By Jeffrey Walker (Vice-Chair, Office of the UN Special Envoy for Health), Matthew Ramirez (Aspen Management Partnership for Health), Nikki Tyler (USAID’s Center for Accelerating Innovation and Impact), Precious Phiri (Malawi Federal Ministry of Health), and Reuben Ligowe (USAID/Malawi)
Strong community health systems can play an integral role in delivering essential healthcare interventions, especially to women and children, in providing linkages to the health system, and in improving the resilience and preparedness of health systems to respond to heath crises, such as Ebola. As the profile of strong community health systems continues to advance, increasing attention has been paid to the important role that leadership and management play in strengthening these systems. Mounting evidence demonstrates that ‘management matters’ and is essential in driving systemic, sustainable change. It is through this lens that a multi-sectoral collaboration, The Aspen Management Partnership for Health (AMP Health), began. AMP Health looks to address the root causes of sub-optimal health services at the community level by providing a menu of support to Ministries of Health to strengthen management and leadership capacity. Working in the Ministry of Health, seasoned mid-career private sector professionals (termed management partners) are seconded to Ministries of Health. These management partners – as well as other offerings provided through the AMP Health platform – provide strategic, focused, and long-term support to address the most pressing community health priorities in a given country. Currently, AMP Health operates in three countries (Kenya, Malawi, and Sierra Leone) and is expanding to new countries in the coming months.
AMP Health’s model is already working – as evidenced through its support to the Malawi Federal Ministry of Health (FMoH) in creating the country’s first ever National Community Health Strategy (NCHS). To guide the myriad community health activities necessary in the face of decentralization, resource constraints, increased focus on community-level prevention and promotion, and quality of community health services, the FMoH recognized the need to develop a costed, actionable National Community Health Strategy – a strategy akin to those developed in the private sector. The FMoH, through the Community Health Services section, led the development of the strategy with support from key partners, including AMP Health, Dalberg Global Development Advisors, Save the Children, UNICEF, the World Bank, the United States Agency for International Development’s Center for Accelerating Innovation and Impact (USAID CII), and USAID/Malawi. Throughout this process, the important role of leadership and management became evident – not only in terms of developing a costed, actionable strategy but also in terms of ensuring a collaborative, practical, and outcomes-focused approach.
The NCHS – launched in July 2017 – outlines how the community health system will function and details interventions to achieve this across six thematic areas: (1) health services delivery; (2) human resources; (3) information, communication, technology; (4) supply chain and infrastructure; (5) community engagement; and, (6) leadership and coordination. The NCHS also contains a costed implementation plan and a return on investment analysis to guide activities and aid in resource mobilization. Over its five-year implementation from 2017 - 2022, the NCHS seeks to improve health outcomes, community ownership, and integration of health services and will contribute to reducing under-5 mortality by 25% and maternal mortality by 20%, deliver a 5:1 long-term economic return on investment, and strengthen the community health system for a generation.
Throughout the development of the NCHS, the FMoH and partners catalogued lessons learned to help other countries in the process of developing their own national community health strategies.
Key insights and lessons learned are outlined below.
· Developing a strategy requires a strong focus and detailed planning up front: The NCHS, including all consultations, was developed in six months. Before beginning the development of the strategy, the FMoH created a roadmap for its development, which included a timeline, and secured all resources needed for its development. The FMoH credits this roadmap with ensuring a streamlined, efficient process that did not need to stop/start multiple times.
· Include people across all levels during strategic development: The NCHS was developed with the input of over 500 stakeholders through an in-depth situation assessment, five zonal workshops, two national workshops, and various interviews. Contributors and participants included FMoH officials, implementing partners, community members, community health workers, and representatives from every district. These extensive consultations secured buy-in from other programs, built teamwork across organizations, allowed people to provide multiple levels of input throughout the process, and also served as an advocacy activity. This process ensured the strategy was owned by all stakeholders, including communities themselves, partners, the FMoH, and local governments. In the face of increasing decentralization, highly consultative processes are increasingly important.
· Have a diverse core working team: The Community Health Services Section was supported by a working team with diverse perspectives and expertise that included other FMoH programs, implementing partners, and consultants. Work was shared across the team, creating an environment with commitment, teamwork, and various skill sets, such as technical expertise of the FMoH and partners paired with leadership and management expertise from AMP Health and USAID’s CII. This dynamic ensured sufficient preparation for each activity –contributing to a well-run process, quality output, and building the team’s credibility.
· Align – and co-create – with other national policies: In Malawi, the NCHS was developed in parallel with the Health Sector Strategic Plan II (HSSP II). This integration led to alignment between national policies, strengthened relationships between FMoH departments, and was well received by partners. It also ensured that key elements of the NCHS are advocated for, and planned at, multiple levels.
· Prioritize: During NCHS development, workshop participants were frequently required to prioritize issues and activities in groups by thematic area using stickers and flipcharts. This visually showed how many issues and activities were under consideration, and the importance of prioritizing to have a greater chance of successful implementation.
· Ensure there are early, achievable wins in the strategy: Incorporate early, achievable targets to build momentum for implementation and to reinforce the strategy across the system.
· Clearly define community health and how it fits within the overall health sector: It is important to clearly define community health and establish how it integrates with broader health and community systems. This includes outlining how community health takes places, at what levels it is delivered and managed, and defining the roles of various contributors. For Malawi, this included considerations for the roles and relationships of multiple cadres of community health workers (CHWs), management positions at the district and national level, and community groups and committees.
· Set ambitious, but achievable, targets to support resource mobilization: The NCHS lists ten outcome and output targets that are intentionally ambitious but still meant to be achievable. This supports advocacy for resources based on targets in the strategy, but also recognizes the limitations of implementation. For example, Malawi policy recommends a 1:1,000 health surveillance assistant (HSA) to population ratio, though by 2022, the NCHS targets a 1:1,345 HSA to population ratio.
· Community health systems can be costed in many ways: Be clear in communicating the scope of costing; for example, costing community health workers versus costing a community health system that includes community health workers, supplies, supervision, training, community health infrastructure (e.g., housing for community health workers, health posts), and interventions. The scope of costing greatly influences total costs. Organizing costs by categories, as well as start-up versus recurrent costs, makes it easier to understand the biggest cost drivers, as well as ‘steady-state’ cost of implementation separate from start-up activities/costs. This supports cross-country costing comparisons and understanding factors for varying per capita implementation. And remember that different partners – be it Ministries of Finance, public sector donors, or private sector investors – will be able to fund different activities, so tailoring advocacy materials or discussions appropriately can potentially lead to greater success.
· Importance of flexible, quickly accessible funding: Any process can face unexpected challenges or setbacks. Having flexible, quickly accessible funding can ensure minor challenges don’t lead to major setbacks. In this regard, the NCHS benefitted from the AMP Health country fund, a small fund accessed through the management partner, which filled gaps to ensure that unexpected issues and delays with funding from the FMoH and other partners did not delay activities or the process overall.
As a result of this process, the Malawi FMoH developed an actionable, costed community health strategy with a clear path to guide stakeholders throughout its implementation. It also gave the Malawi FMoH the opportunity to lead by setting targets and prioritizing costed activities to reach these targets, which has already aided conversations around resource mobilization within other Ministries, development partners, and the private sector.
As the Malawi FMoH states, “NCHS was developed by all to be implemented by all for the benefit of all for the next generation. There are no beneficiaries and implementers, we are all in this together.”
To learn more about the Malawi work and see how you can help, please visit http://www.ampforhealth.org/malawi/.
AMP Health is a partnership of The Aspen Institute, GlaxoSmithKline, Horace W. Goldsmith Foundation, Margaret A. Cargill Foundation, Merck, Global Health Alliance/UNSEO, Sall Family Foundation, USAID, GAVI.
 Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations.
 In Malawi, CHWs are commonly known as HSAs.