proposed to address inefficiencies in the current South African healthcare system, including home-based HIV testing and counseling (HTC) programs. Yet wide-scale adoption of mHealth has not occurred. Even as infrastructure barriers decrease, a need to better understand perceived adoption barriers by skateholders remains. 

Utilization of community-based health planning and services compounds in the Kintampo North Municipality: a cross-sectional descriptive correlational study

The Community-based Health Planning and Services (CHPS) initiative was introduced to improve coverage and utilization of basic health services for people in remote rural communities whose use of orthodox health services was hitherto limited by distance. So the objectives of this study were to examine the extent of patronage of CHPS compounds in the Kintampo North Municipality , factors associated with their use and challenges faced by community members regarding the use of these facilities. 

The effect of community health worker–led education on women’s health and treatment– seeking: A cluster randomised trial and nested process evaluation in Gujarat, India

A community-based health insurance scheme operated by the Self-Employed Women´s Association in Gujarat, India reported that the leading reasons for inpatient hospitalisation claims by its members were diarrhoea, fever and hysterectomy- the latter at the average age of 37. This claims pattern raised concern regarding potentially unnecessary hospitalisation amongst low-income women. 

Integrating Community Health Workers Into Medical Homes

Though evidence supports the value of community health workers (CHWs) in chronic disease self-management support, and authorities have called for expanding their roles within patient-centered medical homes (PCMSs), few PCMHs in Minnesota have incorporated these health workers into their care teams. They undertook a qualitative study to (1) identify facilitators and barriers to utilizing a CHW model among PCMHs in Minnesota, and (2) define roles played by this workforce within the PCMH team

Increasing advance personal planning: the need for action at the community level

Advance personal planning is the process by which people consider, document and communicate their preferences for personal, financial and health matters in case they lose the ability to make decisions or express their wishes in the future.

There is a need for rigorous evidence to demonstrate wheter a community action approach is effective in estabilishing whole community adoption of advance personal planning. 

Developing and deploying a community healthcare worker-driven, digitally- enabled integrated care system for municipalities in rural Nepal

Integrating care at the home and facility level is a critical yet neglected function of healthcare delivery systems. There are few examples in practice or in the academic literature of affordable, digitally-enabled integrated care approaches embedded within healthcare delivery systems in low- and middle-income countries. Simultaneous advances in affordable digital technologies and community healthcare workers offer an opportunity to address this challenge. This article describe the development of an integrated care system involving community healthcare worker networks that utilize a home-to-facility electronic health record platform for rural municipalities in Nepal.

Scaling community-based services in Gauteng, South Africa: A comparison of three workforce-planning scenarios

The introduction of community-based services through community health workers is an opportunity to redefine the approach and practice of primary health care. Based on bestpractice community oriented primary care (COPC), a COPC planning toolkit has been developed to model the creation of a community-based tier in an integrated district health system

Community-based integrated approach to changing women's family planning behaviour in Pakistan, 2014–2016

Pakistan is currently experiencing a clear imbalance in population needs and available resources. Although contraceptive use increased from 11.9% in 1990 to 35% in 2013 and the fertility rate declined from 5.4 births per woman in 1990 to 3.8 in 2013, women in Pakistan still report a high unmet need for family planning services, of −20%. This indicates that contraceptive use in Pakistan is at suboptimal levels and inadequate to meet the growing demand for fertility services. So the aim of this study was to assess the effectiveness of a community-based integrated approach in changing women's behaviour regarding contraceptive use

Implementation and clinical effectiveness of a community-based non-communicable disease treatment programme in rural Mexico: a difference-in-differences analysis

Non-communicable diseases (NCDs) account for the five largest contributors to burden of disease in Mexico, with diabetes representing the greatest contributor. However, evidence supporting chronic disease programmes in Mexico is limited, especially in rural communities. Compañeros En Salud (CES) partnered with the Secretariat of Health of Chiapas, Mexico to implement a novel community-based NCD treatment programme. This article describe the implementation of this programme and conducted a population-based, retrospective analysis, using a difference-in-differences regression approach to estimate the impact of the programme

Community health workers and accountability: reflections from an international “think-in”

Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and expected to enhance or embody health system accountability. During a ‘think in’, held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger “accountability ecosystem.” While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs’ social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. To that end, this study put forward several propositions for further conceptual development ...

Community Health Worker Programs to Improve Healthcare Access and Equity: Are They Only Relevant to Low- and Middle-Income Countries?

Community Health Workers (CHWs) are proven to be highly effective in low- and middle-income countries with many examples of successful large-scale programs. There is growing interest in deploying CHW programs in high-income countries to address inequity in healthcare access and outcomes amongst population groups facing disadvantage. This study is the first that examines the scope and potential value of CHW programs in Australia and the challenges involved in integrating CHWs into the health system. The potential for CHWs to improve health equity is explored.

Universal health coverage necessitates a system approach: an analysis of Community-based Health Planning and Services (CHPS) initiative in Ghana

The 9th Global conference on health promotion (Shanghai 2016) reaffirmed the role of primary health care (PHC) in achieving the 2030 Sustainable Development Agenda. Gaining much international recognition, the community-based health planning and services (CHPS) initiative is considered one of the pragmatic strategy in delivering on the promise of universal health coverage (UHC) through the PHC strategy, in Ghana. Yet, certain key factors threaten its successes – renewing the relevance of this study to present the barriers to and facilitators of the initiative. According to their findings, CHPS contribution particularly in bridging geographical access to health cannot be demeaned. Nevertheless, the full functioning of the initiative is limited by factors centered on the following themes: health governance and leadership, provision of services of quality, financial risk protection strategies targeting public health, information and care continuity, and the right mix of trained health professionals of even distribution across communities. Addressing the challenges ...

Does supportive supervision enhance community health worker motivation? A mixed-methods study in four African countries

Supportive supervision is an important element of community health worker (CHW) programmes and is believed to improve CHW motivation and performance. A group supervision intervention, which included training and mentorship of supervisors, was implemented in Ethiopia, Kenya, Malawi and Mozambique. In three of the countries, this was combined with individual and/or peer supervision. A mixed-methods implementation study was conducted to assess the effect of the supervision intervention on CHWs’ perceptions of supervision and CHW motivation-related outcomes. The study suggests that there is potential for integrating supportive group supervision models in CHW programmes. A combination of group with individual or peer supervision, preferably accompanied with methods that assess CHW performance and corresponding feedback systems, could yield improved motivation and performance.

The Governance of National Community Health Worker Programmes in Low- and Middle-Income Countries: An Empirically Based Framework of Governance Principles, Purposes and Tasks

National community health worker (CHW) programmes are increasingly regarded as an integral component of primary healthcare (PHC) in low- and middle-income countries (LMICs). At the interface of the formal health system and communities, CHW programmes evolve in context specific ways, with unique cadres and a variety of vertical and horizontal relationships. These programmes need to be appropriately governed if they are to succeed, yet there is little evidence or guidance on what this entails in practice. Based on empirical observations of South Africa’s community-based health sector and informed by theoretical insights on governance, this paper proposes a practical framework for the design and strengthening of CHW programme governance at scale.

Evaluating a Community-Placed and Clinically Integrated Community Health Worker Program

Community health worker (CHW) programs can act as bridges between patients and health care teams, but the complexity and variability of program components and outcomes make them difficult to evaluate. This evaluation used a realist approach to identify underlying mechanisms and contextual factors associated with successful implementation of a community-placed CHW program affiliated with a primary care practice in the Midwest United States. The analysis identified mechanisms by which stakeholders built trust, self-efficacy, and empowerment to improve patient-centered outcomes and experiences.

Community health extension program of Ethiopia, 2003–2018: successes and challenges toward universal coverage for primary healthcare services

The Alma-Ata Declaration of 1978 identified primary health care (PHC) as the key approach to the attainment of the goal of “Health for All”. The PHC approach tackles the main health problems in the community through the provision of essential health services. The implementation of the PHC approach relies on health workers, including community health workers (CHWs) Ethiopia has been implementing a community health extension program (HEP) since 2003. The aim of this studya was to assess the successes and challenges of the HEP over time, and develop a framework that may assist the implementation of the program toward universal primary healthcare services

Integrated care for older people (ICOPE): guidance for person-centred assessment and pathways in primary care

The ICOPE guidance for person-centred assessment and pathways in primary care (ICOPE Handbook) helps community health and care workers put the recommendations outlined in the ICOPE Guidelines into practice. The Handbook assists with setting person-centred goals, screening for loss in a range of domains of intrinsic capacity and assessing health and social care needs to develop a personalised care plan. The care plan may include multiple interventions to manage declines in intrinsic capacity, provide social care and support, support self-management and support caregivers. The domains of intrinsic capacity include cognitive decline, limited mobility, malnutrition, visual impairment, hearing loss and depressive symptoms.

Community Health Workers Improve Linkage to Hypertension Care in Western Kenya

Elevated blood pressure (BP) is the leading global risk factor for mortality. Delay in seeking hypertension care is associated with increased mortality.

The aim of this study investigated whether community health workers, equipped with behavioral communication strategies and smartphone technology, can increase linkage of individuals with elevated BP to a hypertension care program in western Kenya and significantly reduce BP.

End-line Assessment of Integrated People-Centered Health Services in Nelson Mandela Metro Municipality, Eastern Cape Province, South Africa

Since 2013, the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project has been working closely with the South African Department of Health (DOH) and its partners in five provinces to accelerate the reduction of morbidity and mortality through improving access, utilization, and satisfaction with essential HIV services. Drawing on its partnership with the World Health Organization (WHO) Service Delivery and Safety Department to promote people-centered care as an essential pillar of health service quality, ASSIST secured support from the USAID Office of Health Systems to pilot WHO’s global framework on integrated people-centered health services (IPCHS) in the Nelson Mandela Metropolitan District in Eastern Cape Province.

The pilot project consisted of a baseline assessment to harvest patient, provider, and decision maker perceptions and satisfaction regarding integration and patient centeredness in HIV services at onset of the project; training in quality improvement and IPCHS concepts and methodology; facility-based identification ...

Building a Thriving Primary Health Care System: The story of Costa Rica

Situated in Central America, Costa Rica’s 4.9 million citizens have access to one of the most effective primary health care systems in the world. The country’s unique, team-based model of primary care service delivery successfully combines preventive and curative care to provide comprehensive primary health care to nearly all Costa Rican citizens. This case study examines the process by which Costa Rica developed its laudable primary health care system, fully describes the functioning of the system through both clinical and patient perspectives, and elucidates key lessons about primary health care delivery that can be learned from the Costa Rican experience.

Collaboration for Impact: Co-creating a Workforce Development Toolkit Using an Arts-based Approach

The identification, communication and management of health risk is a core task of Community Health Workers who operate at the boundaries of community and primary care, often through not-for-profit community interest companies. However, there are few opportunities or resources for workforce development. Publicly funded researchers have an obligation to be useful to the public and furthermore, university funding is increasingly contingent on demonstrating the social impact of academic research. Collaborative work with participants and other stakeholders can have reciprocal benefits to all but may be daunting to some researchers, unused to such approaches.

The context, strategy and performance of the American safety net primary care providers: a systematic review

The objective of this research is to synthesize evidence on the relationship between context, strategies and performance in the context of federally qualified health centers (FQHCs), a core safety net health services provider in the United States. The research also identifies prior approaches to measure contextual factors, FQHC strategy and performance. Gaps in the research are identified, and directions for future research are provided.

Connecting communities to primary care: a qualitative study on the roles, motivations and lived experiences of community health workers in the Philippines

Community health workers (CHWs) are an important cadre of the primary health care (PHC) workforce in many low- and middle-income countries (LMICs). The Philippines was an early adopter of the CHW model for the delivery of PHC. This study aims to address this gap by examining the lived experiences and roles of BHWs in urban and rural sites in the Philippines.

A mixed-methods evaluation of the impact of a person-centered family planning intervention for community health workers on family planning outcomes in India

Person-centered quality for family planning has been gaining increased attention, yet few interventions have focused on this, or measured associations between person-centered quality for family planning and family planning outcomes (uptake, continuation, etc.). In India, the first point of contact for family planning is often the community health care worker, in this case, Accredited Social Health Activists (ASHAs).

Overcoming barriers to maternal and newborn care through integrated facility and community-based services

There has been growing interest and experience of community health workers (CHWs) in recent years, especially with the goal of Universal Health Coverage. Typically, the CHWs have provided combinations of health promotion messages, treatment of childhood illnesses, malaria-control measures, nutrition interventions, family planning, and screening and supervised treatment for HIV and TB. Many CHW programs function semi-autonomously with supplies and supervision coming with varying regularity from health facilities.

For many years, this community-based health care approach included the training of traditional birth attendants (TBAs). TBAs were, for the most part, given short training courses and sent back to their communities with little or no continuing connection with health facilities. The approach was halted twenty years ago when it became clear that trained TBAs were not making any impact on maternal and newborn deaths from complications of pregnancy and childbirth. A Skilled Birth Attendant (SBA) policy, to train and deploy greater ...

Strengthening the role of community health workers in supporting the recovery of ill, undernourished children post hospital discharge: qualitative insights from key stakeholders in Bangladesh and Kenya

Undernourished children in low- and middle-income countries remain at elevated risk of death following hospital discharge, even when treated during hospitalisation using World Health Organisation recommended guidelines. The role of community health workers (CHWs) in supporting post-discharge recovery to improve outcomes has not been adequately explored.

Transforming health care: stories of changemakers across the world

This film weaves together and amplifies the stories from individuals and groups intentionally leading change, wherever they are situated in their respective ‘system’. It reveals some of the many ways that these changemakers have managed to significantly impact their health care environments and improve health outcomes, often through relatively small, local interventions. Their experiences span subjects such as improving patient safety and reducing patient harm; preventing the death of newborns through a model that places parents at the centre of specialized care; transforming mental health programming; addressing the root causes of teenage suicide; saving the lives of babies born with anomalies; or promoting community health and introducing compassion in health leadership. 

 Why transformative approaches in health care?

The COVID-19 pandemic has revealed the challenging, stressful and highly complex environments that staff working in health and social care must navigate. Health systems are a microcosm of the societies ...

The role of community health workers in palliative care in a rural subdistrict in South Africa