Galvanizing Action on Primary Health Care: Analyzing Bottlenecks and Strategies to Strengthen Community Health Systems in West and Central Africa

In West and Central Africa, “leaving no one behind” requires strengthening community health systems by increasing health financing, improving supply chain system, and fostering community ownership and partnerships in all settings. Countries with high child mortality rates should improve service delivery through better integration. Galvanizing context-specific country actions is fundamental to improve primary health care services and move toward universal health coverage.

Supplement to: Simen-Kapeu A, Reserva ME, Ekpini RE.Galvanizing action on primary health care: a regional analysis of bottlenecks and strategies to strengthen community health systems in West and Central Africa. Glob Health Sci Pract. 2021;9(Suppl 1).https://doi.org/10.9745/GHSP-D-20-00377Please make an overall assessment of your domain analysis "Legislation / Policy" -Select a single line : Documents (policy and strategies) available on child and community health Documents (policy and strategies) requiring few improvements (minimal revision required) Documents (policy and strategies) requiring major improvements ( important amendments required)

COMMUNITY HEALTH PROGRAMME
Supplement to: Simen-Kapeu A, Reserva ME, Ekpini RE.Galvanizing action on primary health care: a regional analysis of bottlenecks and strategies to strengthen community health systems in West and Central Africa.Glob Health Sci Pract.2021;9(Suppl 1).https://doi.org/10.9745/GHSP-D-20-00377

Proposed solutions to solve identified bottlenecks
Governance / coordination at all levels 1.Is there a national coordinating committee for child health?Is there a national coordinating committee for community health?are they fully functional with defined roles and responsibilities? 2.
Is the private sector engaged, on both coordination and implementation, of community health at all levels?3.
Is civil society engaged, on both coordination and implementation, of community health at all levels?

4.
Is there a coordination system at the community level as " health management committee 'or equivalent (COGES, COSA, etc. )? 5.
If the management committee exists at Community level, does it : The spots are clearly defined ?
The members were elected by the community ?
Reporting and performance evaluation mechanisms are in place and functional ?
Collaboration with the health center is effective ?
The committee is engaged in health planning activities at the local level and in the activities of CHWs (or equivalent) P lease make an overall assessment of your domain analysis " coordination » -Select a single line : Coordination in place and functional at national and decentralized level Functional coordination at all levels but presents some challenges of implementation (2 out of 5 elements away s) Coordination is not functional and presents major challenges at the communal ( 4 out of 5 elements are absent ) Funds for community health are also generated by the government (funds disbursed)?What percentage ?3.
The Community Health strategic plan has is developed and budgeted?Supplement to: Simen-Kapeu A, Reserva ME, Ekpini RE.Galvanizing action on primary health care: a regional analysis of bottlenecks and strategies to strengthen community health systems in West and Central Africa.Glob Health Sci Pract.2021;9(Suppl 1).https://doi.org/10.9745/GHSP-D-20-00377 4.
The Community Health operational plan is developed, budgeted and funded? 5.
A resource mobilization plan for community health is developed?6.
Is there an investment framework for community health ?P lease make an overall assessment of your domain analysis Does the national logistic information management system take into account the Community level?or is there a parallel system for the moment ? 3.
Essential medicines for child health (ORS, Zinc, antibiotics, ACT, etc. ) can be found in the national list of essential medicines ? 4.
The procedures for the distribution and storage of products at Community level are clearly defined in a manual available to all in the field?

5.
Is the country experiencing periodical stock shortages / stockouts of child health essential commodities in health centers or at community level?Is there an alert system in place?What medicines are more concerned?6.
Community health workers have a kit that includes the timer, thermometer, and records / registers?do they have a place to store the drugs?

7.
The revolving fund/ cost recovery mechanism is in place and functional?
Please make an overall assessment of your domain analysis " National Supply Chain and Management (SCM), especially the community level " -Select a single line : The national SCM system (mainly community level) is functional The national SCM system (mainly community level)) requires improvements (2/7 elements are absent) The national SCM system (mainly community level)) requires significant improvements (4/7 elements are absent) The national SCM system (mainly community level)) is non-functional / need to be effectively designed Supplement to: Simen-Kapeu A, Reserva ME, Ekpini RE.Galvanizing action on primary health care: a regional analysis of bottlenecks and strategies to strengthen community health systems in West and Central Africa.Glob Health Sci Pract.2021;9(Suppl 1).https://doi.org/10.9745/GHSP-D-20-00377Is there a national document that describes the types, roles and responsibilities of community health workers and their supervisors?2.
Is there a document on job description?on the recruitment process ? 3.
Is there a national document that describes the training required for CHWs or equivalents?Are the material / training tools are available at all levels (national, district health center) for periodic consultation?

4.
Do all CHW or equivalent types have employment contracts currently valid? 5.
Is there a mechanism in place for the regular assessment of CHW and their supervisors performance? is it functional ?6.
Is there a document that outlines the CHWs supervision mechanisms? is it functional (documented) at the operational level?are the funds available to facilitate the supervision processes?7.
Is there a document that specifies the mechanisms of retention and motivation?P lease make an overall assessment of your domain analysis " Human ressources (RH ) » -Select a single line : The Is the reference and counter-reference system defined in the policy document?Is the system in place (forms, cards, transport) and functional?Is the reference system built with local communities that contribute?
Supplement to: Simen-Kapeu A, Reserva ME, Ekpini RE.Galvanizing action on primary health care: a regional analysis of bottlenecks and strategies to strengthen community health systems in West and Central Africa.Glob Health Sci Pract.2021;9(Suppl 1).https://doi.org/10.9745/GHSP-D-20-00377 3) Management of cases of malaria, diarrhea , and pneumonia at Community level : Analyze the integration of case management of the three major childhood illnesses at Community level : This integration is allowed in the policy ?
In the field, CHWs or equivalents take care of the three diseases?or some CHW or equivalents are designated for the detection and management of malaria cases only ?
CHWs are equipped and provide a report on the number of cases followed at home for the 3 diseases?
3.b For the implementation of Community IMCI , the country is in : a) planning phase and working on the development of national normative documents?(b) pilot / project phase in selected areas?c) scaling-up phase ?

4)
Analyze the integration of MNCH and Is the community health information system in place and functional? 3.
Does the national health information management system take into account the Supplement to: Simen-Kapeu A, Reserva ME, Ekpini RE.Galvanizing action on primary health care: a regional analysis of bottlenecks and strategies to strengthen community health systems in West and Central Africa.Glob Health Sci Pract.2021;9(Suppl 1).https://doi.org/10.9745/GHSP-D-20-00377Community level ?if not why ? is there a non-integrated system for the moment?4.
Is there information on the management of cases of illness in children and the number of children treated specifically for malaria, diarrhea, and pneumonia in the national system ? 5.
Is patient follow-up documented? on cards or registers ?
Please make an overall assessment of your HMIS domain analysis -select a single line :  Community HMIS is functional, integrated into national system, and adequate (no obstacles)  Community HMIS requires some improvements (2/5 elements not effective)  Community HMIS requires significant improvements (3/5 elements are not functional) 1.
Link between the health center and the community: Does the health center have trained staff able to provide IMCI (3 diseases)?Does the health center effectively coordinate the implementation of CHW programme?Is the role of the health center clearly defined?Is there a monthly or regular interaction between the health center staff and the community around the CHW work?

2.
The supervision of the health center is effective and documented: supervision guide available?performance assessment tools available?Effective and documented follow-up?

3.
The algorithms and standards for the management of the 3 diseases (not only one) are available in health centers?

4.
The services provided are equitably directed to the most vulnerable or hard-toreach or poor populations (have they been identified with the community through a process?Is there a defined mechanism to support them)?
Please make an overall assessment of your domain analysis " quality of care » : Implementation of a quality service effective and documented Need some improvements (some obstacles observed) -2 out of 4 elements not covered) Need important improvements (major obstacles observed -3 out of 4 elements not covered)

Proposed solutions to solve identified bottlenecks
Supplement to: Simen-Kapeu A, Reserva ME, Ekpini RE.Galvanizing action on primary health care: a regional analysis of bottlenecks and strategies to strengthen community health systems in West and Central Africa.Glob Health Sci Pract.2021;9(Suppl 1).https://doi.org/10.9745/GHSP-D-20-00377 elements are missing ?Why ?) Community involvement 1.
Existence of operationnel guide on community engagement ? 2.
Are there any social accountability and citizen engagement mechanisms in place and operating at the community level ? 3.
The community plays an important role in supporting the CHW (ie discussing its role or goals, providing regular feedback) and helping to establish CHW as a community leader ?4.
Community leaders interact continuously within a defined framework with CHWs on health issues using data collected by CHWs ? 5.
CHWs uses existing multisectoral community structures (eg, health committees, community meetings) for logistics, reference, or other ?6.
The group of youths, women's groups or other community groups are active extensions in support of CHW work? 7.
The community interacts with the CHWs / equivalents and their supervisors during visits to provide feedback and resolve issues?8.
A wide range of community members play a role in planning the CHW program and provide feedback to the health center ?
After answering the previous questions, please make an overall assessment of your domain analysis " community engagement and partnerships » -please select only one line : Community involvement is effective and adequat Community involvement requires some improvements (3/8  Policy and governance: The national logistics management information system does not integrate the community level; the community-based management information system is parallel or developed for specific diseases; procedures not defined for the distribution and storage of products at community level (no manual) 13 Product quality and patient safety: No national drug control laboratory certified by a standard accreditation agency 11 No drug quality monitoring system that meets the criteria (sampling, regular tests and actions in the past 12 months) 13 Patient safety monitoring system (pharmacovigilance) do not meet all defined criteria (questionnaire) 17 Procurement and availability of medicines National quantification of drugs not systematically done every year (if done, it is mostly project-related); the quantification of community needs is not up to date or not taken into account during the national quantification 14 No monitoring and e-tracking system for the selected products from the first storage point to the health facility 15 National drug distribution system does not take into account the community level -parallel system linked to specific projects; Algorithms, protocols, and standards for integrated management of childhood illnesses not available at health centers/ no quality improvement mechanism 16

Heath information system
No community health monitoring and evaluation plan 11 The community health information system is not fully functional; collection and analysis of community-based data is not regular 11 The community health information system is parallel/or not yet integrated into the national health information system 11 Algorithms, protocols, and standards for integrated management of childhood illnesses not available at health centers/ no quality improvement mechanism 16

Community ownership and partnership
Lack of community engagement plan/guide 13 Mechanisms for social accountability and citizen engagement at the community level not in place or not functional 14 Lack of framework to guide/maintain monthly community dialogue between CHWs and community leaders using monthly data collected for analysis and decision making 11 Youth/women's groups or peer groups are not active extensions in support of CHWs 12 Community does not interact with CHW (or equivalent) supervisor during visits to provide feedback and resolve issues 13 Community members do not play an active/leadership role in CHW program planning 13 Abbreviations: ACT, artemisinin-based combination therapy; CHW, community health worker; ORS, oral rehydration salts; PHC, primary health care.
Introduction to the context of the Community Health Programme Bottleneck Analysis (and Underlying Causes) of the National Community Health Programme

Policy and strategic documents not adapted to current context
(full development required)

HR domain has adequate / functional system The HR domain requires improvements
(2/7 elements are absent) The HR domain requires significant improvements (4/7 elements are absent) The

P lease make an overall assessment of your analysis of the domain -select a single line: Geographic accessibility and availability of services adequate Need some improvements
Supplement to: Simen-Kapeu A, Reserva ME, Ekpini RE.Galvanizing action on primary health care: a regional analysis of bottlenecks and strategies to strengthen community health systems in West and Central Africa.Glob Health Sci Pract.2021;9(Suppl 1).https://doi.org/10.9745/GHSP-D-20-00377 7) Analyze the integration of MNCH interventions and birth registration at Community level: Defined in the policy?CHWs or equivalent know the mechanism to follow and practice it?Search for non-(Only one third out of 11 elements are not implemented) Requires significant improvements (2/3 out of 11 elements are not implemented) Geographic accessibility /

Community involvement is not effective
Supplement to: Simen-Kapeu A, Reserva ME, Ekpini RE.Galvanizing action on primary health care: a regional analysis of bottlenecks and strategies to strengthen community health systems inWest and Central Africa.Glob Health Sci Pract.2021;9(Suppl 1).https://doi.org/10.9745/GHSP-D-20-00377

Health system areas Common Bottlenecks Identified by at Least 11 of 22 Country Teams During Workshops, Whatever the Grading of the Health System Areas
CHWs or equivalent trained and operational according to the policy compared to national needs 15 Referral and counter-referral system nonfunctional -and no contribution from local communities in most cases Supplement to: Simen-Kapeu A, Reserva ME, Ekpini RE.Galvanizing action on primary health care: a regional analysis of bottlenecks and strategies to strengthen community health systems in West and Central Africa.Glob Health Sci Pract.2021;9(Suppl 1).https://doi.org/10.9745/GHSP-D-20-00377No effective integration of MNCH and TB/HIV+ interventions (policy, implementation, tracking of patients, and resources) 13 No effective integration of MNCH interventions and birth registration OR at pilot stage 11 Very limited promotional and preventive adolescent sexual and reproductive health services at the community level 11 Early childhood and education (including day care centers) interventions not in place or embryonic / pilot 19 Supervision of CHWs by the health center is limited (less than 70% of CHWs covered) / not effective (no supervision guide / tools available / instability of staff) or poorly functional (no regular assessmentno feedback) 15