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Advancing a community health co-creation strategy to achieve universal health coverage in Africa

Any sustainable solution to strengthen community health must begin by bringing all stakeholders to the table and avoiding fragmentation of limited resources.
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It is well documented that reorienting health systems towards primary care will bring us closer to Universal Health Coverage (UHC), where the full continuum of essential health services—from health promotion to prevention, treatment, rehabilitation and palliative care—is accessible and affordable for all people. Strong primary care can lead to lower health costs, better population health, higher patient satisfaction, fewer unnecessary hospital admissions and greater socioeconomic equity. 

To achieve UHC, countries need to have strong, efficient and equitable health systems that are rooted in the communities they serve. Community health, supported by a robust and well-equipped health workforce, is at the heart of primary care. However, investment in community health is far from where it needs to be. 

Community health workers (CHWs), for example, play a critical role in bridging the huge health worker shortage gap while providing both essential health services and pandemic response. The reality is that there will be no UHC without CHWs—yet they are often unsalaried, unsupported and under-resourced, lacking sufficient training, equipment and supervision. A vast majority of CHWs are volunteers, receiving minimal to no compensation. In Africa, 85% of CHWs, most of them women, are not paid for their work. 

Many countries have developed ambitious plans to scale and integrate community health workers but they need cohesive support to implement them quickly and effectively. Sub-Saharan Africa, in particular, faces a $5.4 billion annual financing gap for community health. Financing remains the largest systemic barrier to scaling and sustaining quality community health services. 

One plan, one budget, one implementation approach 

Across the African continent, more than half of its people—around 615 million—are still not accessing the healthcare they need. At Johnson & Johnson, we champion community health strategies at the national level as an integral part to achieving UHC, and support the Monrovia Call to Action launched at the 2023 International CHW Symposium. As specified in the same call to action, for community health strategies to be efficient and effective, there needs to be “one plan, one budget, one implementation approach.” It’s clear the next leaps in community health require collective action. 

To that end, the Johnson & Johnson Foundation and the Skoll Foundation invested $25 million to launch the Africa Frontline First Catalytic Fund (AFF-CF) last year, which was matched by the Global Fund. AFF-CF seeks to mobilize at least $100 million to triple the number of salaried CHWs in 12 African countries, aligned with the community health priorities identified by the Ministries of Health in each country. 

Additionally, the Johnson & Johnson Foundation supported co-creation workshops to convene stakeholders to develop short- and long-term objectives for community health platform building in four countries to date—Kenya, South Africa, Nigeria and Uganda. Each co-creation workshop was tailored specifically to identify and address gaps in each country’s pathway to strengthening community health programming to achieve UHC, and mobilizing policy change and domestic ownership to ensure long-term sustainability. 

Galvanizing support for country-based community health platforms 

In Kenya, we celebrated the outcome of such collaborative work when President William Ruto launched a new initiative to integrate CHWs formally into the health system. This momentous milestone was achieved against the backdrop of the Community Health Units for Universal Health Coverage (CHU4UHC) platform co-created with the Ministry of Health in 2020 which led to a holistic Kenya Community Health Strategy developed through a multi-stakeholder and multi-sectoral participatory process, with input from county governments, civil society, development partners and, crucially, community members themselves. 

CHU4UHC played a catalytic role in mobilizing changemakers in Kenya such as ELMA Philanthropies to collaborate on a single plan aimed at addressing CHW issues—including remuneration and digitalization—at a systemic level. With government and other stakeholders on board from the outset, we worked together to identify the strategic investments needed to support professional CHWs within a sustainable community-based primary healthcare system capable of achieving UHC. 

Taking the lessons from CHU4UHC, a similar platform—the CHW Think Tank—was established in South Africa, in partnership with the National Department of Health, to strengthen the country’s Ward-Based Primary Health Care Outreach Teams strategy of CHWs alongside nurse team leaders to support community-based primary healthcare. The Think Tank comprised broad representation, including governmental and civil society organizations, NGOs, academia, developmental partners and funders, all appointed by the Director General for Health. 

The CHW Think Tank promoted critical thinking and enabled robust discussion to inform targeted ways to support CHWs and develop the policy and framework to implement the strategy. The Think Tank also laid the foundation for identifying and prioritizing five initial key policy interventions, including accreditation of CHW training, supported training of CHWs and outreach team leaders, supporting the policy review process, evaluating the implementation of a mobile health application, and strengthening monitoring and evaluation of the CHW program. 

The co-creation workshop in Nigeria focused on identifying, analyzing and recommending solutions to specific areas of gaps in mental health, oncology and midwifery, and improving access to care. Facilitated by the Medicaid Cancer Foundation, Liverpool School of Tropical Medicine and Real Visionaries, attendees included policy makers at all levels, including the Federal Ministry of Health, as well as educators, clinicians, professional organizations and NGOs. 

By coming together as a collective for the first time, the stakeholders were able to develop a roadmap for future action, which includes driving urgent policy reforms to make mental healthcare available at the primary care level, building an oncology nursing workforce to improve the availability and quality of cancer prevention and service delivery, and to strengthen midwifery education and community midwifery. 

In Uganda, the co-creation work builds upon the country’s efforts to develop a National Community Health Strategy (NCHS), which was delayed by the COVID-19 pandemic. The effort to finalize NCHS aimed at aligning the contribution of key players towards the delivery of health services at the community level and to strengthen Uganda’s community health system by harnessing existing policies, guidelines and experiences of multiple actors and implementers in the community health space. We partnered with UNICEF in Uganda to bring together stakeholders to strengthen capacity to implement NCHS at the national, regional and district levels. This work led to the successful launch of the Uganda National Community Health Strategy in February of 2023. 

Acting together, creatively and decisively to minimize fragmentation of resources 

We have lost decades of progress in public health due to COVID-19, including disruptions to essential health services resulting in backsliding progress on immunization rates and a growing shortage of health workers. Strong community health programs are a proven high-value investment that can accelerate progress towards UHC, global health security and economic recovery. We have to come together as stakeholders with a united goal and put our resources behind strengthening community-based primary care. 

The turning point in Kenya in the first year was when ELMA Philanthropies expressed interest in working with us to build the “one program.” Johnson & Johnson Foundation and Elma Philanthropies have been co-funding the work 50-50 under one budget that is allocated to partners for the implementation of national community health priorities driven by the Ministry of Health. 

Private and philanthropic partners are uniquely positioned to drive systems change and increased investments in community health programs. If we can get to a point where all funders in community health can set individual projects aside and put their resources all on the table to stimulate governments to prioritize national community health programs, I believe we will have solved one of the biggest challenges in global health—and we will realize the promise of UHC in Africa.