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Introduction: The renewed commitment to primary health care (PHC) presents an opportunity to strengthen health systems in West and Central Africa (WCA). Though evidence-based costeffective interventions that are predicted to prevent up to onethird of maternal, newborn, and child health complications and deaths with universal coverage have been identified, more than 50% of people living in rural areas or from poor families still do not have access to these interventions in resource-constrained settings. Methods: We conducted a multicountry systematic analysis of bottlenecks and proposed solutions to strengthen community health systems through a series of collaborative workshops in 22 countries in WCA. Countries were categorized by their under-5 mortality rate (U5MR) to assess specificities related to reported challenges. We also reviewed existing data on selected health system tracer interventions to analyze country profiles. Results: The bottlenecks identified as severe or very severe were related to health financing (19 countries, 86%), essential medical technology and products (16 countries, 73%), integrated health service delivery (14 countries, 64%), and community ownership and partnerships (self-reported by 14 countries, 64%). Only the integrated service delivery was self-reported as a severe challenge by countries with high U5MR. The issue of human resources for community health was one of the least reported challenges. Conclusion: In WCA, strengthening community health systems as part of PHC revitalization efforts should focus on increasing health financing and innovative investments, strengthening the logistics management system, and fostering community ownership and partnerships. Countries with high U5MR should also reinforce integrated service delivery approaches through innovation. Government actions galvanized by global and regional ongoing initiatives should be sustained to ensure that no one is left behind.
Between January and April 2019, we contacted all 24 countries in the United Nations Children’s Fund (UNICEF) WCA region27 to conduct a systematic analysis of their community health system. We excluded Gabon and Sao Tome and Principe in the regional analyses as they reported not having a national community health policy or strategy (neither as a separate document nor clearly embedded in the national health strategic plan) or a clear framework describing the national community health program at the time of the survey. This was the only exclusion criteria. We then performed 2 analyses as followed. To assist countries in their analysis of health system bottlenecks, including identifying challenges that prevent the scale-up of community-based interventions and potential solutions, we developed the community health system bottleneck analysis tool, taking into consideration the World Health Organization (WHO)/UNICEF draft PHC operational framework (Supplement).2 The tool development involved: (1) adapting the health system framework used by Dickson et al. for the maternal-newborn bottleneck analysis tool,25,26 and (2) using the programmatic components described in the interagency Community Health Worker Assessment and Improvement Matrix (CHW-AIM)28 to assist data collection, compilation, analysis, and cross-country comparison. The bottleneck analysis tool, which is a questionnaire, was divided into 7 health system building blocks: (1) leadership and governance (including policies and coordination), (2) health financing, (3) human resources, (4) essential medical technologies and products, (5) health service delivery (and quality of care), (6) health information systems, and (7) community ownership and partnership.29 The seventh building block, community ownership and partnership, was included on the basis of the recommendations of the Ouagadougou Declaration on PHC.30 The tool was tested in 2 countries and slightly revised. To better analyze supply chain challenges, we considered the recommendations of the United Nations Commission on Life-Saving Commodities to improve access to essential commodities.31,32 We considered the following areas: (1) availability of policy or strategy, (2) finances, (3) efficiency regulation, (4) product quality and patient safety, and (5) procurement and availability of inputs. Second, we selected the 3 recommended essential medicines that are required to treat the major causes of child deaths: amoxicillin, oral rehydration salts, and zinc, as well as artemisinin-based combination therapy. The community health bottleneck analysis tool was used in a series of national workshops held between January 15 and April 30, 2019, in the 22 selected countries. The number of workshop participants varied by country and included members of national technical working groups that consisted of program managers from the ministries of health, UN agencies, nongovernmental organizations, bilateral agencies, and other stakeholders at national levels. Members of the working groups were experts from diverse fields nominated by their governments to provide advice on community health issues on a regular basis. The workshop brought the working group members together to assess bottlenecks and propose strategies to strengthen community health systems. More than 200 individuals participated in these ministry of health-led workshops. Participants were oriented on the use of the tool during the first day of the workshop. Participants examined each of the 7 health system building blocks—based on data and experience—to identify the key challenges. The groups then came to a consensus on whether the bottlenecks to the health system area should be graded as good (not a bottleneck), needs minimal improvements (minor bottleneck), needs important improvements (severe bottleneck), or inadequate (very severe bottleneck). Finally, participants proposed potential strategies to address priority challenges identified. The ministry of health program managers and working group members were responsible for collating all responses and submitting the final data; they also served as points of contact for clarification of any issues. In November 2019, the first high-level regional forum on community-based PHC organized in Benin was an opportunity to further discuss and validate the results with the 13 country teams who participated in the meeting. Workshop participants used the community health bottleneck analysis tool to examine the 7 health system building blocks and identify challenges. We received complete national-level data from 22 countries. We reviewed all the bottlenecks for each health system building block and all solutions presented by country participants (Tables 1 and and2).2). Issues reported by at least 3 countries were further reexamined against recent country surveys14 to assess their persistence. From all bottlenecks, we extracted those that workshop participants categorized as severe or very severe to establish whether there were health-system areas that could be prioritized to move forward. For more context-specific subanalysis, we categorized the bottleneck analysis data from the 22 countries into 2 under-5 mortality rate (U5MR) categories: U5MR of more than 75 deaths per 1,000 live births and U5MR between 25 and 75 deaths per 1,000 live births. A health system block is defined as a priority if at least 50% of the reporting country teams graded the health system area as severe or very severe. We also reviewed all strategies proposed by country teams to address identified challenges and proposed a grouping by country typology whenever possible. Country Self-Grading of Health System Domains as Severe/Very Severea Bottlenecks to Strengthen Community Health Systems (N=22 Countriesb) Country Self-Grading of Health System Domains as Severe/Very Severea Bottlenecks to Strengthen Community Health Systems by Under-5 Mortality Rate Category (N=21 Countriesb) To complement the bottleneck analysis in the 22 countries in WCA, we selected tracer indicators from the health system building blocks and indicated the coverage of key indicators for children to analyze countries’ progress toward reducing child mortality from a multisectoral lens. We categorized countries according to the latest U5MR, relative to one of the targets for the third Sustainable Development Goal (SDG3), which is to end preventable deaths of children under 5 years old by 2030, with all countries aiming to reduce under-5 mortality to at least 25 per 1,000 live births (LBs). Based on this target we proposed 3 groups of countries: Group 1 countries had U5MR of 25 deaths per 1,000 LB or less, Group 2 countries had U5MR between 25 and 75 deaths per 1,000 LB, and Group 3 countries had more than 75 deaths per 1,000 LB. We further analyzed health system tracer indicators from existing global data to assess the profile of countries studied, taking into consideration the health system building blocks. Selected indicators can be found in Table 3. Data were most available on health facility service delivery, while data on essential medical products and technology were limited, with only 8–9 countries reporting on the chosen indicators. Variations were also found within health financing—data on national health financing was complete for all 22 countries but became less available for PHC-level financing data. The list of indicators included 5 indicators on health financing, 4 indicators on essential medical products and technology, 2 indicators on health workforce (focused on community health), and 4 indicators on health facility service delivery. To complement the analysis, tracer indicators for child health interventions and child health-related multisectoral interventions that address overlapping children’s deprivations were also added. Grouping of 22 West and Central African Countries According to Under-5 Mortality Rates Showing Selected Health System Tracer Indicators (Financing, Supply, Health Workforce, and Service Delivery) and Child Indicators Abbreviation: U5MR, under-5 mortality rate.
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