Community Health

Community Health System

As the complex needs of people facing the double burden of health issues and socio-economic difficulties are increasingly identified and addressed, the importance of community-level health and social services is magnified. Improvement methods can be applied at the community level to address the quality and coverage of health and social welfare services, strengthen linkages between the community and the health system, and enhance the capacity of existing groups and networks to affect health issues in their own communities. 

A particular area of focus for improvement in community health is to strengthen the effectiveness and sustainability of programs that rely on community health workers (CHWs). Due to large catchment areas and numbers of households they are expected to cover, CHWs are frequently inadequate to provide services to all households needing them.  Although CHWs are usually linked to facilities, facility health care teams often do not have the time or capacity to address the challenges facing CHWs. Leveraging existing networks and indigenous structures to work together to improve the health of community members can improve CHWs’ acceptance, morale, and performance.

Le travail du centre de santé de Kinyami au niveau communautaire

Cyriaque Bimenyimana

Nurse, Kinyami Health Center, Burundi

Propos recueillis par Bède Matituye

Je suis Cyriaque Bimenyimana, titulaire du centre de santé de Kinyami, district sanitaire Giteranyi en province de Muyinga. J’avais participé, en décembre 2013 à une formation sur comment renforcer le système de santé communautaire organisée par le Ministère de la Santé et University Research Co. Y ont également participé un des chefs collinaires, un animateur communautaire et un responsable d’une association locale. Nous avions été invités pour notre formation car notre centre de santé ne faisait pas partie des sites pilotes retenus pour le système de santé communautaire. Au retour de la formation, nous avons pris la décision nous-mêmes d’initier certaines activités pour renforcer notre système de santé communautaire.

Love thy neighbor: Tanzanian communities mobilize their own for HIV testing and care

Kate Fatta

Improvement Advisor for Knowledge Management, USAID ASSIST Project/URC

“I’ve always heard people talk about ‘community engagement’ and ‘community mobilization’, now I see, this is the real way to do it,” said Regina, the District Home-Based Care (HBC) Coordinator of Muheza, while meeting with the community improvement team in Kwemsala. This comment struck me when she said it, and now, weeks later, I continue to think about it and the work that I saw when I visited communities involved in the Tanzania Community Linkages activity in the Tanga Region.

MaNHEP – Testing changes at the community level

Kim Ethier Stover

Senior Improvement Advisor, USAID ASSIST Project/URC

In previous blog posts I mentioned that when I began working on the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP), I had to shift my thinking from facility-level improvement to the community level.  To begin with, we set up community-level quality improvement teams and trained them. Then, it was time to get to the business of improving care.

Rethinking training for low literacy audiences

Kim Ethier Stover

Senior Improvement Advisor, USAID ASSIST Project/URC

Beginning in 2010, as part of my role as Senior Quality Improvement Advisor on the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP), I led the staff in building capacity of quality improvement teams in 51 rural communities in Ethiopia. In addition to building the capacity of quality improvement teams, we needed to develop the capacity of district and health center staff to support community-level quality improvement teams.  The challenge was that quality improvement team members had low levels of literacy or were illiterate.  Therefore, we were required to rethink the way that we approached improvement training.   

An interview with Dr. Ram Shrestha:Supporting Community Health Workers- Where do we stand?

Rhea Bright

Quality Improvement & Human Resources for Health Advisor, USAID Bureau for Global Health Office of Health Systems

In this post, Rhea Bright interviews Dr. Ram Shrestha.

As a health professional, whenever I visit a rural village in a low-or middle-income country, several thoughts come to mind. Knowing that the formal health system usually ends at a health center, dispensary, or health post in these rural communities, does everyone in this village have access to health services? How can we ensure that there are enough health workers in nearby facilities to provide needed services? Are there community health workers (CHWs) in this village, and are they well supported? I started thinking more and more about these questions as World Health Worker Week (April 7-11, 2014) approached…consequently even more questions came to mind.

Using mHealth to Improve the Performance and Engagement of Village Health Teams

Emily Lanford


A component of Uganda’s national strategy since 2001, Village Health Teams (VHTs) serve as an initial point of health system contact for much of the country’s population.  Unfortunately, the number of available VHTs and the scope of their duties are not sufficient to reach all households needing services.  Further exacerbating the problem is that Uganda is plagued by grave disparities between the number of patients requiring medical care and the number of available doctors able to provide those services (the ratio is estimated to be 1:24,000 by the World Health Organization).  

Giving hope: A story on how community networks support persons living with HIV/AIDS

Mabel Namwabira


The USAID ASSIST Project and Uganda’s Ministry of Health supported a project to improve the quality of chronic care services in 10 villages in Buikwe district from June 2012. This followed an assessment at 14 health facilities in September 2011 which revealed minimal community support for HIV/AIDS patients. At one health facility in Buikwe district in May 2012, over 90 People Living with HIV (PLHIV) had dropped out of care for more than 3 months. Out of 90, only 10 were traced due to incorrect contact information given by PLHIV to their care providers.

Focusing on the person, not the problem

Nigel Livesley

Regional Director for South Asia, USAID Applying Science to Strengthen and Improve Health Systems (ASSIST) Project, University Research Co., LLC (URC)

I really like this case study by Tiwonge Moyo because it highlights the importance of focusing on the person not on the problem.  Many aid projects come in with a set of solutions for specific problems.  For example, education projects may give school materials to improve education or nutrition/livelihood projects may provide animals to improve economic security.  The needs of people and communities, though, are usually more complex and single solutions may not always work. 

The Human Experience of Supporting a Humphrey Fellow

Emily Lanford


Beginning on May 1, 2013, the health workforce development (HWD) unit at University Research Company (URC), LLC began its six week sponsorship of Madhavi Dwivedi, a Humphrey Fellow from India whose host was Emory University.  The objective of her work was to identify ways to strengthen the existing engagement tool that is being applied to URC’s Community Support activity in Uganda.   As a part of her work at URC, she conducted a literature review on engagement and influencing factors such as supervision and feedback.  Additionally, Madhvi identified existing M-health initiatives that are cu

Improving uptake and retention of PMTCT services

Rhea Bright

Quality Improvement & Human Resources for Health Advisor, USAID Bureau for Global Health Office of Health Systems
AIMGAPS nurse explains CHSS in Tanzania

An AIMGAPS facility nurse explains the Community Health Systems Strengthening Model (CHSS) to her colleagues during a training session in Iringa, Tanzania, where these nurses are being prepared to serve as community QI coaches for their catchment areas.

Photo by Rhea Bright, URC

Under the USAID Health Care Improvement Project (HCI), my colleagues in Tanzania and I have been working with the Ministry of Health and Social Welfare (MOHSW) and EngenderHealth in the Iringa Region of Tanzania to improve uptake, retention, and the quality of prevention of mother-to-child transmission (PMTCT) of HIV services. Rather than focusing solely on improving care at one point of service along the PMTCT continuum, our improvement efforts looked at improving PMTCT services across the entire continuum of care, from the antenatal period, through the entire breastfeeding period, until the HIV status of the exposed infant is definitively determined at 11 facilities in Iringa.

In order to address the gaps in PMTCT care that were identified at the 11 facilities, a data system was developed, quality improvement (QI) teams were formed, and facility QI teams began to track indicators for various PMTCT services that should be delivered during antenatal care (ANC), labor and delivery as well as in the post-natal/infant follow-up period.  Providers began testing changes at their respective facilities to address areas in need of improvement.  However, we noticed that some indicators improved (i.e. HIV positive pregnant women started on ARV or ART; and definite testing of the HIV exposed infant), while others lagged behind (i.e. early booking for antenatal care (ANC); male partner involvement; exclusive breastfeeding; and infant and child follow-up visits).  After providers tested several different changes at the facility level and saw little to no improvement in those indicators, it became apparent that improvement efforts would need to go beyond the facility.