The Multiple Lenses on the Community Health System: Implications for Policy, Practice and Research

Abstract

Community health systems (CHSs) have historically been approached from multiple perspectives, with different purposes and methodological and disciplinary orientations. The terrain is, on the one hand, vast and diverse. On the other hand, under the banner of universal health coverage (UHC) and the Sustainable Development Goals (SDGs), a streamlined version of 'community health' is increasingly being consolidated in global health and donor communities. With the view to informing debate and practice, this paper seeks to synthesise approaches to the CHS into a set of 'lenses, ' drawing on the collective and multi-disciplinary knowledge (both formal and experiential) of the authors, a collaborative network of 23 researchers from seven institutions across six countries (spanning low, middle and high income). With a common view of the CHS as a complex adaptive system, we propose four key lenses, referred to as programmatic, relational, collective action and critical lenses. The lenses represent different positionalities in community health, encompassing macro-level policy-maker, front-line and community vantage points, and purposes ranging from social justice to instrumental goals. We define and describe the main elements of each lens and their implications for thinking about policy, practice and research. Distilling a set of key lenses offers a way to make sense of a complex terrain, but also counters what may emerge as a dominant, single narrative on the CHS in global health. By making explicit and bringing together different lenses on the CHS, the limits and possibilities of each may be better appreciated, while promoting integrative, systems thinking in policy, practice and research.

Factors influencing the integration of comprehensive sexuality education into educational systems in low- and middle-income countries: a systematic review

“…Topics such as homosexuality, initiation ceremonies, and contraception conflicted with dominant religions and cultural practices [30,48]. Collective action in the delivery of SRHR services in community health systems can promote ownership, trust and sustainability for the integration of CSE interventions [49][50][51]. It is important for interventions to suit the local context.…”

Community engagement for the Voluntary Medical Male Circumcision (VMMC) program: an analysis of key stakeholder roles to promote a sustainable program in Zambia

“…In addition to these three forms of power, the study identified additional forms or sources of power namely collective action which consists of activities conducted in communal spaces such as schools, churches, health facilities, media platforms, as well as relational power which is about community / family connectedness. Mapping and considering these forms of power ( and in particular the two additional forms of power) when implementing programmes is vital as a community health system “ consists of the set of local actors, relationships, and processes engaged in producing, advocating for, and supporting health in communities and households outside of, but existing in relationship to, formal health structures” ( Schneider & Lehmann, 2016 ; Schneider et al ., 2022 ).…”

“…To effectively manage varied power and interests, there is a need to widen participation and promote collective action and accountability ( George et al ., 2018 ; Mulubwa et al ., 2020 ; Schneider et al ., 2022 ; Tetu et al ., 2021 ), in the delivery of VMMC. This study showed that increasing stakeholder engagement in planning, delivering, and monitoring VMMC programmes could be one way of enhancing the delivery, uptake, and sustainability of VMMC.…”

Contemporary Health Policy and Management: Challenges Remaining

“…As policy leaders consider new and effective ways to plan, implement, monitor and evaluate programmes that engage the meaningful participation of diverse groups of citizens, evidence can add clarity to the process and validate the development of comprehensive policies. Policy leadership in health must foster the consolidation of community networks based on social solidarity and two-way trust that can generate analysis, share knowledge, and bring pressure and legitimacy to bottom-up policy-making [25,26].…”