COMMUNITY SYSTEMS STRENGTHENING Keynote address by PROF MIRIAM K. WERE ON THE OCCASION OF THE AMREF HEALTH AFRICA INTERNATIONAL CONFERENCE, 2014 NAIROBI, KENYA 24 th – 26 th NOVEMBER,

1.CENTRALITY OF COMMUNITIES IN THE WORK OF AMREF HEALTH AFRICA AMREF AFRICA’s 10 year strategy is entitled: “PUTTING AFRICAN COMMUNITIES FIRST: ENHANCING CAPACITY AND PARTICIPATION TO CLOSE THE GAP IN HEALTH SYSTEMS.”  The first point I want to make is to congratulate AMREF for recognizing the importance of communities in health promotion, prevention of disease and in health services delivery since the 1970’s  These congratulations are doubled by the increasing focus on communities in the first three year business plan (2010 – 2014) and in the second one (March 2014 – Feb 2018) 2

1.2 Vision Healthy people living good quality lives in robust and vibrant communities that make up healthy and vibrant Counties all over the nation resulting in a healthy Nation overall. 3

1.3 Mission To promote the Community health approach as the modality for social transformation for development from the community level by establishing equitable, effective and efficient Community Health Services in Community Health Units all over a nation. 4

2. WHY IS THE COMMUNITY APPROACH SO IMPORTANT FOR AFRICA? If it doesn’t happen in the community, it just doesn't happen! If it happens in the communities it happens in the nation. 5

6 Specifically the community approach is crucial because:- 2.1It brings health services closer to mothers and children who are the most vulnerable and who need them the most. 2.2 Communicable disease reduction from community based action e.g. construction and use of latrines, participation in immunisation and community based first line care reduces the disease burden 2.3Better management & prevention of non- communicable diseases and their reduction takes place through Community Dialogue Days that leads to internalization of how non-communicable diseases can be prevented through appropriate lifestyles that get adopted by the community which is much stronger than individuals changing alone.

2.6Improved quality of care at health facilities-–especially for non communicable/chronic diseases-- as decongestion occurs at health facilities both in outpatient and inpatient services. 2.7Containment & even reduction of financial cost to health sector from reduced and reducing disease burden because of disease prevention and health promotion through empowered communities as well as more effective and efficient organisation of health services aided by decongestion of health facilities Adoption of community norms that promote health and prevent disease occur from participation in monthly Community Dialogue Days/Events and quarterly Community Action Days/Events. 2.5 Possibility is enhanced for achieving universal health coverage through establishment of Community Health Services since coverage with health services at facilities alone is still less than 50% in most of Africa.

3. COMMUNITY SYSTEMS STRENGTHENING 3.1 First crucial step in Community Health Systems Strengthening is Formal recognition of the community level as part of the national health system e.g. 1.Ethiopia’s Health Extension Program (HEP) 2.Ghana’s Community-Based Health Planning & Services (CHPS) 3.Kenya’s Community Health Strategy/Services (CHS) 8

9 3.2 Deliberate commitment to Processes for peoples’ participation, involvement and Empowerment through:-  Establishing/Strengthening structures to facilitate this;  Deliberate hope &confidence building process;  Sharing in decision-making including what the people see as their priority health problems  Raising awareness on the social and physical determinants of health that must also be addressed.

3.3 Having clarity on the Key Steps In Establishing Community-level Health Work: 1)Financing of Community Health Services; 2)Clarity on what constitutes a Community Health Unit; 3)Clarity on who provides Community Leadership & Governance 4)Clarity on mechanism of motivation and retention of the Community Health workforce 5)Recruitment and Training of Community Health Workforce; 10

11 6.The Community Entry Process &clarification of interaction between health workforce and the Community Health Unit; 7.Clarity on mechanisms for strengthening the Interface/Linkage of the Community Level with Health Facilities; 8.Clarity on mechanisms for supportive supervision for Community Based Health Services; 9.Monitoring and evaluation for Community Health Services: 10.Partnership in support of Community Health Services ; 11.Role of Multi-Sectoral Approach in Advocacy and Communication; 12.High Impact Interventions for Community Health Services.

3.4 The WHO Framework for the Community Health System 12

4. COMPONENTS OF COMMUNITY HEALTH SYSTEMS STRENGTHENING. The six building blocks for health systems strengthening can be applied to the community level as a means of gaining clarity in what needs to be strengthened. THE BUILDING BLOCKEXAMPLES ISSUES TO BE ADDRESSED IN STRENGTHENING 1. Community level Leadership/Governance Community Health Committees Specifics of:-  Roles & responsibilities  Criteria for selection  Training modules 2. Community Level Health Workforce  Ethiopia’s Health Extension Workers (HEW)  Ghana’s Community Health Officer (CHO)  Kenya’s Community Health Assistant (CHA)  Roles and responsibilities  Basis for selection for training  Training curriculum  Volunteers to work with the health workers & their training 13

THE BUILDING BLOCKEXAMPLES ISSUES TO BE ADDRESSED IN STRENGTHENING 3. a) Information Community health information tools  What information is to be collected  How to be collected  How to be used b) Research Determination of workload for community health personnel. 4. Services to be delivered --Organisation of Health Education sessions  Treatment of malaria?  Treatment of pneumonia?  Child birth? etc.  What each of these entails 14

THE BUILDING BLOCKEXAMPLES ISSUES TO BE ADDRESSED IN STRENGTHENING 5. Community level medical products and technologies Kenya’s CHA Medical Kits  Items for prevention e.g. contraceptives  Items for diagnostics e.g Rapid Diagnostic Test (RDT) for Malaria  Items for treatment e.g. antimalarial items  6. Community-Level Health financing  From the national budget  From income generating activities  From development partners  The various expenditure items to which the finances go at the community level  Performance-Based Financing/payment of 15

5. IN CONCLUSION  The more a country in Africa makes the community level the FOUNDATION of the health system through successful implementation of Community Health Service, the more progress is made towards a healthy population with positive health indices.  If it doesn’t happen in the communities it just doesn’t happen in the nation.  If it happens in the communities it happens in the nation. 16 THANK YOU VERY MUCH FOR YOUR KIND ATTENTION