Welcome to our course on Understanding and Strengthening Health Systems for Global Health. During the course we will provide you with an overview of the main elements or building blocks of a health system based on the World Health Organization’s guidance. You will have the opportunity to explore four main areas of health systems in global health with particular reference to low and middle income countries. The first area focuses on understanding health service organizations, the challenges. Our second module looks at WHO’s six major building blocks or health systems components with particular reference to primary health care and the need for community participation in planning, delivery and assessment of these systems components. in our third module we examine the specific systems component of human resource development and capacity building. The fourth area consists of health policy making and advocacy with stakeholders. This course is geared toward learners who are already involved in managing health and development programs on the ground in low and middle income countries or who are preparing for such a management role. The main lectures will span a four-week period with approximately 2-4 hours of viewing learning materials per week. We have one peer graded essay wherein you will use skills in ‘organizational’ diagnosis to better understand a challenge in an organization where you are or have worked. There are also quizzes. We hope you will engage with your fellow learners in discussion forums to learn from each other.
What Are Community Systems?
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En provenance du cours de Johns Hopkins University
Understanding and Strengthening Health Systems
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À partir de la leçon
Health Systems: Basic Functions and Building Blocks
The World Health Organization has described six major components or building blocks of a health system. In this module we will examine those components and delve more deeply into the aspects of financing, commodities and service delivery, especially through Primary health Care. We examine a ‘missing’ component, community systems.
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William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
Welcome to our session on community system strengthening.
This is part of our module on health systems.
We've been talking about things like financing, health workforce, commodities,
but all of these aspects of the health system
must be geared towards serving the community,
to serving the clients, to serving people.
So, we must understand also that the community is organized as a system.
And so, we want to achieve a partnership or
a close working relationship between the community and
the health system for maximum and most effective coverage of our health services.
Some of you may have already taken our MOOC on community change in public health.
And there, we briefly talked about the characteristics of a community.
We want to stress again the importance of looking at the community as a system,
almost like a living organism.
And we have different systems within the community
that build together to create a well functioning community,
we have a social system, a geographical system,
a political system, an economic system and a cultural system.
These systems embody the basic resources with which
a community can solve problems and make health improvements.
It's important to compare community systems with
the WHO health system framework or the building blocks.
As you may recall,
we have six of those,
WHO building blocks for a health system,
we have leadership and governance,
we have healthcare financing,
we have the health workforce,
we have medical products and technology,
we have information and research or some people
call it monitoring and evaluation or health information systems.
And of course, all of this put together AIDS service delivery,
providing what people actually need to improve their health,
maintain their health, prevent health problems.
As we've mentioned before on the right hand side,
you see the five community systems.
And so, my contention is that the framework that you see on the left,
should have had a seventh component which is the community.
But since it doesn't, we're going to be adding it here,
so you can see the importance of understanding
the context in which the health system works.
So we want to look at how community systems actually function.
And I'll just briefly describe those five systems within the community,
so we can see how they relate to health and how
the health system can work together with those in partnership,
we see here a community meeting,
we have the political system that involves power, leadership and governance.
As you recall, leadership and governance were one of
the components of the WHO building blocks,
but the community also has leadership and governance,
how they get things done,
how they plan to solve problems.
And so, this is an important part,
if the community is involved in providing health services,
guiding health services, we need to recognize that
community leadership and health systems leadership need to work together.
The economic system in the community determines the resources that people have
that are available to them to expend on preventing disease,
on promoting their health,
the occupations of people,
how they make a living,
the distribution of those resources,
the fact that some people in the community have more resources than others.
These are some of the concerns that we have.
So again, if we're talking about these service delivery component,
and if there are any charges involved to finance to health system,
we must understand what the community can afford.
We also have our social,
cultural and geographical systems.
We can see the decorations on the house here in Burkina Faso,
are very indicative of cultural issues,
and we want to be aware of that.
We need to keep our eyes open.
At a time, when I was teaching at the University of Ibadan,
one of the things that we did to understand the community systems was
to take our students and walk around the community and look for these things.
We looked for evidence of the cultural system and ask local people what does this mean?
How does this affect your life?
We ask people about the social system when
we looked at institutions within the community,
whether it were the religious institutions,
clubhouses, were there associations?
Workplaces. These are the things we need to think about in terms of the social system.
And of course, the geographical system is extremely
important in the sense that where things are located,
where people are located in relation to general resources,
to the jobs that they do.
But in particular to the Health Services, it's extremely important.
In fact, within the communities own cultural health system,
the geography is important.
Are people near a forest where they can find
herbs and roots that they can make their own medicine?
Or are they close to a health center?
It may be that they're closer to
a private medicine shop than they are to a formal health facility.
So, we need to be aware of all these components going on in
the community and see how the health systems that we hope will reach people,
will actually fit in.
And again, create this partnership between the community and the health system.
We've mentioned some of this,
but we want to see clearly how the community systems relate to health.
In the social system,
we have social networks that provide guidance and support for people generally.
But also, to help guide them for preventative activities, to seek treatment,.
We have community-based organizations
that are concerned about health and community development.
So these are all aspects of the social system in the community that
interact with and help people take
advantage of the health system and the health facilities.
The cultural system of course has to do with indigenous medicine.
We mentioned before that there are practitioners of that.
So, it also relates to health human resources.
Many times when are organizing programs like village health worker programs,
these indigenous healers, actually
participate as a community health worker, community health volunteer.
We also learn about people's preferences and how we can
design our health services better based on their cultural expectations.
The economic as we said,
the affordability of the health options that are available to people,
the impact of cost of the illness on being able to earn a livelihood,
The geographic, again, said that this has to do with access.
Are they close enough to the services?
Are the services brought to them,
the mobile clinics, in immunization outreach?
Are there trained village health workers?
Who on the spot can deliver some essential services?
What is the transportation system?
Again, this is not just a rural problem, it's an urban problem.
Because again, we may have access challenges
from rich neighborhoods and
poor neighborhoods depending on where the services are located.
The transportation system in some of the cities doesn't work well,
so people spend a long time in traffic even if the health facility is not so distant.
So, we have to look at this context of where the community is situated,
where the health resources are situated.
And finally, the political.
To what degree is the community able to make decisions about its health?
Are there community health and development committees?
Are there ways that the health service itself, formal health service,
having advisory committees or other things,
makes itself accountable for service provision?
We see here a hand drawn map by some nurses in a clinic in Nigeria.
And this is a very important thing to get an understanding, one,
of the geography, but two,
the definition of the community.
And so, what these nurses do is to draw a map of
their catchment area so that they know the
smaller villages that may come to their clinic,
they know access to where schools and markets and other kinds of resources are,
if they need to do outreach.
And it's things like this that The Global Fund for HIV, TB,
and Malaria has taken advantage of to develop its own concept of community systems.
It's one of the few international donor organizations that is taking effort
to support improving the community's ability
to participate in delivering health programs,
in this particular case,
Malaria, TB, and HIV.
But again, the Global Fund stresses in documents,
that we'll give you links too or make available online,
that the community structures, mechanisms,
and processes of how they get things done,
who are the main actors, we said leadership.
The guidance that they provide encourages people who are planning
for a Global Fund grant to look closely at the communities that they will be serving.
And again, from the social point of view,
they want the planners of these programs to
figure out how are the community members organized.
Are there formal organizations?
Are there networks?
Are there civil society organizations that could participate actively in planning
and delivering health services that are receiving financial support from the Global Fund?
And of course, other donors can tag onto this so that everyone works in concert.
But the important thing is that there are formal community systems and informal.
And leadership is a good example.
There may be villages with Chiefs.
There may be urban neighborhoods with elected Councilors. Those are formal.
You can recognize people by their title,
but there are also informal systems.
Some of the associations may be social.
There may be elderly people who are recognized for their knowledge,
and they may serve an important role in leadership.
There may be the associations that form around certain local trades.
The medicine sellers have associations
in many communities and districts where they are located.
The traditional healers have their associations.
So, there are organizations that we need to be aware of.
Some have formal constitutions,
some are more informally structured,
but all of these need to play a role in planning health services.
One of the issues that we've talked about under
primary health care has to do with community health workers.
And there are many, many definitions of a community health worker,
some paid, some not,
but usually, these are the most frontline person in the health system.
And again, there's a crossover between the community system because most of
the community health workers come from
social networks, local community-based organizations.
They're selected by the community through community meetings and decision making.
They provide this interface between the health system and the community system.
So, they play a very important role,
whether they're paid a very minimum salary,
or whether they are completely volunteer.
Obviously, even though the individual worker may not get a very large salary,
when you have the hundreds and hundreds of them that you need in the district,
it does add up.
And so, volunteer community health workers are also a value.
The key thing with any volunteer program is that you want to make sure that
the workload is such that a volunteer can handle it
along with his or her main job as a hairdresser,
seller in the market,
a farmer, a carpenter.
But these are issues in terms of that program organization.
The fact that they exist,
they are of the community,
they live in the community,
they represent community groups,
they can even be representative of specific vulnerable groups.
We have people who are living with HIV,
who provide home-based care for other people affected by HIV.
We want to make sure that
community volunteers are women because in this particular picture here,
you see a community volunteer on the left
providing intermittent preventive treatment
to prevent Malaria to a pregnant woman in her village.
And it's very important culturally for there to be
this gender sensitivity that you wouldn't have
a man coming into a house asking who is pregnant.
So, the pregnant woman is helping
the community health worker wash her hands before she will then,
get out the medicine to give the woman for the intermittent preventive treatment.
These are some of the things that we need to take into
account when we're thinking about the populations of special groups,
the special needs of the community when primary health care workers,
community health workers are selected.
And clearly, people who have close links that actually live in their community,
understand their community, are the people who should be community health workers.
And basically, when programs are organized,
the organizers usually meet with the community,
discuss with them what their needs and interests are,
and discuss with them the characteristics that they would like
to see when they select their own community health workers.
So again, this is the intersection between the community system and the health system.
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