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Community health system concepts

West Africa suffered as a result of the Ebola epidemic during 2014-2015. What role did trust play in the virus spreading? Read to find out.
A male health care worker speaks to a group of people at a town meeting
© UNICEF/UNI176799/Ryeng

What is community health and why does it matter?

In 2014-15, the Ebola virus swept through Guinea, Liberia, and Sierra Leone, with an estimated 28,000 cases and 11,300 deaths.

Why did this epidemic spread so far and result in so many deaths?

What do you think were the main causes?

You might have pointed to the characteristics of the virus, which can spread through close contact, especially with sick and dead persons, with no drugs or vaccines (at the time) to treat or prevent the illness.

Another major contribution was the poor quality of the health services, particularly in rural areas, with insufficient health workers, lack of health facilities, poor infection control, and lack of basic medicines, diagnostic tests, and supplies.

But a factor you may not have thought about is the degree of trust between communities and authorities. Civil conflict and lack of connection with health facilities resulted in a lack of trust in authorities and health care service. As a result, many infected patients and their families chose to avoid the treatment centres, and to bury their dead secretly to avoid the mandated cremation. Fear and suspicion had tragic consequences in some instances. In an incident in Guinea in September 2014, eight members of a team trying to raise awareness about Ebola were killed by villagers using machetes and clubs.

“A key lesson of this EVD outbreak is that it is difficult to engage communities unless there is already a well-developed relationship and a network of health workers who are already accountable to and embedded within communities.” (Scott, Crawford-Browne & Sanders, 2016, pg. 6)
This experience brings home the importance of the role of the community health level of the health system, which we will explore further over the next few steps.
What is the community health system? How can we describe it?
Community health has a long history of frameworks, beginning with Primary Health Care in the Alma-Ata Declaration, and more recently expanding to the ideas of people-centred health care.
We can identify two key elements of community health: one element relates to the delivery of appropriate services to people at the community level, frequently involving community health workers; and the second element relates to the engagement and involvement of community members in the planning and delivery of these services.
Two key frameworks guide our approaches to these elements.
This framework defines integrated health services as health services that are
“managed and delivered so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services, coordinated across the different levels and sites of care within and beyond the health sector, and according to their needs throughout the life course” (pg. 2).

People-centred care is an approach to delivery of care that consciously adopts individuals’, carers’, families’ and communities’ perspectives as participants in, and beneficiaries of, trusted health systems that are organised around the comprehensive needs of people rather than individual diseases, and respects social preferences.

A people-centred approach is needed for:

  • Equity in access: For everyone, everywhere to access the quality health services they need, when and where they need them.
  • Quality: Safe, effective and timely care that responds to people’s comprehensive needs and are of the highest possible standards.
  • Responsiveness and participation: Care is coordinated around people’s needs, respects their preferences, and allows for people’s participation in health affairs.
  • Efficiency: Ensuring that services are provided in the most cost-effective setting with the right balance between health promotion, prevention, and in- and-out patient care, avoiding duplication and waste of resources.
  • Resilience: Strengthening the capacity of health actors, institutions and populations to prepare for, and effectively respond to, public health crises.

2). WHO Community Engagement Framework for Quality, People-Centred and Resilient Health Services

Community engagement is a process of developing relationships that enable stakeholders to work together to address health-related issues and promote well-being to achieve positive health impact and outcomes.

The CEQ framework provides direction on how to integrate engagement functions to successfully implement the WHO Framework on integrated people-centred health services (IPCHS), through the active participation and engagement of health service users, local communities and civil society.

The framework identifies four key factors to achieve community engagement:

  • Governance: The prevailing attitudes, behaviours and interactions occurring in populations and institutions within sovereign states.
  • Leadership: strong and committed leadership based on core values, a clearly articulated mission and a shared sense of purpose.
  • Resources: time; spaces and technology that support participatory processes and collaboration; and the relevant tools, and methods.
  • Prepared and supported workforce: able to engage with other professionals, sectors, patients, their families and local communities in planning and collaborative efforts to improve health.

The CEQ framework recognises that strength in any system comes from connections. If health care systems are to exhibit strength and resilience when tested, they must be built on strong interconnections between health care professionals and community members. To create and sustain such a system, each must work together, sharing information, building trust, and engaging each other in such a way that goals become mutual and everyone feels empowered to contribute to the system’s success.

Thinking of a health system/service that you know, what are three aspects of that service that strengthen community engagement and people centredness; and what are three aspects that inhibit or constrain this?

Scott, V, Crawford-Browne, S & Sanders, D, 2016, ‘Critiquing the response to the Ebola epidemic through a Primary Health Care Approach’, BMC public health, vol. 16, no. 1, p.410.
World Health Organization, 2016, ‘Framework on integrated, people-centred health services’, Sixty-ninth day health assembly – Provisional agenda item 16.1, World Health Organization.
© Nossal Institute for Global Health at the University of Melbourne
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