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Lenses, Metaphors and Research Priorities on Community Health Systems. Report of Workshop, Chaminuka Lodge, Lusaka, Zambia, 10-14 June 2019

Authors:
WORKSHOP REPORT
Lenses, Metaphors
and Research Priorities on
Community Health Systems
Chaminuka Lodge, Lusaka, Zambia
10-14 June 2019
PREFACE
This report has been compiled by a group of public health and health system
players, engaged in thinking, researching, policy-making and advocacy on
community health systems (CHS). With an explicit interdisciplinary focus, this
group met for a week (10-14 June 2019) at the Chaminuka Lodge in Lusaka,
Zambia to collate our collective understandings of the CHS and generate a
set of research priorities that can form the basis of future collaboration. Our
common starting point was our positioning as embedded researchers and
practitioners in our respective country settings, namely, Zambia, Sweden,
South Africa, Guatemala, Tanzania and Uganda.
We thought it important to capture the rich and diverse thinking that emerged
during the course of the week, not only for ourselves but also for others in-
volved in the global conversations on the CHS. We are embarking on a series
of dissemination activities and products based on the workshop, and are
planning further gatherings that will bring together researchers, practitioners
and decision-makers across diverse settings.
This report is the first step in this process and is intended as an overview of
our deliberations at the workshop, which culminated in the drafting of a col-
lective statement, the Chaminuka Manifesto on the CHS.
The workshop was organised by our three institutions and hosted by the
University of Zambia. It forms part of an ongoing collaboration between us,
jointly funded by the Swedish Foundation for International Cooperation in Re-
search and Higher Education (STINT), the South African National Research
Foundation (NRF), and a network grant (ResearchLink) from the Swedish
Research Council (Vetenskapsrådet, VR).
We trust you will find the contents of this report interesting, and look forward
to further debate on the meanings and practices of community health sys-
tems.
Helen Schneider, School of Public Health, University of the Western Cape
Joseph Zulu, School, of Public Health, University of Zambia
Anna-Karin Hurtig, Department of Epidemiology and Global Health, Umeå
University
November 2019.
INDEX
Why the workshop? 03
Why the report? 04
What did we do? 05
Lenses and definitions 05
Collective action and responsiveness (community) lens 07
Health system hardware lens 08
Health system software lens 09
Critical perspectives lens 11
Defining Research Priorities for the CHS 12
Research priorities for the CHS 14
Domain maps and metaphors for research on the CHS 15
Methodologies 17
Engaging decision-makers and practitioners 19
The Chaminuka manifesto on research and practice in
the community health system 21
Appendixes 25
The idea of a community health system (CHS),
while by no means recent, is gaining traction as
part of new global agendas on primary health
care (PHC) and universal health coverage (UHC).
The current concept of the CHS brings together
various strands of thinking and programming that
have evolved over the past two decades. These
strands include renewed support for community
health worker (CHW) programmes as part of the
Millennium (and now Sustainable) Development
Goals, community system strengthening linked to
the Global Fund for HIV/AIDS, Malaria and TB,
and a growing interest in social accountability as
an engine of health system change.
In 2017, a coalition of bilateral, multi-lateral and
international non-governmental organisations
held a conference entitled ‘Institutionalising Com-
munity Health’ in Johannesburg, South Africa.
A ‘Community Health Roadmap’, led by USAID,
UNICEF and the Bill and Melinda Gates Founda-
tion (https://www.communityhealthroadmap.org/)
was subsequently launched in September 2019
as a follow-up to the conference. The Roadmap
seeks to consolidate the activities and direct the
investments of international agencies in an initial
group of 15 low and middle-income ‘RoadMap’
countries. These global processes are associat-
ed with an array of consensus statements, guide-
lines, web portals, e-health technologies, toolkits
and research prioritisation exercises on the CHS,
which collectively, constitute a veritable ‘epistem-
ic’ project to shape global thinking and policy di-
rection on the CHS at country level.
While less fragmentation in international initiative
on the CHS is to be welcomed, a historian of glob-
al health recently remarked of the convergence
of UHC and the Health Security Agendas: Is this
being done ‘so that a handful of people can pre-
sume to civilise the whole world? Reaching effec-
tive UHC is based on creating variable, context
specific healthcare at different levels of national
and sub-national governance. Not to be confused
with the top-down imposition of [the] idea of a
few.’ (Sanjoy Bhattacharya @JoyAgnost 22 Sep
2019). This report represents the perspectives
of a network of players, informed by their expe-
riences of the CHS in a range of country settings
(low, middle and high income), and keen to centre
a diversity of perspectives in emerging global de-
velopments.
Since 2017, the Universities of Zambia, Umeå and
UWC have met on a regular basis, finding syner-
gies between two initiatives to build our research
capacity and collaborations on the theme of the
CHS. This has been funded by South African
NRF - Swedish STINT and a network grant (Zam-
bia-Sweden) from the Swedish Research Coun-
cil VR. This collaboration (referred to as “U2U”)
has drawn in a wider network of researchers and
activists linked to the three partner Universities
– from the Universities of Cape Town, Makerere,
Muhimbili and the Center for the Study of Equity
and Governance in Health Systems, Guatemala.
Over the three years, U2U has hosted the follow-
ing activities: a workshop for doctoral candidates
from our various institutions, in Cape Town in
November 2017; joint sessions at the 5th Global
Symposium of Health Systems Research in Liver-
pool in October 2018; comparative case studies of
collaborative governance in local health systems;
and exchange visits between institutions.
WHY THE WORKSHOP?
03
We report here on the last and summative work-
shop held under the NRF-STINT agreement in
June this year. The workshop brought together 33
participants (listed in an appendix to this report)
from the seven institutions in our wider the net-
work, as well as frontline workers, managers and
senior policy makers from the Zambian Ministry of
Health. Over one week, this collective leveraged
their diversity (discipline, position and geography)
to undertake a multi-disciplinary exploration and
mapping of research priorities for the CHS.
Our varied positionalities encouraged us to consider more carefully our starting points and assumptions
on the CHS. For example, some of us have focused on the role of community health workers in health
systems, others on citizen mobilisation and advocacy; some of us on health systems, others on multi-sec-
toral development; some on macro-level policy and design, others on frontline action; some of us are
researchers, others practitioners and policy-makers.
By explicitly surfacing and harnessing different perspectives, we were able to stimulate rich thinking and
a variety of representations of the CHS (textual, visual and metaphorical) at the workshop. In the process,
we challenged the idea of a single narrative on the CHS, and emphasized the development of a mul-
ti-faceted research agenda that could accommodate multiple perspectives and starting points. We have
compiled this report in part to inform our own future work and collaboration, and in part to share insights
developed during the course of the week with others working in or researching the CHS.
WHY THE REPORT?
04
The workshop programme is provided in the appendix to this report. In sum, it involved activities and
processes focused on:
Lenses and definitions of the CHS: the workshop began with an exploration of different starting points
or ‘lenses’ on the CHS, and the different definitions of a CHS arising from these.
Research priorities for the CHS: in the build-up to the workshop, participants were asked to contribute
a list of research themes they considered to be priorities. These were further elaborated and grouped
over the week using a modified concept mapping methodology. The outcome of this was a series of
concept domains, metaphors and collective statements (declarations) for research on the CHS.
Engaging the practice of the CHS: thinking on priorities was informed by a day of inputs from poli-
cy-makers, practitioners, and trainers on the experiences of the Zambian Community Health System.
Research methodologies for the CHS: while the concept mapping process was unfolding we shared
experiences with novel research methodologies for the CHS.
Chaminuka Manifesto: the statements and deliberations of the week were compiled into a joint mani-
festo for research and practice on community health systems.
In the pages which follow report in more detail on these various elements.
In the first activity of the workshop, different perspectives and assumptions on the CHS were explored.
Based on contributions prior to the workshop, we proposed four general starting points or ‘lenses’ on the
CHS.
The first lens, ‘health systems hardware’, involves looking ‘into the CHS’ as the site of programmes,
most commonly CHW programmes, but also other outreach activities of the formal health system, such
as adherence clubs, women’s groups and clinic committees. This lens foregrounds the design, align-
ment, financing, training, supervision, supply chain processes, M&E systems and health outcomes of
such programmes. Such a lens would typically be associated with national ministries of health.
The second lens, ‘health systems software’, also involves looking into the CHS from the health sys-
tem, but from a relational and social point of view. This lens also shifts from an emphasis on the what
(design) to the how (implementation) and typically speaks to realities at lower levels of the health
system. At this level, the ‘people’ and ‘every day governance’ challenges of rigid mindsets, fragmented
relationships, power dynamics and mistrust amongst an array CHS actors are felt most strongly.
WHAT DID WE DO?
LENSES AND DEFINITIONS
05
The third lens, ‘responsiveness and collective action’, is the view from ‘within the CHS’ taking the
perspectives of community actors as the starting point. Needs and priorities are as defined by commu-
nity actors themselves, who seek – either as individuals or collectives - to establish their own health
agendas and achieve greater responsiveness from formal sector players for these agendas. This per-
spective is underpinned by values of rights and justice.
The fourth and final lens, ‘critical perspectives’, looking ‘above the CHS’, examines the CHS from po-
litical-economy perspective, interrogating and seeking to critically examine normative and dominant
discourses and practices on the CHS. It asks: what interests lie behind current global developments?
How should we view the CHS from a decolonial perspective? How do we ensure that contextually rel-
evant programmes emerge at national and sub-national levels?
Box 1: Rich picture instructions:
A rich picture is used to identify the main connections, influences, interactions and relationships
in a situation
It is called a rich picture because it illustrates the richness and complexity of a situation.
Use pictures, text, symbols (arrows, money) and icons to graphically illustrate the situation
Some starting questions:
Who are the stakeholders and how do they relate to the CHS?
Are there important relationships between stakeholders in the CHS?
Are there any key physical structures?
Are there intangibles you need to mention?
Each of the lenses was presented as
equally valid, whilst acknowledging
that in research and practice, certain
lenses are more dominant than oth-
ers. Participants selected a group,
based on their own positionality, and
were given an hour to collectively
draw a ‘rich picture’, write a definition
and identify key frameworks or meth-
odologies associated with this lens.
Instructions (Box 1) and examples of
the rich picture were given to partici-
pants.
06
This group represented a community health sys-
tem as a geographically bounded (although po-
rous) and complex set of inter-related systems
within other systems. The group recognised that
the CHS is influenced by top down (macro lev-
el) influences, for example, law, policy, donors/
funding structures, global and national politics,
economics etc. and bottom-up factors and pro-
cesses (housing, water, sanitation, environment,
livelihoods and shocks). Both perspectives are
relevant to understanding the CHS and the need
and possibilities for collective action.
The picture also represents the nature of action in
the CHS, specifically the need for building ‘bridg-
es’ to enable community voice, empowerment
and collective action, underpinned by values of
the right to health and human rights. Key actors
include health advocates/champions, community
health workers and other ‘boundary spanners’;
and community leaders. Intermediary spaces
include health facility committees/clinic commit-
tees; ward based committees/local government
and the ombudsman.
They defined the CHS as follows:
Community health systems are complex, over-
lapping systems that are generating of health,
well-being and development; that foreground and
are responsive to community voice, empower-
ment, rights and accountability; and which recog-
nise the importance of intermediaries (individuals,
organisations, networks) that align communities
within systems.
COLLECTIVE ACTION AND
RESPONSIVENESS (community) lens
Research would typically examine:
Feedback mechanisms into the formal health system,
such as health centre committees, hospital boards,
ombuds, and local political structures;
Community monitoring (such as citizen score cards);
Asset based community development;
Multisectoral engagement;
Intermediary or boundary spanners;
Social networks.
Research methodologies would
typically involve:
Critical lenses/theories;
Participatory action research;
Photovoice and other visual methods;
Embedded research;
Power analysis;
Stakeholder engagement;
Asset mapping.
07
08
The hardware group focused primarily on the
CHS as a sphere/space of service delivery. Initia-
tives in the CHS would include CHW programmes
and accountability and coordinating structures
such as neighbourhood health committees (NHC)
in Zambia. The CHS sphere is connected in a hi-
erarchical manner with the local and higher levels
of the health system (districts and ministries of
health) by a series of bridges between spaces.
This lens is concerned with how to reduce bar-
riers to access, for example, ‘a crocodile might
stand in the way of crossing the river’ or there
may be long distances to the health service. It is
also concerned with improving health outcomes,
such as reducing maternal mortality and HIV/TB.
This lens may recognise that outcomes are in-
fluenced by community level factors outside of
health (e.g. schools, sports fields, community be-
liefs, faith-based organisations and activities of
NHCs). Ideally outcome indicators would be dis-
cussed with the NHCs and CHWs at the centre of
the CHS, and joint solutions developed, although
the group noted that most of the time this hap-
pened in a top down manner. This group also re-
flected on the many different partners engaging
actors at all three levels of the health system, all
trying to meet health targets. This results in frag-
mentation, even if the partners do enable com-
munities to access needed services. This group
acknowledged that the hardware (designs, struc-
tures, outcomes), ultimately cannot be seen as
separate from the ‘software’ (relationships, cul-
tures etc.) of the CHS.
HEALTH SYSTEM
HARDWARE LENS
The group defined the CHS as follows:
The CHS is a focus of service delivery designed to provide accessible and acceptable
health services at community level, by the community and for the community. It is the interplay between
the formal health system and what goes on in the communities, informed by what we want to achieve,
both in the communities and formal health services. It involves leveraging community resources, with the
allocation of resources, implementation and coordination from the formal health system. It also involves
mechanisms to enable communities to take part in decision making on resource mobilization, and pro-
mote community ownership and hold the health system accountable. The CHS is the place where we can
gauge whether service delivery/activities have been successful through indicators measuring outcomes
and general health systems performance.
Research would typically examine:
Affordability, acceptability, availability, appropriateness and quality of services in the CHS;
Health system building blocks: service delivery, financing, HRH, information systems etc.;
Priority setting frameworks, such as effectiveness and cost-effectiveness;
Integration frameworks; Quality improvement frameworks.
A health system software lens places actors, their relationships and power at the heart of the CHS. These
actors are part of larger, layered hierarchies (from micro to macro), existing in political, economic and
gendered contexts. Relationships are both within and across elements of the wider system. Relationships
are influenced by contextual factors as well as our differences as human beings (individual personalities,
religious beliefs, agency and capacity), and entail issues of trust, motivation and power. The multiple
‘hands’ in the CHS are an indication of the capacity for collective action (‘power with’), the brain repre-
sents knowledge and mindsets (‘power to’), while the heart represents intrinsic motivation (passion), trust
and agency (‘power within’).
Initiatives in the CHS need to engage questions of power. For example, do these initiatives reinforce or
actively challenge gender norms.
The group defined the CHS as follows:
Community health systems are complex, dynamic and adaptive systems built by diverse people with
different levels of power in relation to each other. Relationships can be formal or informal; cut across
different levels (micro, meso, macro); involve a variety of actors - private and public, individual and insti-
tutional; and have both tangible (seen) or intangible (unseen) components.
09
HEALTH SYSTEM
SOFTWARE LENS
10
Research would typically examine:
Power and power relations, using a variety of
frameworks (Gaventa’s cube, street level
bureaucracy, Foucault etc.);
Relationships of trust;
Intersectionality;
Adaptive implementation;
Legal, moral, ethical frameworks for
decision-making, governance and leadership
Values of solidarity, equity and participation.
Research would typically involve:
Use of critical and feminist theories;
Co-production, embedded, participatory
action research;
Social network and stakeholder analysis;
Discourse analysis;
Power mapping;
Ethnography.
A critical perspective lens on the CHS is not generally regarded as important or relevant, with research
often focused on the immediate preoccupations of service delivery or collective action in the CHS. How-
ever, such a lens is key to understanding the evolution, forms and dominant discourses on the CHS
globally and in country health systems.
This lens locates the CHS historically, showing its origins in the post Alma Ata period, its ebbs and flows
globally, up to the recent re-emergence as part of Universal Health Coverage (UHC). These ebbs and
flows have to be seen in relation to major forces impacting on countries, such as the structural adjustment
programmes and neo-liberal economic orders from the 1980’s onwards, the health crises which have fol-
lowed and the re-emergence of disease-specific community programmes as part of ‘task-shifting’ ideas
in the Millennium Development Goals era.
This lens also recognizes the huge geographic variation in manifestations of the CHS, the need for ap-
proaches to the CHS to be locally defined within specific contexts, rather than a one-size-fits-all approach
and to not essentialise the CHS as a (often disease-specific) CHW programme, as is often the case in
global guidance. It asks: where are agendas being set and who is sitting at the table and where? who is
involved in the development of the guidelines, who gets to generate (and consume) knowledge, with what
underlying assumptions about the CHS? Is the current enthusiasm for the CHS a genuine effort to widen
access and empower communities, or a symptom of the failure to resolve health system challenges at
other levels?
This group defined the CHS in a normative sense as follows:
A CHS is an intersectoral, participatory, equity focused, locally embedded, context appropriate, empow-
ering set of complex relationships, actors and processes for health, well-being and social justice that
forms the foundation for the formal health system and is a key element of health system strengthening.
With respect to research, this lens would typically:
Be pre-occupied with the biography (who) and geography (where) of knowledge production on the CHS;
Undertake historical analyses, including of shifting global discourses;
Draw on contemporary thinking on de-coloniality;
Adopt political economy, feminist, intersectional approaches;
Seek to disrupt dominant discourses and put forward counter narratives;
Make visible the way in which power operates.
CRITICAL
PERSPECTIVES LENS
11
12
Building on the different lenses, concept mapping was used to facilitate a structured, participatory ap-
proach for integrating our collective ideas about what is important for strengthening and researching
community health systems. The concept mapping process was guided by the steps outlined by Tro-
chim & Kane (2005). Some adjustments to the steps were made in an effort to ensure that the process
was inclusive and participatory.
The steps followed were as follows:
An invitation to participate in a brainstorm, the first step of the concept mapping process, was sent
by email to workshop attendees two weeks prior to the meeting. The email asked participants to
respond to the focus prompt statement - “In order to strengthen Community Health Systems, the
research priorities I would like to see are….” Responses were compiled and consolidated, reaching
a total 75 statements after removing or combining statements with similar focus.
When the workshop commenced, there were new participants who had not had the opportunity to
participate in the brainstorming by email. To ensure that everyone’s voice was included in the
workshop’s collective efforts to conceptualize what is important to strengthen community health
systems, and drawing on the discussion of lenses, all workshop participants took time to review the
list of 75 statements, assess if their own ideas were reflected and add statements if their ideas were
missing. This assessment took place in small groups, from which an expanded list of 98 statements
was drawn up.
DEFINING RESEARCH
PRIORITIES FOR THE CHS
In the next step of the process, participants were invited to sort and rate the 98 ideas that were gen-
erated. Participants had the option to complete the sorting and rating individually or in groups. This
step was conducted using the ‘GroupWisdom’ software platform, which enables participants to group
statements into themes and to label the themes electronically. A total of 17 returns (whether com-
pleted as individuals or in groups) for this activity was received. A hierarchical cluster analysis of the
data enabled visualization of the ideas that were more frequently grouped together on a point map
(see below), where proximity of the points corresponding to each statement (as numbers) reflects the
frequency with which they were sorted together. A core team reviewed the outcome of this analysis,
from which coherent 10 clusters (or domains) were identified (Figure).
The 10 ‘cluster solution’ (or domains) was then presented to the workshop participants, who then re-
viewed the coherence of the domains and the idea statements clustered within them in small groups.
Based on these discussions, the concept mapping team found general consensus about the domains
that were judged to be coherent and adequately capturing an important theme. An overview of the
integrated list of domains with examples of what they represented was presented back to the work-
shop participants.
In a final, qualitative and interpretive step, participants (in four groups) developed CHS research
‘landscapes’ in the form of hand drawn concept maps capturing the CHS research domains identi-
fied. These maps drew on, but differed from the computer-generated cluster map in two key ways:
they depicted the meaningful relationships between domains (visually and in the declaration) and
presented an overarching conceptualisation, analogous to a metaphor, for research on the CHS. The
process thus enabled a new level of synthesis, collective sense-making and consensus on research
priorities (reflected in the Table below). Groups then wrote a consensus “declaration” for strength-
ening community health systems, which fed into an overall Chaminuka Manifesto on research and
practice for strengthening the CHS.
The sections which follows report on the final research domains identified through this process, and on
the maps produced.
13 1 William Trochim, Mary Kane, Concept mapping: an introduction to structured conceptualization in health care, International Journal for
Quality in Health Care, Volume 17, Issue 3, June 2005, Pages 187–191, https://doi.org/10.1093/intqhc/mzi038
14
The table below is a synthesis of priority research domains, with their definitions and examples arrived
at through the group process.
Cluster domain
Clarifying purpose
and values, ensuring
inclusive CHS
Design,
implementation,
M&E of strategies to
strengthen the CHS
Social, political and
historical contexts
Community health
workers
Social accountability
Interface between
CHS and the broader
health system
Governance and
stewardship
Ethical methodologies
for researching the
CHS
Definition
The core values, assumptions and
principles that characterise our framing
of the CHS and therefore of research
on the CHS, such as equity, inclusive-
ness, whole of society approach, social
determinants and locally driven.
Decision-making and programmes to
strengthen the CHS through all phases,
from context-sensitive designs and
models, the implementation and scale-
up of programmes, and monitoring and
evaluation strategies.
The history, political-economy, social
and gendered contexts of the CHS at
all levels, from global to local knowl-
edge, beliefs and practices.
Focus on the life-cycle of the CHWs,
including effective strategies for
identifying, selecting and recruiting,
training and developing, supporting
and retaining CHWs.
Community accountability and
responsiveness and participation
mechanisms; strategies for collective
action and effective citizen
participation.
The interface/interplay between
community health systems and the
broader health system; between the
community and health service, and
between the CHS and other CHS.
The oversight, direction and
stewardship required to strengthen the
CHS, ensure accountability, promote
inter-sectoral collaboration, overcome
fragmentation, ensure allocation of
resources and build trust.
Methodologies and processes that
align with the values of the CHS and
contribute to social change.
Examples of statements
Geared towards reducing inequalities
Focused on intersectional needs
Concern with the health of people (vs disease)
Focused on the social determinants of health
Takes into account perspectives of vulnerable groups
Different models of the CHS
Examples of strong community health systems
Strategies to guide programme implementation
Scaling up locally driven innovations
Monitoring at community level
Performance indicators for the CHS
Context sensitive evaluation strategies
Historical development of CHS
Politics and policy on the CHS
Discourses on CHS
Influence of local knowledge, beliefs and cultural
practices
Gender relations
CHS and the PHC approach
The CHS as nested in larger systems and society
Retention
Motivation
Training
Roles on paper vs practice
Embeddedness in communities
Empowerment and agency
Impact
Participation mechanisms
Responsiveness
Collective action
Power relations
Resource allocation
Overcoming fragmentation
Partner coordination
Balance between formal sector and volunteers
Roles of boundary spanners
Building trust between formal health care system
and CHS
Power dynamics within CHS
Involving private for profit actors
Intersectoral collaboration in CHS
Overcoming fragmentation
Partner coordination
Community resource mobilization
Sustainability
Embeddedness
Catching complexity
Participatory action research
Engaging with communities
Contributing to change
Co-producing knowledge
Context sensitive
RESEARCH PRIORITIES FOR THE CHS
As individual groups developed concept maps
showing the relationships between cluster do-
mains, they spontaneously produced four distinct
metaphors or representations of the CHS: 1) the
CHS as a living, ecological system; 2) the CHS as
a building; 3) the CHS as systems nested within
other systems; and 4) the CHS as level of action
(micro, meso, macro). These are described further
below.
CHS as a complex, living system
The relationships between research priorities for
the CHS can be illustrated with the metaphor of a
holistic, connected ecosystem life cycle. The CHS
is the trunk of the tree, with the size of the trunk
representing the stages of development of the CHS
and different trees, the different CHS contexts, as
in the figure below. The size of the trunk represents
the significance of the CHS in overall health sys-
tem contexts. Inside the trunk, the different lenses
of software-hardware-social accountability consti-
tute the core of the trunk, being all three permeat-
ed by the tree sap (critical thinking). The roots of
the tree are the community which influences and
decides the organization of the CHS. To survive,
the trees need water from the river. The river rep-
resents the historical, political and social context
that shapes the CHS and the in water-flow, is the
time dimension. The branches of the tree repre-
sent the different sectors of the society (transport,
agriculture, services, trade, ….) that should be in-
fluenced by the trunk (CHS in all sectors) and the
fruits mirror the health and well-being of the com-
munities. These various ideas form the basis for a
contextualised approach to research on the CHS,
but can also be the focus of research themselves.
The clouds depict specific research priorities for
the CHS (including governance, the role of CHWs,
mechanisms of social accountability etc.) and the
rain falling into the trees and river, the strengthen-
ing of the CHS, as a product of research. The CHS
ideally grow slowly, engaging the formal health
system in a process of continuous collaboration
represented by the interface of the two systems.
DOMAIN MAPS AND METAPHORS
FOR RESEARCH ON THE CHS
15
The CHS as bricks and mortar
In this representation, CHS research do-
mains are presented as a connected
whole, this time as a house. Values and
purpose of the CHS form the foundation
for research on CHS. Governance pro-
vides the roof and the interface between
the CHS and the broader health system
are the rafter beams supporting the roof.
The pillars or walls represent specific the-
matic areas: CHWs; social accountability;
CHS strengthening cycles (planning, im-
plementing, monitoring and evaluating);
and the historical, political and social con-
texts. Power, trust and relationships form
the framework holding together the differ-
ent elements. Our research methodologies
should also reflect an understanding of the
connectedness of the various domains.
The CHS as systems within systems
In this representation of the key research domains and priorities, the community health system is em-
bedded in communities and in the broader health systems with porous boundaries between them. As
such, the CHS represents a significant health system asset comprising both hardware elements such as
human resources, drugs and technologies, as well as software elements such as values, relationships
and trust. Communities exist within and are part of health systems, and communities and health systems
are comprised of systems within systems. Values and purpose are placed at the heart of research, and
research priorities are framed by notions of complexity. Ideas of collective action and the need for critical
perspectives cut across all the various domains.
16
The CHS as levels (micro, meso, macro)
Here the research domains for the CHS are
represented at micro, meso and macro lev-
els, underpinned by values of inclusivity that
inform principles and practice of the CHS.
Research on the design, implementation,
monitoring and evaluation of programmes is
conducted at the micro-level. This includes a
focus on both social accountability and CHW
programmes. The meso-level concerns re-
search into the interfaces with the formal
health system, and the governance responsi-
bilities towards the CHS. These are embed-
ded in macro-level considerations of history,
society and politics.
The lenses and research priorities that surfaced during the course of the workshop were naturally tied to
considerations of ethical methodologies for research and practice that align with the purposes and values es-
poused by the group. While addressing the range of CHS research priorities requires different methodologies,
there was overall consensus that approaches needed to firstly, foreground social justice and social change,
and secondly, recognise the CHS as a complex adaptive system. Key principles included participation, social
action, embeddedness, co-production, ongoing reflective learning, context specificity and sensitivity to lan-
guage (‘on’ vs ‘in’ vs ‘for’ vs ‘with’ the CHS). In addition to these key principles, the group recognised the critical
importance of doing away conventional hierarchies of research evidence governing the field. So, for example,
participatory research on the lived experiences of the community health system or political-economy analyses
are as valid as a randomised controlled trial of a complex intervention, or a cost-effectiveness analysis of a
CHW programme to reduce neonatal mortality. Research should be problem rather than method driven and the
overarching methodology should draw on a range of data collection activities that best respond to the complex
question at hand.
17
METHODOLOGIES
Participants shared their emerging experiences with various forms of participatory research
in the CHS, including photovoice, ‘DrawingOut’, community dialogues, stakeholder
reflective meetings, community asset mapping, and film. Co-production of knowledge and
close attention to the ‘biography’ and ‘geography’ of knowledge production were at the core
of these approaches.
Also discussed was the increasing commercialisation of publishing and the need to develop and promote
open access alternatives. Participants were challenged to play an active role in identifying ways and op-
portunities to engage debates and developments in this area.
18
Decision makers and practitioners involved in the
Zambian CHS, with whom UNZA’s School of Pub-
lic Health has long standing relationships, formed
an integral part of the workshop. They included
senior policy makers, trainers, frontline providers
(Community Health Assistants - CHAs) and their
supervisors in the Ministry of Health, and partner
agencies (Clinton Health Access Initiative (CHAI)
and Innovation Poverty Action (IPA)).
One day of the workshop was devoted to presenta-
tions and discussion of developments in the Zam-
bian CHS, with additional reflections on the Tan-
zanian experience. These inputs were immensely
valuable in the following ways:
The long-term relationship between SPH, UNZA
and Zambian MOH provided an example of em-
bedded research that addresses context specif-
ic research, implementation and development
needs;
Examples of constructive partnerships between
MoH and non-state (including external) actors
demonstrated how these can complement gov-
ernment efforts in strengthening social account-
ability, availability and use of information by the
community as well as capacity of community
structures and actors in providing and monitor-
ing service delivery;
Knowledge of current developments, such as
the recent establishment of the Community
Health Unit in the Zambian Ministry of Health,
provided insight into the visions, constraints
and possibilities of implementation, ensuring
that thinking on research priorities remained
grounded in real-world concerns and contexts;
Inputs from experienced CHAs provided in-
sights on the challenges and strategies for en-
gaging and promoting community participation
in planning, coordination, implementation and
monitoring in the CHS.
Case studies on the training and supervision of
CHAs illustrated how training in supportive su-
pervision coupled with provision of supervisory
tools can help address supervisory challenges,
by building the capacity to provide mentorship
and coaching to CHWs.
The experiences of Tanzania highlighted the
long histories and many waves of intervention in
the CHS and the need for critical perspectives
on developments in the CHS.
There was unanimity in the group on the need for
more opportunities to promote dialogue between
researchers, policy-makers and practitioners, with-
in and across the countries represented at the
workshop.
ENGAGING DECISION-MAKERS
AND PRACTITIONERS
19
Structure of Zambian Community Health System (Source: Zambian Ministry of Health)
20
From 10-14 June 2019 a group of people came together at the Chaminuka Lodge, Zambia to develop an
agenda for research and practice to strengthen community health systems (CHSs). The group
included community health workers (CHWs), scholars, policy-makers and practitioners from six
countries: Zam-bia, South Africa, Sweden, Tanzania, Uganda and Guatemala, encompassing a wide
range of personal and professional experiences. We recognised that our different experiences
shaped our views of the world and our approach to the CHS. Deliberately approaching the CHS
through a variety of lenses and acknowledging that there is no single narrative of the CHS, we
grappled collectively with the complexity of the CHS and the multiple perspectives on research and
action in the CHS which need to co-exist with each other.
We were brought together:
by a shared belief in the centrality of communities to health systems functioning, and the need to move
towards recognising and (re)centering the people, families and communities that are at the core of any
health system;
with a common purpose to further understanding of the vital role played by communities and communi-
ty health systems in building responsive health systems; and to strengthen community health systems
within and across their settings;
the need to shift the ‘biographies’ (who conducts) and ‘geographies’ (where conducted) of research
and thinking on the CHS.
Over the course of a week-long workshop, the participants developed a set of core principles that should
inform all work on CHS, and a research agenda to guide future collaborations.
The Chaminuka manifesto on research
and practice in the community health
system
21
This is the Chaminuka Manifesto:
We believe that communities are complex social systems with long histories, imbued with power relations
that play out between people, families, neighbourhoods, committees, and health workers. We understand
community health systems as embedded in these community social systems and in broader health sys-
tems, with porous boundaries between them. The CHS represent a significant health system asset or
resource comprising both hardware elements, such as human resources, drugs and technologies, as well
as software elements such as values, relationships and trust.
Health systems typically engage the CHS through community health worker (CHW) programmes. CHWs
are mandated to provide primary and preventive health services, but both their mandate and their capac-
ity to carry it out effectively are impacted by factors such as motivation, training, degree of embedded-
ness in communities they serve, and the disjuncture between their role as described on paper, and what
is expected in practice. It is therefore vital that the research takes seriously the lived realities of CHWs,
and seek to establish effective strategies for identification, selection and recruitment of CHWs and best
practice for training and continuous development of CHWs, enhance their agency, motivation and job sat-
isfaction, and remove barriers to effective retention of CHWs in and relationships with the health system.
22
We believe that the CHS is also a site for the empowerment and participation of communities within
broader health systems, allowing communities to hold government to account. This is to be achieved by
strengthening community participation mechanisms that shift power relations, ensuring responsiveness
of health systems to community needs, and actively pursuing strategies for collective action. This entails:
Building capacity for collaborative governance and accountability, understood to include oversight,
direction and stewardship to enable and strengthen the CHS, promote intersectoral collaboration,
overcome fragmentation, ensure allocation of resources and build trust;
Strengthening the interface and relationships between CHSs and their broader health systems, as well
as between the community and health services;
Recognising the importance of addressing imbalances in power and building trust in relationships
between stakeholders in strengthening the CHS.
We also believe that it is the responsibility of governments to support and strengthen the CHS,
which includes:
Working to overcome health system fragmentation
Ensuring equitable resource allocation to CHSs
Coordinating partnerships between actors within CHSs, and monitoring the impact of external partner
actions on CHSs
Ensuring balance of power between formal sector health workers and volunteer CHWs
Recognising the importance of boundary spanners which mediate relations between CHSs and broad-
er health systems
Building trust between the formal health care system and the CHS
Strengthening the capacity of communities to hold government to account for maintaining their re-
sponsibility to the CHS.
We are explicit in positioning the values and principles underpinning our understanding and conceptu-
alisation of CHS, and therefore our research in, on and for the CHS. Core to our values is the need to
foreground marginal and vulnerable populations, and to fight to make those who are invisible, visible.
The values and principles we believe should be taken into account when designing, implementing,
monitoring and evaluating the CHS, are:
A focus on reducing inequalities by acknowledging and striving to meet the intersectional needs of
individuals as members of complex communities
A concern with the health and wellbeing (including physical, mental and social wellbeing), rather than
a disease-focused approach
A commitment to locally-driven solutions
A whole-of-society perspective that seeks to harness the social determinants of health to promote
wellbeing.
23
As such, we believe that research on, in, for, and with CHS should:
Be inclusive
Be locally-driven and embedded in communities and societies
Generate new knowledge through co-production
Centre around community engagement through non-hierarchical participatory methodologies that
foreground trust, balance of power, and strong and sustained interpersonal relationships
Acknowledge the complexity and context sensitive nature of CHSs, through a whole-of-society per-
spective
Always be conducted with the intention of contributing to real-world social change
Shift the centre of knowledge generation on the CHS to countries themselves, and in ongoing dialogue
with policy-makers and practitioners.
In conducting this research, it is crucial to take account of, and research, the history, political-econ-
omy, and social and gendered contexts of the CHS, from global to local, including local knowledge
beliefs and cultural practices. We understand this complex context not only as the context in which
CHS are embedded, but also as the context in which researchers conduct their work. In doing so, we
recognise that global imbalances in knowledge generation may allow for certain ideas, interests and
discourses on the CHS to dominate in ways that silence others.
The participants of the Chaminuka workshop resolve to continue building collaborations, research
partnerships and community engagement platforms to strengthen community health systems. We
further commit to conducting ethical, emancipatory research for and with all stakeholders towards
inclusive empowered communities, while acknowledging the importance of histories, power and rela-
tionships, and using critical perspectives to understand the impact of these contextual factors on our
daily work and relationships.
24
U2U Workshop on Community Health Systems
Lusaka, Zambia
10-14 June 2019
Monday: Setting the scene and getting going
09:00-10:00 Welcome and introductions (Zambia team)
10:00-10:30 Overview of workshop (Helen and Anna-Karin)
10.00-11.00 TEA
11:00-13:00 Multiple lenses on Community Health Systems (group work)
12:00-13:00 LUNCH
14:00-15:00 Report back of group work
15:00-15.30 TEA
15:30-16:30 Sorting and rating themes within the CHS
(Concept mapping group)
Tuesday: Adopting different methods in CHS
8:30-10:30 Participatory and visual methods and in CHS
(Chama, Meg, Leanne, Moses)
10:30-11:00 TEA
11:00-12:00 Concept mapping (Alison)
12:00-14:00 LUNCH
14:00-15:00 Asset mapping and other tools from the field
of development (Jill)
15:00-15:30 TEA
15.30-1630 Open access for free? Some reflections (Miguel)
Wednesday: Towards resilient community health systems in Zambia
08:30-9:00 Role of the School of Public Health in promoting resilient
CHS – an overview; Prof Michelo
09:00-10:30 Community health in Zambia
- Structures and policies that handle planning processes; Director,
Department of Public Health, MoH
- Continuum of health systems:
• Recruitment, training, placement and supervision of CHAs - Director for
Training School for CHAs
• Career ladder for CHAS recruitment and motivation of CHWs by IPA
(Nampaka)
• Plenary
10:30-11:00: TEA
11:00-13:00: Experiences of working in community health systems
- Health messaging, translating messages and referrals = in community
health systems – case studies (Experiences of CHAs) By CHAs
- Training CHAs/CHWs to deliver CSE in schools in the Zambia; the case
of the RISE study (by Chavula)
- Experiences of integrating CHWs in Tanzania – Sirili
- Plenary
APPENDIXES
25
13:00-14:00 LUNCH
14:00-15:00 Developing and communicating health programs/policies
• The MMDP project in Luangwa – Patricia and Adam
• Communication of policies from the national level to the
community health systems- Kasapo
15:00-15:30 TEA
15.30-17:00 Concept mapping: best fit of maps
(Concept mapping group)
Thursday: Discussion on priorities and way forward
8:30-10:30 Concept mapping including consolidation of research
priorities (Concept mapping group)
10:30-11:00 TEA
11:00-13:00 Concept mapping including consolidation of research
priorities (Concept mapping group)
13:00-14:00 LUNCH
14:00-15:00 Collaborations and writing teams
15:00-15:30 TEA
15:00-16:30 Collaborations and writing teams
Friday: Wrapping up
8.30-10:30 Report back on discussions on Thursday afternoon
and next steps
10:30-11:00 TEA
11:00-12:00 Next steps
12:00 LUNCH
Departure
26
PARTICIPANTS
Who
Charles Michelo
Joseph Zulu
Doreen Sitali
Malizgani Chavula
Chama Mulumbwa
Adam Silumbe
Kasapo Chibwe
Margarete Munakampe
Wanga Zulu
Chila Simwanza
Anderson Banda
Chansa Kafwimbi
Mildred Chisenga
Felix Chewe
Nampaka Nkumbula
Aldina Mesic
Olatubosun Akinola
Dylan Edwards
Anna-Karin Hurtig
Isabel Goicolea
Miguel San Sebastian
Frida Johnson
Alison Hernandez
Helen Schneider
Uta Lehmann
Tumelo Assegaai
Eleanor Whyle
Leanne Brady
Lance Louskieter
Jill Olivier
Marsha Orgill
Sirili Nathanael
Moses Tetui
Role/Institution
Dean, School of Public Health,
University of Zambia (UNZA)
Assistant Dean, School of Public Health, UNZA
Lecturer, School of Public Health, UNZA
Tutor, School of Public Health, Zambia
PhD student, UNZA and Umeå University
PhD student, UNZA and Umeå University
PhD student, School of Public Health UNZA
PhD student, School of Public Health, UNZA
Chief Community Nursing Officer, Ministry
of Health (MoH)
Assistant Director, Community Health Unit, MoH
Trainer, CHA Training School, MoH
CHA supervisor, MoH
CHA, MoH
CHA, MoH and President, CHA Association
Policy Manager, Innovations for
Poverty Action – Zambia
Senior Research Associate, Innovations
for Poverty Action - Zambia
Clinton Health Access Initiative
Management Partner, MoH
HOD, Department of Epidemiology and
Global Health, Umeå University
Associate Professor, Umeå University
Professor, Umeå University
Post-doctoral fellow, Umeå University
Researcher, Centre for Health Equity and
Governance in Health Systems
Professor, School of Public Health, UWC
HOD, School of Public Health, UWC
PhD student, School of Public Health, UWC
PhD student, School of Public Health & Family
Medicine (SPHFM), UCT
Research and PhD student, SPHFM, UCT
PhD student, SPHFM, UCT
Associate Professor, SPHFM, UCT
Senior Lecturer and PhD student, SPHFM, UCT
Lecturer, School of Public Health and Social
Sciences, Muhimbili University
Senior Research Fellow, Department of Health Policy
Planning and Management, Makerere University
Country
Zambia
Zambia
Zambia
Zambia
Zambia
Zambia
Zambia
Zambia
Zambia
Zambia
Zambia
Zambia
Zambia
Zambia
Zambia
Zambia
Zambia
Zambia
Sweden
Sweden
Sweden
Sweden
Guatemala
South Africa
South Africa
South Africa
South Africa
South Africa
South Africa
South Africa
South Africa
Tanzania
Uganda
27
DESIGNED BY NADO GRAPHICS
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