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Table 3 The role of community and health systems in reinforcing Community Health Worker programming

From: A Community Health Worker “logic model”: towards a theory of enhanced performance in low- and middle-income countries

Community system elements
1. Vision Leadership articulates a clear vision for achieving health and development outcomes for the community
2. Service and resource availability Leadership identifies all curative and promotional health and social services available to the community and their social accessibility to community members
3. Equity Leadership ensures vulnerable and disenfranchised groups have equitable access to essential health and social services
4. Collective action Leadership ensures collective processes and actions that can promote the community’s health and development
• Mobilizes community assets to engage in key policy, legal, and governance activities (such as campaigns, solidarity movements, and other advocacy actions)
• Ensures participatory decision-making by actively engaging community members in identifying problems and concerns, implementing their plans to solve these problems, and taking responsibility for their actions
• Facilitates consensus-building and collaboration that fosters trust, respect, negotiation, openness, conflict resolution, creativity, and responsibility among members
• Identifies areas in which community groups and members need to make changes in the way they work together and provides guidance and support in making these changes
• Respects and values the viewpoints of community members and cultivates community input and action
• Ensures transparency and accountability through meetings and other means of communication with stakeholders and community members
• Manages power relationships within and beyond the community to promote community development and well-being
• Fosters ownership over team decisions by suggesting new ideas, expressing opinions, and pointing out ways to overcome obstacles
5. Knowledge management Leadership acknowledges, documents, and disseminates individual and community achievements and challenges encountered in improving the community’s health
6. Mentoring Leadership fosters the development and emergence of new leaders and other assets
7. Sustainability Leadership ensures any successes in improving the community’s health can be sustained beyond short-term projects:
• Sustains a program’s focus of activity and gains funding and resource commitments
• Encourages the development of mutually reinforcing partnerships with formal health and development structures and actors beyond the community
• Supports strengthening productive linkages with groups within the community
• Encourages and cultivates self-help activities
Social belonging/cohesion  
1. Trust/belonging • Community members exhibit trust among group members and feel part of the community
• Community members have positive perceptions of their communities, value their diversity, celebrate together, and have a sense of control and ownership in relation to planning and implementing local programs and activities to improve their health and well-being
2. Historical perspective Community members understand the community’s history
3. Compassion Community members show a sense of compassion for others in the community
4. Identify Community members have a shared identity and are willing to take action based on that identity
5. Commitment Community members have a commitment to achieving outcomes and positive change and a shared responsibility for improving the community
Resource mobilization  
1. Identification The community routinely identifies external and internal resources (funding, people, organizations, facilities, material, time) to help achieve its health goals
2. Procurement The community routinely accesses external and internal resources (funding, people, organizations, facilities, material, time) to help achieve its health goals for the community
3. Use The community uses resources (funding, people, organizations, facilities, material, time) in new, creative, and effective ways to achieve its health goals
4. Allocation The community makes informed decisions about fair distribution of resources and resolves conflicts regarding distribution, including distribution of common resources
Health system elements
1. Governance • Formulates and aligns all health sector strategies and technical policies
• Identifies roles of public, private, and voluntary health system actors and of civil society at central and decentralized levels of the health system
• Provides robust oversight and regulation of health markets and all health activities in the public and private sector
• Holds all health system actors in the public and private sectors accountable for activities and results
• Provides incentives that reward good performance and sanctions poor performance to all health system actors in the public and private sector
• Ensures collaboration and coordination across sectors in government and with actors outside government
• Ensures generation, analysis, and use of intelligence on health sector performance trends
2. Financing • Raises adequate funds for the health sector
• Allocates these funds in accordance with population needs and in ways that ensure people can use needed services
• Pools funds when possible to ensure people are protected from financial catastrophe or impoverishment associated with having to pay for services
• Purchases packages of high-quality, high-impact services
• Promotes transparency and accountability in financing systems
• Ensures generation, analysis, and use of intelligence on the performance of the health financing system
3. Health workforce • Develops national workforce policies and investment plans
• Defines the roles, responsibilities, and performance expectations (as stated in service agreements or contracts, for example) of all health workers
• Ensures appropriate recruitment and development of the workforce (skill mix/cadre development)
• Ensures appropriate deployment and distribution of health workers relative to fixed facilities and burden of disease
• Uses strategic information to monitor the availability, distribution, and performance of health workers
• Establishes regulatory mechanisms to maintain the quality of education/training and practice
• Engages with multiple stakeholders and sectors for human resources for health (HRH) planning and workforce development
• Develops retention schemes that take into consideration local and international labor markets
• Designs training programs and other capacity development activities that facilitate integration across service delivery and disease control programs
4. Service delivery • Organizes and regulates the health care delivery system in a way that ensures delivery of effective, safe, quality personal and non-personal health interventions to those who need them, when and where needed, with minimum waste of resources
• Develops an organized provider network to ensure close-to-client care
• Adapts, adopts standard practice guidelines for the delivery of essential services in line with the HRH plan
• Delivers package of integrated services based on population health needs
• Generates demand for services through an understanding of the user’s perspective, raising public knowledge, and reducing barriers to use (cultural, social, financial, gender, etc.)
• Ensures proper management of service delivery at all levels to maximize service coverage, quality, safety, and minimize waste, including supervision, performance incentives, and a functioning referral system
• Oversees infrastructure and logistics (i.e., buildings, utilities, waste management, transport, communication)
5. Medical products, vaccines, and technologies • Ensures equitable access to essential medical products, vaccines, technologies, equipment, and supplies of assured quality, safety, efficacy, and cost-effectiveness by:
Developing national policies, standards, guidelines, and regulations in accordance with local laws
Setting and negotiating prices, using information on prices and international trade agreements
Ensuring reliable manufacturing practices and quality assessment of products
Developing procurement, supply, storage, and distribution systems
• Promotes rational use of essential medicines (drugs, vaccines), commodities, technologies, equipment, and supplies
6. Information • Ensures the collection (via population-based, facility-based, and special surveys), analysis, dissemination, and use of timely and high quality information on:
Health status
Financial risk protection
Health service use
Client satisfaction with services
Health behavior
Health system performance
Events that threaten public health security
• Ensures long-term capacity to archive and manage information, as well as promote its availability in the public domain and application