This document discusses district health systems strengthening (DHSS) and the role of communities in DHSS. It outlines several previous community health initiatives from 1987 onward that engaged communities but had weaknesses. The DHSS approach focuses on outcomes, prioritization, data-driven decisions, and local ownership. The theory of change is that improved implementation management will reduce bottlenecks and improve health through monitoring, course corrections, and policy/budget changes. The role of communities in DHSS includes monitoring, reprioritizing bottlenecks/solutions, prioritizing solutions, service delivery, and diagnosing demand-related barriers. Countries that have implemented DHSS are listed. An example from one country shows a bottleneck of low service utilization addressed through user fee

1. District Health Systems Strengthening for
communities with communities:
The role of “C” in DHSS
Ngashi Ngongo, MD, MPH
UNICEF New York

2. Building on previous experiences…
• Bamako Initiative in 1987
– PHC facility-centered approach
– Focused on access to essential drugs
– Community participation in PHC management
– Included user fees and cost recovery
• IMCI in 1990
– Has focused on improving skills of HCW in hospitals and PHC facilities
– Proven effective in improving quality of care
– Weak on systems strengthening and changing family practices
• RED Strategy in 2002
– EPI-centered and focused on planning, monitoring, supervision, outreach and
community involvement
• Marginal Budgeting for Bottlenecks (MBB) in 2002
– Results-based planning and budgeting tool
– Used to estimate marginal costs of overcoming health systems bottlenecks

3. DIVA/DHSS Basic Principles
1. Outcome focus
2. FOCUS = Prioritization (populations,
interventions, bottlenecks, solutions)
3. Data-driven EVIDENCE
4. Local ownership (Implementation
management)

4. DIVA/DHSS Theory of Change
Improved Implementation management
Culture of
data use for
action
Accountabili
ty for results
Stakeholder
participation
Improved
targeting and
prioritization
Increased
efficiency +/-
budget
Joint and
Harmonized
implementation
RT monitoring
and course
correction
Reduced MNCH supply, demand and quality
bottlenecks
Changes in national policies and budgets
CHANGES
SHORT-TERM
RESULTS
MEDIUM AND
LONG-TERM RESULTS
People-centered
DHSS

5. Steps in the DHSS Cycle
1. Outcomes of interest e.g. mortality
2. Underserved populations
3. Subset of effective interventions
4. Priority Bottlenecks and their causes
5. Priority (Local) Solutions
6. RTM + adjustment + Feedback loop
2-4 years: Mortality
reduction
Annually: Disparity
reduction
coverage and quality
5
Annually: Changes in
Quarterly: Bottleneck
reduction

6. The role of “C” in DHSS
• Frequent monitoring
and accountability: DRC
“C” based MNCH
surveillance and
Uganda U-Report -NEW
• Re-prioritization of
bottlenecks and
solutions: MALI
(COSA)
• Prioritization of
solutions and planning
ZAMBIA (CHAZ)
• Service delivery: DRC
(family Kits and iCCM)
• “C” based diagnosis of
demand related
barriers: BOTSWANA
and DRC (FGDS AND
KII) and MALI (LQAS)
STEP I
Diagnose
Rapid data
collection
STEP II
Intervene
(Plan &
Implement)
STEP III
Verify
Rapid data
collection
STEP IV
Adjust

7. Countries supported to date: 25+
Entry points Sub-Saharan Africa Asia
Child survival Benin, Botswana, DRC,
Malawi, Sudan, South
Sudan, Zambia
Bangladesh, India,
Indonesia, Mongolia,
Nepal, Philippines
PMTCT Cameroun, Cote d’Ivoire,
Ghana, Kenya, Lesotho,
Malawi, Namibia, Nigeria,
Tanzania, Zimbabwe
iCCM Mali, Sierra Leone,
Uganda
Nutrition Malawi
EPI Mozambique, Liberia

8. Bottleneck: LOW UTILIZATION
• Low care seeking: Less than half of
the target population sought care
from ASCs
• Financial barriers: 90% mothers
interviewed cited financial barriers
to seeking care from ASCs
LOW
UTILIZATION OF
SERVICES
Solution: CONSULTATION FEE
REDUCTION And CHW INCENTIVES
• User-fee reduced by 2/3
• Non-financial incentive: Trophy for
three best performing CHWs
• Monthly performance monitoring
by CHWs

10. Conclusion
• Communities do not act in isolation
• Communities must operate in a well
functioning health system
• Therefore, an effective and sustainable
community response MUST include the
strengthening of the district health systems

11. Thanks and God Bless