Everyone Contributes: Community as Part of the Health System

Most of us live in a community and belong to overlapping groups of people. While academic and medical disciplines define community health in various ways, the idea of community members contributing to improved health is relatively simple. It is not a radical idea: home remedies and help from traditional health practitioners have been used within families, clans, tribes, and communities for millennia. In this era of renewed focus on people-centered primary health care and achieving universal health coverage (UHC), we must recognize the potential of communities to improve health.

What is the actionable idea? It is that communities contribute to improved health outcomes in measurable ways, so we should invest in broad community health. This is recognized by governments, health economists, actors in the formal health sector, and the World Health Organization, and upheld by a growing body of evidence. Instead of continuing to promote the idea that all care must be provided by clinicians in formal health facilities, donors like the United States Agency for International Development, UNICEF, and the Bill & Melinda Gates Foundation are investing in community health, expanded options for self-care, and health ecosystems.

In some countries, this includes policies that promote community health with the health system. In Nepal, Ethiopia, Madagascar, Tanzania, Mali, Uganda, Laos, and Liberia, for example, inclusion of community health workers, community health volunteers, and health extension workers and broader community roles in the health system are becoming the norm.

In Madagascar, the Ministry of Public Health (MOPH) updated the 2009 National Community Health Policy in 2017 and 2021 with revisions about specific roles for local officials and non-health state actors. The revisions updated key strategies including improved community health volunteer (CHV) training and supervision and continued integration of community health structures into the health system. This enabled investment in community health, including through the USAID Community Capacity for Health Program (CCHP), which supported training of more than 10,000 women and men selected by their communities to be CHVs. These volunteers worked in 34 districts of seven regions that have a total population of 6.6 million (28% of Madagascar’s population).

The Malagasy volunteer community health workers, who are certified by the MOPH to provide an integrated package of preventive and select curative care, blossomed into a health workforce in remote places under often difficult conditions. Many thrived thanks to the support of local officials, health and development committee members, youth, mothers and other caregivers, the closest MOPH health clinic, and CCHP.

How have CHVs contributed to health in these communities?

1. CCHP’s interventions to support the implementation of the National Community Health Policy enabled CHVs to contribute directly or indirectly through the community referral system to more than half of the family planning and child health care services in the program’s seven regions. This is a significant contribution to UHC and improved access to primary care.
2. CHVs treated more than 370,000 cases of malaria in children under 5 in fewer than 5 years (2016–2021).
3. CHVs increased the use of contraceptives by youth by more than 8% since 2017.

It isn’t only CHVs who contribute to health in these seven regions. Ordinary citizens manage community-financed health transport systems for emergencies, while others contribute to and manage village health savings programs. Some act as youth peer educators, and through an approach known as Champion Communes, many work collectively to meet specific national health and sanitation goals. Community members helped build the 4,125 village health huts where CHVs work and contributed the land on which the health huts are built and the materials to build them. Truly, everyone contributes.

Inclusion of all kinds of people in the practice of community health increases broad knowledge of high-impact health activities and the likelihood that any part of a community health system will be sustained. There are many barriers to success, such as unreliable supplies of medicines and contraceptives and meeting the needs of people living in extreme poverty. However, meaningful engagement of citizens within an organized community health system is a critical step to achieving UHC and ultimately creating a people-centered health system.

Written by Elaine Rossi, Associate Director