Community Health Transformation: Paths to a Comprehensive and Transformative Community-Based Health System to Enhance Maternal, Newborn, and Child Health Equity and Health System Resilience in Rural Ethiopia

Abstract

Background: In low- and middle-income countries (LMICs) including countries in sub-Saharan Africa (SSA), maternal, newborn, and child health (MNCH) has been a major public health problem, and this has become a key development challenge in the region and persists as an important agenda of the Sustainable Development Goals (SDGs). Over the last four decades, in LMICs community health worker (CHW) programs have been emphasized as a major strategy in promoting primary healthcare access and improving health outcomes, including MNCH in Ethiopia. Despite the contribution of the program to improve MNCH, SSA countries including Ethiopia continue to have the highest child and maternal mortality occurrences in the world. To achieve the SDGs, Ethiopia must reduce neonatal deaths from 29 to 12 per 1000 live births and maternal deaths from 412 to 70 per 100,000 live births in unreliable health system environments and with increasingly constrained health resources. In Ethiopia, the CHW-based health program continues to operate without the transformational capacity to comprehensively respond to persisting preventable and treatable MNCH challenges. The COVID-19 pandemic has amplified the problem. Evidence is limited in multiple areas to address MNCH inequity and health outcomes to scale up the best practice and to transform the CHW program to contribute to a resilient community health system in Ethiopia. The main goal of this study is to gather and analyze evidence on paths to comprehensive, equitable and transformative community-based health systems (CBHS) to enhance MNCH equity and outcomes in Ethiopia and beyond.

Methods: My thesis is a multi-phase study comprising of a systematic review and qualitative case study including Focus Group Discussions (FGD), Key Informant Interviews (KII) and document review on CHW-led MNCH program in rural Ethiopia. My data sources are two FGDs with CHWs, twelve key KII with multilevel public health policy actors, and a policy document review related to the CHW program. I conducted a thematic analysis of the systematic review and qualitative data. My study is informed by multiple theoretical frameworks including the socioecological framework, the World Health Organization's Health system framework, the state–society synergy framework, and the Multiple Streams Framework (MSF).

Findings: My thesis is article-based, in keeping with the requirements of a manuscript-based PhD thesis, comprising systematic review and qualitative case studies. Results are being published and under review. The first two thesis papers, the systematic review and the protocol, examine the perceived barriers to and facilitators of the effectiveness of CHWs to ensure MNCH equity and a resilient community health system in SSA. The third thesis paper is based on qualitative data and examines the multilevel challenges of Ethiopia's CHWs program to deliver optimum MNCH and build a resilient community health system. The fourth thesis paper examines the critical success factors (CSFs) in developing a transformative resilient community-based health system in rural Ethiopia using COVID-19 as a policy window. Finally, the fifth thesis paper examines how multi-stakeholder engagement contributes to the co-production of optimized MNCH outcomes and a resilient community health system in rural Ethiopia. Discussion and Implications: In Ethiopia over the last three decades a nation-wide CHW-based program has been emphasized as an efficient, effective, and equitable strategy to address the broad ambition of primary health promotion and disease prevention for a largely rural population. However, as Ethiopia continues to have the highest child and maternal mortality occurrences in the world, the program continues to experience multiple challenges. My thesis finding emphasized the gap between the macro (national) level CHWs program and the challenge during implementation at the micro (district) level. This calls for the need to sustain opportunities and address the gaps in the CHWs program and for a paradigm shift for comprehensive, equitable and transformative CBHS.

Moving beyond the program's successes and failures over the last three decades, Ethiopia's CHW program needs a paradigm shift guided by community health co-production and transformation framework (CHCT) to ensure comprehensive, equitable and resilient CBHS. Areas that need transformational change include: Building on the existing enabling and CSF by focusing on fragmentation of the health system; Ensuring sustainability, alignment and continuum of macro-level to micro level multi-stakeholder engagement in the HEP optimization plan; Enhancing the resource alignment for results; Prioritizing the work and living condition of CHWs; Moving beyond the WHO's incomplete health system framework "one size fits all" to agile CHCT and a multidimensional framework; Enabling a powershift to enhance an embedded multipronged co-production approach to ensure comprehensive, equitable and resilient community health; Building an embedded health system resilience management system and health system change management; emphasizing an approach beyond donor dependency, with practical alternatives such as domestic resource generation and mobilization with an appropriate management system; Integrating a gender transformative approach in primary health (social and structural level ); Strengthening health diplomacy; Context based health goal setting and prioritization (national and sub national). Research: Rural CBHS building and infrastructure; Participatory action research (PAR) with CHWs and community; private sector engagement in CBHS; Task shifting in low infrastructure setting; multidisciplinary community health approach; moving from the renovation of vertical and selective primary healthcare prevention approaches to logistically and technically well-organized comprehensive and multi-dimensional CHCT framework for comprehensive, equitable and transformative CBHS. Conclusion: Building on the last four decades, the Ethiopian community health program needs transformation towards a comprehensive and transformative resilient CBHS to enhance MNCH equity using a CHCT framework. Closing the health equity gap in LMIC countries including Ethiopia, it is critical to ensure comprehensive equitable and transformative resilient CBHS. To ensure universal health coverage, promote health equity and achieve global health goals including SDG #3, beyond the current context of the highest MMR and Under Five Mortality Rate (U5MR) situation, the Ethiopian government must: Build comprehensive, equitable and transformative resilience by identifying and aiming to address the deep structures that cause or increase vulnerability and risk CBHs; Meaningfully engage multiple stakeholders at multiple levels in the co-production of knowledge and structures necessary for health system transformation; Enhance a synergetic approach by enabling the powershift essential for effective co-production; Utilize an integrated theoretical approach to address the multidimensional issues influencing community health transformation; Integrate a gender transformative approach in the primary health system (social and health system level); Strengthen digital technology for the community health programming; Invest in rural health infrastructure, including the working and living condition of rural CHWs.