So, there are number of indicators that we can look at.

We need numbers and percentages for these elements.

Again these are the six community system strengthening activities,

I've expanded a bit on the resource side.

But, what we'll see quickly here is some of the examples of these for each one.

For enabling environment and advocacy,

we can look at the number and/or percentage of

community-based organizations that have been involved in program reviews,

that have been involved in planning,

that have been involved in number of activities that ensure better delivery of services.

We can look at the number and percentage of community organizations that have

actually developed and implemented a communication plan in their village.

So we get the community members involved in

health education or social and behavioral change communication.

Because again coming from neighbors,

this is much easier to communicate and understand and more effective.

We can look at the number of these community-based organizations who have a member

that is volunteering for either advocacy with the health services,

education with community responsible for delivering services.

When we're looking for indicators of linkage, collaboration and coordination.

So, we're looking at the community-based organizations that actually deliver services.

We're looking at the organizations that have meetings,

where planning is done,

where feedback is taken so that they understand how and evaluate their activities.

When we're trying to develop human resource capacity,

we can certainly identify community health workers and volunteers,

who are currently working,

and the number that have received training or

retraining or refresher training or training on a new area.

So, we can certainly keep track of that.

One of the things, of course,

that's implied in that is if you knew you trained

100 community health workers in the catchment area of your clinic and in one year and,

then a year later, do you still have 100 working?

Have some people dropped out? Why did they drop out.

But, basically we can keep track of, as indicators,

the number, who have been trained,

who are been working,

and when replacements are made.

So, we certainly want to keep track of that.

One of the things just as an aside when you have the community-directed approach.

Yes, you do have community volunteers working,

but the community is in charge.

So, we expect that people will drop out.

A woman may leave the village to go live with her daughter,

who has just had a new baby.

We may find that somebody has

an employment opportunity in another area and leaves the village.

But, it's not as serious as one might think because if the community is in charge

of the program they can identify new people to take up this responsibility.

So, the community makes a decision.

It's not dependent on an individual.

But, clearly, it's more efficient if you have somebody,

who serves for some time.

You don't have to keep training and retraining and retraining.

The issue of supervision is important.

Has anyone come out from the health center to supervise the community organizations?

Have they supervised the community health workers?

Have the community organizations

supervise the people they selected as community health workers.

Again, some of these people,

who are community volunteers,

are actually paid or receive a little allowance.

If this is part of the promise that was given during their recruitment,

we need to keep track of whether that promise has been taken care of every year.

We recognize that money can actually get in the way because sometimes if they're

promised a little salary and then the ministry is a

bit behind in paying then people may drop out.

So, we wanted to be very careful about that.

But, sometimes also with a community-directed approach,

it's the community itself who decides that they will provide some type of support.

So often in kind to their community health worker.

And so we want to keep track of that because again we

want to keep the community volunteers satisfied and working.

And this of course leads right into the financial resources.

Where's the money coming from?

So, one thing is that sometimes with the global funds and

other kinds of donor programs some money is

made available to community-based organizations.

So, when that happens, simple,

but accurate financial reports,

what happened to that money?

But then we also want to see is the community able to raise some of

its own money to do activities and keeping track of that.

We want to be sure that the organizations that do

receive support can continue working for some time,

that they're able to follow through for

a few years to make sure that they can achieve their goals.

And, of course, material resources in the community,

either of the community or brought into the community,

need to be monitored and taken account of.

One thing that's important is that when the community organizations and

the community health workers receive essential commodities from the health center,

whether it's malaria drugs or pain medicines like Panadol or aspirin or whether it's

other things for deworming that these commodities

are not only kept safely but that they have a regular stock.

It's difficult to start a program and then

people can't continue their work because they don't have commodities.

We had this experience in one community in Nigeria.

We had trained village health workers.

They had organized their own revolving fund,

collected money from among themselves and their villages,

bought the basic drugs stock and then people paid a minimum amount and they were able to

continually go to a wholesaler and buy more and keep that going.

Whereas the local government trained

some people in another area and they were dependent on

the local government medical stores to get their drugs

and the local government was often late in ordering drugs,

often was out of stock,

and so those village health workers were disappointed in themselves,

they disappointed the community members because they could not

provide the basic services that they were trained to do.

So, this whole issue of managing safely and

accurately keeping records of the stocks, commodities,

supplies for healthcare in the community that are brought to

the community that there is accountability and good stock keeping practices there.

We've talked clearly about community service delivery so far.

But, what we are looking for in terms of

the service delivery is the community's capacity to provide the minimum services.

Again this comes through observing.

When you do supervision,

you can see that the community organizations may be conducting health education sessions.

You can see that the community volunteers they selected

are actually going to the homes and delivering the services,

that they keep records of this so that you know what services were delivered,

were they adequate to meet the needs of the community.

So, this is important.

We want to have accessible services within a defined area.

We said we often work with local clinics and their catchment area.

Their catchment areas may include three or four more villages,

it may include several neighborhoods in urban or peri-urban area.

But the reason we're working with them is that we recognize

that the community members don't always have easy access to a formal facility.

So, again we want to make sure that the supplies are there,

the community health workers are trained and they are

actually delivering and recording the services they deliver.

Again, what we're looking forward for community leadership.

Have we provided any kind of training?

How many people have been trained in better leadership management and accountability

in these community-based organizations and the volunteers that they have selected.

One thing that helps in terms of this accountability,

are there very simple job descriptions or duties for the leaders of these organizations?

So, in terms of what they're expected to do for delivering health services,

organizing the community for preventive activities.

And again this goes back to

the organization that receive the grants from the Global Fund.

Are they actually providing the strengthening, the training,

the technical support to make sure these community-based organizations

understand basic management and basic leadership

so that they can deliver the services themselves?

A number of the monitoring and evaluation indicators we've talked about

because again you don't know if the services have been delivered unless they're recorded,

you don't know if the community resources are being used unless there is record keeping.

So, we want to make sure that either the village volunteer or somebody within

a community based organization is responsible for monitoring and

evaluating the health programs that the community is delivering.

And this involves oftentimes making sure that there are simple and easy to use registers,

reporting forms, summary forms,

and that the community volunteers and

the community organizations are trained to use these forms.

As I mentioned earlier, without such forms,

we would not know the contribution that the community health workers are

making for our community intermittent preventive treatment program for malaria.

We can see when they submit their records the

additional services that they provide above and beyond what the health center could do.

But without them being trained and given the resources to do monitoring and evaluation,

we would not know what the community's contribution was.

And this needs to continue over time with

planning that looks ahead for several years again,

hopefully the programs will maintain the support

to the communities to get these commodities and supplies out to them.

So we want to think about some lessons that we can learn

about community systems and community system strengthening.

We want to remember that communities are composed of

systems that there are social networks,

there are leadership arrangements,

there are economic pursuits that generate resources,

we want to be aware that these components

exist and that these components have an impact on health and they

can be used as an interface with the health system to

strengthen the overall delivery of health services in an area.

So, again, we are very concerned that the community has a clear role,

that they are effective,

that they are working in partnership with the formal health system.

So, again, this interface with

the community systems and the health systems often goes through

the volunteer community health worker so that there is

this constant effort to collaborate and

coordinate the resources of the community and the health system.

So, ultimately, if the community is strengthened,

community-based organization and community volunteers

are strengthened they can make decisions,

take actions, and ensure that services are

delivered that will reach people directly in the communities.

Thank you for being with us.

CSS Indicators

Understanding and Strengthening Health Systems

Meet the Instructors