| How Exemplars successfully integrated initiatives into health systems | Detailed strategies | Country examples and links to more detail |
|---|---|---|
| When appropriate, establish and build on a strong CHW program aligned with the existing health system and designed to fill gaps | Use community health programs to reach hard-to-reach areas (e.g. rural areas or those in challenging geographies) |
Rwanda: Community health worker program compensated for a shortage of doctors, nurses, and midwives after the genocide, and were key to delivery of interventions. (Rwanda narrative) Preventative health care, along with basic treatment regimens and nutrition services. (Nepal narrative) |
| Select community health workers from the local communities, to gain buy-in and build acceptance of the interventions among the communities | Senegal chose older women to form the Bajenou Gokh CHW cadre, because their respect and prestige in Senegalese culture helped them promote sound health practices and care-seeking behavior (e.g. ANC visits). (Senegal narrative) Nepal: Female Community Health Volunteers were held accountable to both Mother's Groups for Health (MGH; comprised of local women) and health facility workers. (Nepal narrative) CHWs elected by villages and required data reporting on standard indicators monthly in exchange for supplies. (Rwanda narrative) |
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| Create accountability structures for the community health workers, among the communities they serve |
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| Regular cadence of meetings between the CHWs and the communities being served |
In Nepal, the Mother’s Groups convene monthly meetings, set agendas, and share key information for the women to then share with their families. (Nepal narrative) | |
| Develop supportive supervision between facility workers and CHWs | In Nepal, supervision meetings between FCHVs and health facility workers are conducted twice a year (Nepal narrative) |
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| Integrate new interventions, where feasible, into existing CHW systems | Ethiopia: Integration of IMCI into Health Extension Worker program promoting sustainability of the program. (Ethiopia narrative) | |
| Set goals for number of health facilities and outposts, and number of trained healthcare providers | Build health facilities and health outposts in strategic locations to increase access | Rwanda emphasized health infrastructure development, including committing to building a health center accessible within 5km of every citizen, and health posts that were even closer. (Rwanda narrative) |
| Aim for the SDG Index Threshold of 4.45 skilled health care personnel per 1,000 people |
In Peru, the SERUMS program required medical program graduate who received government scholarships to work for at least 1 year in rural or underserved communities.(Peru narrative) | |
| Coordinate efforts among donors & partners, to provide training to both facility-based and community-based workers | Bangladesh adopted the Helping Babies Breathe initiative, which aimed to strengthen the capacity of facility and community-based skilled birth attendants in neonatal resuscitation. This effort involved collaboration between the National Institute of Child Health and Development and the American Academy of Pediatrics, Saving Newborn Lives, WHO, and USAID. (Bangladesh narrative) | |
| When improving health system capacity (especially primary care), build off of healthcare systems that people most frequently use |
For the population you are aiming to serve, evaluate the care-seeking behavior (e.g. through surveys and sub-national data) | Peru evaluated care-seeking for antenatal care and basic routine health care visits and used the insights to inform conditions for the Juntos cash transfer program. (Peru narrative) |
| Integrate new vaccines into the routine vaccination schedule |
Rwanda integrated PCV into the standard pediatric vaccine schedule (Rwanda narrative) | |
| Build new interventions into existing surveillance and research infrastructure |
Use existing subnational data (at the most granular level) to inform where interventions should be rolled out | Senegal leveraged research capacity from Albert Royer Children's Hospital in Dakar (Senegal narrative) |
| Look for cost savings and opportunities to use previously-established systems and resources (e.g. synergies and parallel implementation structures) |
Senegal built upon previously-established polio surveillance systems to train CHWs to monitor potential measles cases. (Senegal narrative) | |
| Integrate vertical programs where feasible, ensuring they are folded into national plans and priorities |
Integrate into central planning and monitoring (e.g. HMIS systems), combine with existing training programs, and utilize existing supply chains | Peru integrating vertical ARI and diarrhea programs into IMCI, institutionalized as part of the 2003 Comprehensive Childhood Health Care Model. (Peru narrative) Bangladesh National Nutrition Program was integrated into Health, Nutrition and Population Sector Program as part of SWAp. (Bangladesh narrative) |
| Adapt national plans, policies and legal frameworks to include new and successful programs | Incorporate promising pilot programs into national plans to achieve scale, and tie into other initiatives to bolster uptake | Bangladesh piloted the Project for Advancing the Health of Newborns and Mothers (ProjAHNMo I) in 2001 in three rural Sylhet districts, chosen for their relatively higher neonatal, infant, and maternal mortality rates, as well as their high proportion of at-home deliveries. This in turn informed the introduction of the Saving Newborn Lives initiative at the national level. (Bangladesh narrative) |
| When designing national plans, set clear targets to work towards and establish accountability structures |
Rwanda's MOH developed a National Malaria Control Program, which created a strategic plan from 2006 - 2010 and set U5M-related targets for percentage of pregnant women and children under five either sleeping under ITNs or living in homes treated with IRS, as well as targets for the availability of ACT in facilities. For example, one target was to distribute enough LLINs so there would be at least one LLIN for every two people. (Rwanda narrative) Rwanda invoked the concept of imihigo to ensure that districts set and then met performance goals. (Rwanda narrative) |
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| Adapt the national plans to incorporate new findings from local research |
Rwanda updated national malaria treatment policies based on resistance monitoring in country. (Rwanda narrative) | |
| Develop financial incentives to boost performance of health systems |
Evaluate performance-based finance options | Rwanda piloted performance-based financing in two districts, and later expanded to other health centers, districts, and rural areas. (Rwanda narrative) |
| Determine list of qualitative and quantitative criteria as part of the performance-based finance measures |
Rwanda's performance-based financing resulted in expansion of services to rural areas, and found that there were significant improvements in the intervention facilities compared with control groups. (Rwanda narrative) Peru used results-based budgeting to allocate resources based on measurable outcomes at the central and local level. (Peru narrative) |
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| Train health workers at all levels | Target professionals at the regional level, who can then pass down the training to the local level |
In Peru, training was cascaded from the regional level, then down to local levels. (Peru narrative) In Ethiopia, training of HEWs occurred via a train-the-trainer approach. Some of the "master trainers" were from the local universities, along with FMOH and international orgs. These in turn trained workers in local regions and woredas .1 |
| Tailor global training curriculum to local contexts, and incorporate training for new EBIs into existing training curriculum (to reduce duplicative training) |
In Ethiopia, FMOH leveraged both local experts and international partners (JHU, UW) to create national standard training materials for healthcare providers. (Ethiopia narrative) |