Ndejjo R, Musinguzi G P, Musoke D, Wanyenze RK. Unlocking the power of communities to achieve Universal Health Coverage in Africa (Position paper). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4382 P a g e 1 | 11 POSITION PAPER Unlocking the power of communities to achieve Universal Health Coverage in Africa Rawlance Ndejjo1, Geofrey Musinguzi1, David Musoke1, Rhoda K. Wanyenze1 1 Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda Corresponding author: Rawlance Ndejjo; Address: Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda Email: rndejjo@musph.ac.ug Source of funding The author(s) received no specific funding for this work. Conflict of interest statement The authors declare that they have no competing interests Authors’ contributions RN conceptualised and wrote the first draft of the manuscript. GM, DM and RKW supported the literature review and critically revised the manuscript. All authors read and approved the final manuscript. Acknowledgments The authors wish to acknowledge Prof. Augustino Ting Mayai for his support in the manuscript development process. mailto:rndejjo@musph.ac.ug Ndejjo R, Musinguzi G P, Musoke D, Wanyenze RK. Unlocking the power of communities to achieve Universal Health Coverage in Africa (Position paper). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4382 P a g e 2 | 11 Abstract Africa is at a critical time undergoing demographic, epidemiological, political and socio-eco- nomic transitions and faced with repeated outbreaks of emerging and remerging diseases. The continent also faces other broader challenges of climate change, environmental degradation and pollution testing the resilience of its health systems and hindering progress to achieve health for all. Five years into the journey towards Sustainable Development Goals (SDGs), the continent – similar to the rest of the world – has been gripped with the Corona virus disease pandemic that has caused significant morbidity and mortality as well as severely disrupted health systems and the underlying socioeconomic determinants of health. One of the most significant SDG targets is the achievement of Universal Health Coverage (UHC) where all people have access to quality health services they need without inflicting a financial hardship on them. However, progress to- wards this target has been slow on the continent and requires rethinking current approaches em- ployed. We argue that Africa’s key strength lies in the communities whose potential should be unlocked to build cost effective and sustainable bottom-up health systems founded on Primary Health Care (PHC). Such systems should be founded on community-based services, designed around individuals, families and the community, involving community health workers and other actors, and capitalising on health promotion and disease prevention approaches. A strong com- munity health system should be adequately linked to district, regional and national levels work- ing together to empower and serve populations to make health for all a reality. Keywords: community health, disease prevention, health for all, health promotion, primary health care Ndejjo R, Musinguzi G P, Musoke D, Wanyenze RK. Unlocking the power of communities to achieve Universal Health Coverage in Africa (Position paper). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4382 P a g e 3 | 11 Introduction The central promise in the 2030 agenda for sustainable development is to leave no one behind as countries make progress to achieve the Sustainable Development Goals (SDGs) (1). Although all goals contribute to health, SDG 3 specifically aims to ensure healthy lives and promote well-being for all ages (2). Among the goal targets, target 3.8 purposes to achieve Universal Health Coverage (UHC) for all (2). UHC seeks to ensure that all peo- ple have access to health services they need of sufficient quality from prevention, promo- tion, treatment, rehabilitation and palliative care with the use of such services not inflict- ing a financial hardship on them (3). UHC has great potential to drive achievement of SDG 3 and the 2030 agenda (2, 3). Based on Africa’s unique context and needs, a health system rooted and operationalised within the community holds the promise to achieving UHC for its population. The context: a continent undergoing change and prone to emergencies The Corona virus disease that originated from China in the late 2019 (4-6) has further put a spotlight on the strain of health services delivery and tested the resilience of health systems across African countries. As of 19th January 2021, the continent had registered 3,284,451 COVID-19 cases, 3.5% of all cases globally, and 79,633 deaths (CFR: 2.4%) in Africa Union’s 55 member states (7). Never in the world has the importance of strengthened, resilient and responsive health systems and UHC been more important (8- 11). Moreover, Africa has a high prevalence of infectious diseases including malaria, HIV, tuberculosis among others (12, 13) and is prone to epidemics of emerging and re- emerging diseases including of Ebola, Mar- burg, yellow fever and cholera (14, 15). In- deed, the continent was in 2014 gripped with its deadliest Ebola disease outbreak that greatly affected West Africa (Guinea, Sierra Leone and Liberia) leading to 28,616 cases and 11,310 deaths (16). Some parts of East Africa including the Democratic Republic of Congo (DRC) and Uganda have also suffered repeated outbreaks of haemorrhagic fevers especially Ebola and Marburg (14, 17). These conditions pose threats to health security on the continent and their emergence back rolls progress made in improving health outcomes. For example, the early interventions due to COVID-19 were associated with negative impacts on malaria, HIV, maternal mortality, sexual and reproductive health. The African continent is undergoing several transitions in its demography, disease epidemiology, polit- ical and socio-economic context (18). The continent is experiencing a surge in its young population and with increasing life expec- tancy, the elderly are also increasing. Be- tween 1990 to 2019, the continent has seen the greatest burden of disease shift from com- municable, maternal and neonatal conditions to non-communicable diseases and injury. Conflict, political processes and competing interests across African countries and its in- stitutions continue to impact health in terms of funding and prioritisation, increase vulner- able groups and further health inequities. These political determinants of health further impact the socio-economic context including the poor living conditions, education, unem- ployment, unplanned urbanisation and inade- quate access to healthy foods among others which further impact health outcomes. More- over, the COVID-19 pandemic has further negatively impacted these socio-determi- nants of health reversing gains in education, employment and poverty across the conti- nent. Another challenge that the continent faces is environmental with environmental Ndejjo R, Musinguzi G P, Musoke D, Wanyenze RK. Unlocking the power of communities to achieve Universal Health Coverage in Africa (Position paper). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4382 P a g e 4 | 11 degradation, pollution, and climate change increasing risk of natural disasters such as drought, flooding, and landslides, food inse- curity and vulnerability to infectious diseases (19). These challenges continue to negatively impact the health of Africans, its health sys- tems, populations, economy, and progress to- wards UHC. Health systems in Africa Although Africa has a fair share of health and environmental challenges, access to health services in most parts of the continent occurs amidst several impediments including frag- ile, weak and inadequately funded health sys- tems (20, 21). A health system comprises all organizations, institutions and resources that produce actions whose primary purpose is to improve health (22). The World Health Or- ganization proposed six building blocks of a health system (23): service delivery; health workforce; health information systems; ac- cess to essential medicines; financing; and leadership/governance and deficiencies among these have been shown in Africa for several years. Service delivery on the conti- nent is characterised by challenges including in health worker availability and capacity, and availability of required equipment and drugs (20, 21, 24). The continent also has the least health workforce per capita (24-26). For example, in 2007, Africa had an average of 2.3 health workers of all categories per 1000 population compared to 18.9 in Europe and 24.8 for Americas (25). To meet the basic healthcare needs of its population, Africa re- quires at least one million more health work- ers (27, 28), however, the current growth rate of the workforce is not at par with recom- mended targets (29). In 2001, African Union countries pledged to allocate 15% of their an- nual budget to health to strengthen their health system and ensure disease prepared- ness and response, however, although most countries have increased the proportion of public expenditure allocated to health, only a handful have met the Abuja target (30). Af- rica’s per capita expenditure on health stood at $160 in 2014 far lower than any other con- tinent (30). Across the continent, there have been demonstrated gaps in health systems leadership and governance, health infor- mation systems and access to essential medi- cines (20, 21, 24). These gaps impact the quality of care provided and the resilience of the health system to respond to shocks and stresses hindering progress towards UHC. The promise in community health UHC aims to achieve universal access to strong, resilient and people-centred health systems founded on primary health care (PHC) (3). High quality health systems should be for the people, equitable, resilient and efficient, focussed on both preventing and treating disease and illness, and helping to improve well-being and quality of life (3, 21). Amidst the challenges that Africa faces, it is critical for the continent to generate in- novative strategies to advance the health of its population to achieve UHC. One potential lies in unlocking the power of its communi- ties as a basis for organising and structuring bottom-up health systems. Communities are a group of people with diverse characteristics linked by social ties, share common perspec- tives, and engage in joint action in geograph- ical locations or settings (31). A community health system is “the set of local actors, rela- tionships, and processes engaged in produc- ing, advocating for, and supporting health in communities and households outside of, but existing in relationship to, formal health structures” (32). An effective community health system should: be all inclusive for community members, involve various stake- holders, utilize community structures, and have a functional PHC system. African com- munities are characterised by a sense of cul- ture, togetherness, harmony, and respect and Ndejjo R, Musinguzi G P, Musoke D, Wanyenze RK. Unlocking the power of communities to achieve Universal Health Coverage in Africa (Position paper). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4382 P a g e 5 | 11 consist of community members – adoles- cents, young people, and elderly – leaders and community groups among others. Indi- viduals, families and communities have the ability to promote and maintain health, pre- vent disease, and cope with illness and disa- bility with or without the support of a health- care provider, a concept termed selfcare (33). Self-care interventions includes health pro- motion, disease prevention and control; self- medication; providing care to dependent per- sons; seeking hospital/specialist/primary care if necessary; and rehabilitation, including palliative care (34) and has had wider ap- plicability in health. In sexual and reproduc- tive health, self-care has been successful in improving antenatal, delivery, postpartum and new-born care and combating sexually transmitted infections, including HIV, repro- ductive tract infections, cervical cancer and other gynaecological morbidities (34). In management of chronic conditions, positive outcomes for chronic condition are registered when patients and families, community part- ners, and health care teams are informed, mo- tivated, prepared and working together (35). Reviews have demonstrated the potential of community health programmes in improving health outcomes including for malaria, tuber- culosis and maternal and child health indica- tors (36-40). Moreover, countries in Africa including Ethiopia, Malawi and Rwanda have showcased several benefits from scaling up their community health programmes (41). The key elements for successful community health programmes have been national stew- ardship, embeddedness and integration, cadre and role definition, human resource manage- ment and support, and financing (42). The role of communities in health promo- tion and disease prevention Most health problems in Africa stem from poor hygienic and living conditions, food in- security and poor nutrition as well as emerg- ing and re-merging infectious agents ex- pounded by poverty, lack of health infor- mation and poor health seeking behaviours (43, 44). The continent is also faced with a ‘triple burden of disease’ consisting of al- ready existing communicable, emerging and re-emerging, and non-communicable dis- eases. In line with this, the Astana Declara- tion recognises the need for prioritizing health promotion and disease prevention so that people’s needs across the life course are met through comprehensive preventive, pro- motive, curative, rehabilitative services and palliative care (45). Unfortunately, far so of- ten and in many African countries, the health system is focused on provision of curative services at the expense of health promotion and disease prevention which is not in sync with the continent’s disease burden. In 2010, it was noted that whereas in low-income countries, 70 to 80% of the disease burden was attributable to preventable infectious dis- eases, less than 10% of national expenditures were directed to public population services (46). The contributory factors are the limited funding available for health care leading to prioritisation of short team goals compared to long term objectives, traditional emphasis on direct medical services and development, and limited capacity for health promotion and disease prevention (46). Fineberg et al in dis- cussing the dilemma of why prevention is of- ten overlooked for treatment noted that it is often invisible, requires persistent behaviour change and its results may be delayed in ad- dition to influence of commercial interests and other cultural or personal beliefs (47). To bridge the observed gaps in health promotion, the WHO regional office for Africa passed the health promotion strategy for the African region in 2012 whose aim is to “strengthen the capacity of Member States to develop, implement, monitor and evaluate health pro- motion strategies, policies, and regulatory Ndejjo R, Musinguzi G P, Musoke D, Wanyenze RK. Unlocking the power of communities to achieve Universal Health Coverage in Africa (Position paper). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4382 P a g e 6 | 11 and legislative frameworks” (48). The risk factors and determinants of focus were com- municable and non-communicable diseases, violence and injuries, maternal and child health conditions, and new and re-emerging threats to health” (48). Communities are key resources to take lead in health promotion and disease prevention initiatives and con- tribute to addressing these risk factors. The COVID-19 pandemic has been another re- minder of how important individual and com- munity actions are to maintenance of health and wellbeing. Indeed, individual and com- munity behaviours such as handwashing, so- cial distancing, avoiding spreader events, protecting the most vulnerable and commu- nity resilience, peer and social support and self-management have all been key determi- nants of disease response and its impact. Primary health care as the foundation for Universal Health Coverage PHC is one of the strong pillars of UHC which should be based on community-based services delivery and health promotion and disease prevention. The 1978 WHO Alma Ata declaration recognised health as a funda- mental human right and noted the need for ac- tion by various sectors beyond health to achieve health for all (49). In the declaration, PHC was defined as “essential healthcare based on practical, scientifically sound and socially acceptable methods and technol- ogy made universally accessible to individ- uals and families in the community through their full participation and at a cost that the community and country can afford to main- tain at every stage of their development in the spirit of self-reliance and self-determina- tion” (49). Although PHC should be country and context specific, it should comprise key services for health improvement. These ser- vices include: health education on usual health problems and their prevention and control measures; an adequate supply of safe water and basic sanitation; maternal and child care including family planning, immunisa- tion against major infectious diseases; pre- vention and control of endemic diseases; treatment of common diseases and injuries; and provision of essential drugs (49). PHC recognises health as multisectoral bringing together other sectors such as agriculture, ed- ucation, housing among others to contribute to health efforts (49). Furthermore, the need for individual and community participation in planning and organising PHC is paramount with emphasis on use of local resources and the system supported by trained and lay health workers including physicians, nurses, midwives, community health workers (CHWs) and traditional practitioners who re- spond to community needs (49). PHC should be sustained by integrated, functional, and mutually supportive referral systems. The need for the principles and values espoused in the Alma Ata declaration are now more im- portant than ever and continue to be relevant especially in Africa which should strive to build health systems that capitalise on mid- level professionals and CHWs and recognise the relevance of social determinants of health. Owing to the continued relevance and importance of PHC 40 years later, the Astana declaration reaffirmed the need for PHC ef- forts to ensure that everyone is able enjoy the highest possible attainable standard of health regardless of where they are (45). PHC in- volves the provision of a broad range of pre- ventive and curative services to meet the needs of the population served and remains a cost-effective approach for many low- and middle- income countries (49). Building sus- tainable PHC driven by knowledge and ca- pacity-building, human resources for health, technology and financing thus remains one of the proven approaches to achieve UHC (45). The strong platform of PHC should overarch- ingly be based on community-based services and health promotion and disease prevention Ndejjo R, Musinguzi G P, Musoke D, Wanyenze RK. Unlocking the power of communities to achieve Universal Health Coverage in Africa (Position paper). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4382 P a g e 7 | 11 (3). This however should be contextualised to the current context acknowledging the major shifts in disease conditions and risk factors, technological advancement, and latest evi- dence. Restructuring for universal health cover- age: from bottom up “Health is made at home, hospitals are for re- pairs” has been a common phrase in discus- sions to reform health systems. There is agreement on the importance of health pro- motion that starts with the individual, fami- lies and the community as a central point for building people-centred health systems. These should be equipped with health promo- tion and disease prevention information so that they are empowered and actively en- gaged in maintaining their health and not mere passive bystanders. To achieve UHC, health systems should reach all communities no matter the context. Recognised as the first point of contact with the health system in many communities, CHWs have an im- portant role to play in community mobilisa- tion, education, dialogue, empowerment and basic health services provision (50). CHWs have so far contributed to several health gains in immunisation, maternal and child health and sexual and reproductive health services provision across several countries (38, 51). The WHO has provided guidance to optimize CHW programmes stipulating ways to im- prove the design, implementation, perfor- mance and evaluation of programmes to con- tribute to the progressive realisation of UHC (52). These guidelines cover several areas of CHW programmes including training, super- vision, remuneration and career progression among others aimed to bridge persistent gaps across programmes (52). These guidelines should inform the scale-up and sustainability of well designed, responsive and impactful CHW programmes. Within communities, community action and outcomes go beyond the CHW as the most visible cadre with a no- table contribution of wider community actors and health system factors and thus the need to embrace community health systems (32, 53). CHWs are part of the community health system which in itself is an integral part of PHC and district health systems (53). The other actors at the community level such as local political, religious and cultural leaders, health committees, community groups and faith-based organisations all have important roles to play in advancing community health (32, 54). These actors work without formal bureaucracies relying on trust, acceptability and support of the formal health system influ- enced by local histories, economic and polit- ical systems, and social–cultural norms (32). PHC systems support community health with well-trained health workers, drugs, equip- ment, health information systems, and proper referral systems and should be well financed and governed. With more investment in health promotion and disease prevention at the community level, the disease burden on the PHC system is reduced providing room for health workers to improve their capacity to better support communities including through routine outreaches and screening ac- tivities reaching the underserved. The PHC system should then link with the district health system across the referral pathway to support management of complicated cases or their subsequent referral to the next level (53). The functionality and integration of the health system is paramount right from the CHWs, community health systems, PHC and the overall district health system. This inte- gration should include aspects of joint own- ership and design, collaborative supervision and feedback, incentives, and monitoring systems incorporating data from communi- ties and the health system (54). The district health system should then link with the re- gional / provincial and national health sys- Ndejjo R, Musinguzi G P, Musoke D, Wanyenze RK. Unlocking the power of communities to achieve Universal Health Coverage in Africa (Position paper). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4382 P a g e 8 | 11 tems providing clear pathways for referral and integration. 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