The symposium proved a pivotal moment in advocating for community health workers who should be trained effectively, paid as professionals, adequately supplied, and supportively supervised to advance critical public health goals. With over 700 participants gathered in Monrovia, the symposium included government representation from 46 countries, CHWs from around the world who participated in every session, and high-level representation from Liberia, participating countries, and development partners.

R4D’s Health Systems Strengthening Accelerator team was honored to support the development and delivery of the 2023 CHW Symposium. We facilitated a full-day pre-symposium workshop among 39 country delegations focused on advancing community health roadmaps and improving measurement of progress; and led development of four out of nine of the main symposium’s themed tracks dedicated to institutionalizing financing, professionalizing the community-led workforce, improving the use of data in CHW programs, and gender dimensions in community health programming.

We thank Liberia’s Ministry of Health, USAID, UNICEF, the Global Fund, Last Mile Health, the Community Health Impact Coalition, and all organizing partners for the great team effort that created such a successful global gathering.

R4D strongly supports the symposium’s culminating Monrovia Call to Action, an evidence-based mutual commitment to fund, scale and strengthen community health programs as an integral part of primary health care for the realization of universal health coverage. We commit to support the advancement of CHWs and their integration into strong primary health care systems as we work with governments, civil society, researchers, and other change agents to create self-sustaining systems that support healthy, educated people. 

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About Results for Development
Results for Development (R4D) is a leading non-profit global development partner. We collaborate with change agents — government officials, civil society leaders and social innovators — supporting them as they navigate complex change processes to achieve large-scale, equitable outcomes in health, education and nutrition. We work with country leaders to diagnose challenges, co-create, innovate and implement solutions built on evidence and diverse stakeholder input, and engage in learning to adapt, iterate and improve. We also strengthen global, regional and country ecosystems to support country leaders with expertise, evidence, and innovations. R4D helps country leaders solve their immediate challenges today, while also strengthening systems and institutions to address tomorrow’s challenges. And we share what we learn so others around the world can achieve results for development too. www.R4D.org

Photo © Patrick Adams, RTI International

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R4D experts who are involved with USAID’s Health Systems Strengthening Accelerator are participating closely in the symposium. Their participation includes leading the 2nd day of the pre-conference and contributing to several of the symposium’s technical tracks:

• Track 1: Institutionalizing and financing at-scale, sustainable community health worker programs for PHC2.
• Track 2: Professionalizing, compensating, and protecting CHWs and other community-based and community-led workforce
• Track 7: Digital health solutions to enhance CHW and other community-based and -led workforce programs
• Track 8: Gender dimensions in community health and CHW programming

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At Results for Development (R4D), Ms. Gates is a program associate on the Strategic Purchasing Africa Resource Center (SPARC) and Cross-Programmatic Efficiency Analysis (CPEA) teams. In this role, she assists in program management, country engagement and the facilitation of collaborative learning. She also works with R4D’s coaching team on management of the Experts Database.

Prior to joining R4D full-time, Ms. Gates interned with the R4D-led Health Systems Strengthening Accelerator (Accelerator), the Primary Health Care Performance Initiative (PHCPI) and R4D’s Frontier Health Market (FHM) Engage team to provide support in program management and day-to-day responsibilities.

Ms. Gates holds a BS in public health with an emphasis in environmental/occupational health and a minor in international development from Brigham Young University.

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In June 2022, Results for Development (R4D) and the Strategic Purchasing Africa Resource Centre (SPARC) partnered with the WHO Health Financing Team and the WHO Regional Office for Africa, to host a three-day virtual workshop convening a diverse set of stakeholders, primarily from seven countries that conducted a CPEA assessment: Côte d’Ivoire, Comoros, Kenya, Ghana, United Republic of Tanzania, Nigeria and Uganda.

The workshop’s primary objective was to enable collaboration and learning across countries in the WHO African Region that have conducted a CPEA and to facilitate real and sustainable policy progress
to address and resolve inefficiencies.

This summary report synthesizes the findings and messages related to CPEA implementation, including both the cross-programmatic inefficiencies identified as well as mechanisms to address them. Key themes and learnings include:

• Undue fragmentation across health programs constrained each country’s progress towards Universal Health Coverage (UHC)
• CPEA can be institutionalized as a lever and integrated with other health system reforms to improve efficiency across health programs
• Both technical expertise and political commitment are required to address inefficiencies identified by CPEA
• Coordination, both vertically and horizontally, is critical and can have a multiplier effect throughout the system
• Having a single national plan that’s unified and well connected brings coherence and accountability across the system to address cross programmatic inefficiencies

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As director Centre for Sustainable Health Innovations, Singapore she leads the tripartite InnovationS for UHC Collaborative to catalyze south-south dialogues around leveraging low-cost technological innovations and new models of healthcare in Asia and Africa. She is also co-founder of the Mutual Learning Platform for Mixed Health Systems launched in 2020 in response to the COVID 19 pandemic that convenes the private sector and public health stakeholders for evidence sharing and building interventional capacity for stronger health systems. Her projects on health technology includes a partnership with the Consortia of Affordable Technologies (CamTech) which mentors and seed-funds early stage social impact health innovations in Asia and Africa and the Grand Challenges Grant winner, the Biodiaspora Partnership that tracks and models infectious and vector borne disease through human movement patterns.

As senior public health scientist at the Public Health Foundation of India, she directs the Universal Health Coverage Initiative part of one of India’s seminal health policy exercises on health system reform. She was secretariat director for the government of India’s High Level Expert Group recommendations on universal health coverage, part of the country’s 12th Five Year Plan.

Dr. Balasubramaniam has authored several reports, policy briefs as well as peer-reviewed publications over her career as both a clinician and researcher. She works closely with municipal and state governments regionally and served on a taskforce on primary healthcare constituted Ministry of Health and Family Welfare, government of India and was a member of the technical review group on urban health constituted by the Ministry of Urban Development. She serves on the editorial board of the International Journal of Health Governance, was recently appointed to the editorial board of the newly launched Oxford Open Journal of Infrastructure and Health, and is regional editorial advisor to Oxford University Press’s Healthy Cities and Communities Encyclopaedia. Dr. Balasubramaniam holds visiting faculty positions at the National University of Singapore and the Keenan Research Centre, Toronto, Canada. She is a frequent advisor on health systems and policy to numerous multi-bi lateral organizations including WHO, IDRC Canada, the European Commission, the World Bank, the Wellcome Trust, USAID, DfID, and the Bill & Melinda Gates Foundation.

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At Results for Development (R4D), Mr. Khan is a senior program associate on the market shaping practice. He provides technical and programmatic support to the Maternal and Child Wasting (MCW) project, which works to increase access to nutrition commodities and combat malnutrition in Pakistan and Bangladesh.

Prior to R4D, he worked as a health economics and policy consultant at the Health Finance Institute, working to utilize blended finance approaches to addressing the noncommunicable disease gap. Prior to that, he served as a quality management officer at the Malawi Ministry of Health and Population, through Global Health Corps. In that role, he drafted a five-year health facility accreditation roadmap and finalized the quality of pediatric care standards, with the goal of improving the health care quality in Malawi.

Mr. Khan holds a master’s in public health (with a focus on health management) from the Harvard School of Public Health. He also received a BA from Columbia University in Middle Eastern, South Asian, and African Studies. He is a fluent English speaker.

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SPARC is not just a resource center but a movement. SPARC is engaging as many stakeholder groups across Africa to understand, talk about, and advocate for strategic purchasing to make better use of limited resources for UHC and to hold governments accountable for effective health spending.

Between July 25-28 2022, SPARC convened 80 representatives from Ministries of Health, National Health Insurance agencies, the technical partners consortium, and coaches who support SPARC country engagements from 11 African countries ( Benin, Burkina Faso, Democratic Republic of Congo, Cameroon, Ethiopia, Gambia, Ghana, Kenya, Nigeria, Rwanda, Tanzania and Uganda). At this convening, SPARC hosted a learning exchange between these countries on advancing strategic health purchasing through the government budget.

Why the government budget?

In many African countries, the government budget remains the largest pool of funds. Although the government budget has not been fully leveraged for strategic purchasing, there is growing interest in the region in introducing new health financing arrangements that operate in parallel with the government budget, such as contributory national health insurance, community-based health insurance, and other schemes. It’s clear the government budget remains the most effective and equitable vehicle for strategic purchasing.

It is widely acknowledged that more public resources are required to advance UHC objectives — and public funds — including on-budget donor resources channeled through the government budget, allowing for pooling and allocation of resources to providers in a way that aligns with population health needs. Recognizing the value of the government budget and the opportunities therein, representatives from Burkina Faso, Kenya, Nigeria, Tanzania and Uganda, shared their country experience using the government budget to improve strategic purchasing and remaining obstacles to be overcome.

Resisting further fragmentation by channeling the government budget in existing schemes

Multiple schemes in countries, fragment health resources flowing through the schemes reducing the purchasers’ power to exert influence on how resources are allocated, and the incentives to providers for high quality care. When new schemes are established, often times they worsen the fragmentation in the system by adding a new scheme rather than building on what exists.

Tanzania’s Basket-funding, however, aimed to reduce fragmentation by pooling the government budget and on-budget donor resources into one pool and channeling resources directly to primary health care providers (PHC) through the Direct Health Facility Financing (DHFF) for priority maternal and child health (MCH) services.

In Nigeria, the Basic Health Care Provision Fund channels 1% of consolidated government revenue through three gateways to the National Primary Healthcare Development Agency to finance inputs for PHC providers; to the National and State Health Insurance Agencies to extend insurance coverage to vulnerable groups, and for emergency and pandemic related health services. In so doing, the government budget is building on existing purchasing agencies to transfer resources to providers targeted at PHC and addressing the needs of the most vulnerable population groups.

Prioritizing vulnerable groups and priority services

Channeling the government budget toward priority health services and/or population groups, such as women and children, in a bid to reduce maternal and infant mortality can move countries closer to achieving the sustainable development goals and UHC. The Gratuite program in Burkina Faso transfers government funds directly to PHC providers for MCH services. In Kenya, the “Linda Mama” program runs on a government budget subsidy channeled through Kenya’s National Hospital Insurance Fund for coverage of antenatal care, health facility delivery and postnatal care. In Uganda, budget guidelines stipulate that 30% of facility resources must be used for preventive health services and limits the district health facility budget spending on administration to 15% while the rest should be used for service delivery.

Using the government budget to increase provider autonomy

Provider autonomy refers to the degree of financial and management autonomy health managers have to receive funds, use these funds, and respond to the incentives in provider payment systems. Government budgets are associated with rigid rules for spending public resources to ensure accountability for how these resources are used but may limit how providers can spend resources they receive.

Tanzania’s DHFF recognized PHC providers as accounting units, allowing them to receive public resources, and expanded the decision space for managers to develop facility plans in collaboration with community representatives. DHFF also bypassed the bottlenecks and delays at the district level by transferring resources directly to the PHC level. This has allowed providers to be more responsive to local health priorities and allow more timely receipt of funds.

Burkina Faso’s Gratuite program also increased resources to providers and used a system of pre-payment that allowed for transfer of funds in advance to ensure adequate resourcing of providers and overcoming bottlenecks to resource flowing to the PHC level.

A similar program to transfer funds directly to PHC providers in Kenya, and increasing their autonomy implemented between 2010 and 2012, showed similar successes reducing bottlenecks at the district level, empowering providers to respond to local priorities and improving infrastructure at PHC level. Uganda provides strict guidelines to providers and follows this with supportive supervision and audits. Although this limits provider autonomy, these processes are considered necessary to improve alignment to national priorities and accountability for public resources.

Overcoming remaining obstacles

Despite these successes, there remain challenges in raising adequate resources for health, navigating the politics of moving money and power from one organization to another. For example, Burkina Faso is considering a transition of the Gratiute program to the health insurance agency; and in Kenya the devolved system of government has increased fragmentation of health resources in 47 county governments. Further, a debate on how much provider autonomy is sufficient and how to link the government budget to better performance and quality of care remain important learning questions for SPARC and the technical partners going forward.

For those considering changes in the government budget, it’s important to have a clear vision and strategy — and to look for opportunities to solve problems with steps that have the least resistance from stakeholders, while building trust along the way. For SPARC, this is only the beginning of a learning agenda that builds on these country lessons.

Photo © Strategic Purchasing Africa Resource Center

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