Health Systems Strengthening Excluding Community Systems?

Community Systems addressing and providing health services have been and continue to be an integral part of a country’s response to diseases/ illnesses and therefore part of the health system. The response to the Ebola outbreak in Nigeria, Liberia and Sierra Leone in 2014 provides evidence to the great possibilities that exist in community systems, and their ability to contribute to the effective management of health crises.

This paper provides additional reflection on the French-German non-paper on Health System Strengthening, “Health Systems: Key to Sustainable and Equitable Programming (June 2015).” It is agreed that The Global Fund does need a stronger approach to HSS. Such an approach should be intentional and sustainable and a key component of the 2017 to 2021 Strategy.

The Developing Country NGO finds however, that the discussions so far, on Health Systems, are limiting, lacking universality and are strongly associated with a Euro-centric concept of health systems, where the Government is the sole and primary provider of health services – a concept which seldom exists in the developing world.

There is a common misconception that community systems are for the distribution of condoms and treatment support without infrastructural capacity building and the overhead support. It is not. As much as countries differ, so too will community systems, in their strength, ability and service-provision characteristics. Regardless, large or small, community systems must be seen as a vital part of an efficient and effective health system. Being part of the national health system does not mean being part of government, but part of an interconnected network, which also needs consistent and sustainable investment in order to contribute to the aim of reaching the entire population.

A well functioning health system is one where all its parts – leadership, supply, technology, workers, service delivery – work together with a single goal: better health for all the population. In seeing it this way, the community systems form part of the national health system as well.

As legitimate components in the vehicle that is a national health system, communities (civil society) should be capacitated and invested in by governments, so they too can deliver the agreed services at optimal quality as part of the response. The cooperation between these systems must include the development of a single-entry reporting database, which can be used to measure impact. Countries with these systems, already in place, must recognize the need to include CS in the framework.

The evidence, the world over, points to the reality that Governments and public health-care systems alone will never be able to reach the entire population with the necessary services it needs to achieve the best health outcomes. People, especially those from vulnerable and marginalized groups, are often disadvantaged by the politics to which health systems are often susceptible.

Community systems are better positioned to transcend political agendas and national value-systems, to better complement the national health approach by providing services to, often, hard-to-reach groups and peoples – one of the many benefits for building and strengthening them. Even in countries where the health system provides free sexual health and other services to the public, indigenous populations, undocumented migrants, sex workers and other sexual and gender minorities, including gay, MSM and transgender men and women for example, frequently lack access to those services – their human right to health, going unrecognized. To best achieve strong systems of health, universal health principles should recognize health as a rights for all.

Fundamental problems in health care systems can be addressed only when decision-makers recognize the importance of the interlinking nature of its elements. The Global Fund must understand that in order to achieve its goals, be innovative, make impact, and transition countries (sustainably), CSS must be integrated into HSS.

The challenge in fully supporting and integrating CS into the health systems sometimes stem from legal barriers and conservative policymaking. In the Eastern Europe and Central Asia region, besides stigma and discrimination and human rights violations against key and vulnerable populations, there is a trend of stigmatization of NGOs, especially those working with populations and NGOs receiving funds from international donors. Challenging socio-political and economic environments, like these, have adversely impacted inequalities in health, and changes in health seeking behaviors. This may further increase the vulnerabilities of key populations for HIV, TB and malaria. Many national health systems struggle to reconcile equitable access, high quality services and low and affordable costs. This is where community health services can play their best part.

There must be an integration of community health services into national health systems. This should include an integration of data and CSS indicators into national health management system. This should be guided by epidemiology and public health approach and a principle of helping people in need by enabling the continuation of investments in civil society, while the integration of CSS into HSS lasts. The Global Fund plays its part by requesting from governments that HSS commit a percentage (50-80) of financial contribution to CSS in Willingness to Pay and within transition plans – depending on country focus. This must also include a greater support of monitoring and evaluation processes, risk management and an environment for free and open advocacy.

A well functioning health system should be the key principle with a single goal – better health for all – which cannot be achieve in environments where strong community systems do not exist and aren’t integrated in national health systems.


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