4D Community Health System Strengthening (4D-CHeSS)

Sustainable preparedness for health emergencies can only be achieved through robust and agile health systems. We propose a holistic and agile approach, integrating infrastructure, capacity building, digitisation and local management, in particular in rural districts.

We intervene along four axes:

1. Connectivity and data
2. Community Integration
3. (Health) Pillar Integration
4. Sector Integration

Project Coordinator is Amer Sattar, an entrepreneur and Public Health Advisor. A former Country Director (eHealth Africa), Amer Sattar has designed and implemented multiple public health and emergency management solutions.

In order to detect, respond and recover, there needs to be a health system in place that is supported and trusted by local communities, who are willing and able to consult health workers and follow guidelines. Weak infrastructure, lack of data and of transparency, and pillarisation of the health systems have all led to a breakdown of this trust and to poor performance by health systems, in particular in rural and remote communities.

In order to rebuild this trust, health systems need to show value for the communities they serve, be open about current and imminent health threats, and show a coordinated and consistent approach to personal and public health issues. This requires infrastructure and equipment, training of health workers and health administrators, and reliable, secure and efficient data management, from data collection to data transfer and analysis.

The 4D-CHeSS approach is specifically designed to support rural and/or remote communities in the Global South. Communities have felt ignored and neglected for decades. In many cases, it requires public health emergencies for attention to be given to local healthcare services and infrastructure. Without direct and lasting benefits for local communities, there can be no sustainable impact, or enduring social and behavioral change improving the health status of the community as a whole. We aim to provide communities with the health systems they need, aspire to, and are willing and able to support (including financially).

Our principles of engagement are:

• Involve communities from the onset.
• Be sensitive to local customs, beliefs, needs and aspirations.
• Invest in Health Facilities and Services that have perceived value for the communities.
• Target broader interventions in order to obtain lasting public health outcomes.
• Promote community ownership (complete or partial), without undermining other stakeholders.

Because every context is unique, so are the appropriate solutions. The 4D-CHeSS approach recognises this, and the agile and inclusive nature of the way we implement Health System Strengthening reflects this.

Some of the Public Goods provided by 4D CHeSS:

1. A major step to Universal health Care through a strengthened health system.
2. Improved detection and response of imminent public health threats.
3. Through Sector Integration, a health system embedded in the broader society, enhancing resilience and sustainability.
4. Improved and cost-effective integration of data streams from all actors in- or relevant to the health system.
5. Through the inclusion of existing mobile money platforms, improved access to financial services at the community level.
6. By introducing Electronic Case Management (evolving to Electronic Patient records), easier and more reliable health data reporting, elimination of redundant patient intake at every visit, sharing of relevant patient data between health facilities, etc.
7. A health facility registry that provides information on health services to the population, and allows for resource sharing, coordination of procurement and logistics, and for improved planning at the central level.

The ultimate objective of 4D CHeSS is to provide stronger, more efficient, and affordable health systems to rural communities in the Global South, with reliable and equitable access to basic health care for all members of these communities, including women, children, the elderly, and the poor.

By mobilising society as a whole, including Government, NGOs and the private sector, and by providing all actors with the information they require, we drastically increase the sustainability of a robust and quality-focussed health care system.

We also help remove the perception that the international community (and the Government) only pay attention when there is a global or national public health threat, and integrate disease surveillance and response into a health system that has a permanent and locally relevant interest in the health and well-being of the communities it serves.

Based on the proposed 27-month pilot project (as well as the previous pilot in Guinea), we envisage expanding to additional districts in multiple countries. In addition, we believe the concept to be applicable by many, or even most, international development actors. As a methodology, we would hope to achieve broader recognition, and adoption in all health system strengthening endeavours, be they national, or initiated by international funders.

Some of our digital tools are not open-source (by choice), but we believe the pilot project will make the case for proprietary tools being an efficient, rapidly deployable, and cost effective option for sustainable development of health information systems by providing ongoing development, improvement and technical support to users.

Our basic approach is to define desired outcomes based on the initial engagement with stakeholders (communities, government, etc). That said, there are indicators that are more than likely to come out of such stakeholder interactions:

1. Improved reporting: We would anticipate full digital reporting from the district in question by the end of Year 1, including all project/programme reports, as well as statistical reporting (probably into DHIS2).
2. Completion of Infrastructure Upgrades: By the middle of Year 1, we will have completed the infrastructure upgrades, including facility upgrades, connectivity in all health facilities, and solar power in all (public) health facilities.
3. Electronic Case Management: By the end of Year 1, we target 100% of consultations to be captured in the ECM platform. In agreement with the authorities and the local health workers, we may progress to Electronic Patient records.
4. Local/Community Management: In the course of Year 2, the local health officials and/or the Community Health Association will take over management of the health system, including the digital tools provided by the pilot project. Furthermore, most, if not all reporting will have been automated, based on the deployed Electronic Case Management.

Cost: For a full deployment of the 4D CHeSS concept we require approximately 2MGPB/ district. If successful with the Trinity Challenge, we anticipate replicating in other countries/districts with other funders, including with National Budget funding.

Exposure: Currently, most funders and implementing partners are focussed on specific "pillars", without integration into a broader, more holistic strategy. Based on any Trinity Challenge award, we would seek support from trinity Challenge and its members in persuading other international or national health system strengthening actors to integrate the entire concept or key components into their projects and programmes. 

As team Lead, I hold the following positions:

• Independent Public Health Adviser (free-lance)
• Managing Director of Coloss SA (Guinea) - Low-cost Housing, Community Relations, Public Health Project Design and Implementation.
• Director of TRiCOM (Guinea) - PR and Communications

The Trinity Challenge perfectly matches the 4D CHeSS model in its objectives, flexibility of funding, and private sector participation. Most institutional funders do not allow for effective use of Agile Project Management principles, and for a broad, holistic approach to strengthening Health Systems and Health Information Systems. Apart from funding for this pilot project, we are also seeking exposure, as well as contact with, and support from the Trinity Members in getting the development community as a whole to apply key elements of our model. The slow, and sometimes absent success in deploying digital solutions and improved data management is at least partially due to the common separation between such endeavours and the general improvement of diagnostics and care that is the ultimate objective for the communities and the health workers who serve them. We hope to make the case, with Trinity Challenge support, for bringing the two together, thereby fulfilling the needs of all stakeholders simultaneously.

We are open to collaborating and/or exchanging ideas with any and all Members of the Trinity Challenge, as well as with past, present and future applicant for Trinity Challenge Funding. Although our approach includes Fl@World data integration and our in-house Community Health Application (under development), we are basically tech agnostic, and open to working with any useful solutions available. We can either integrate third-party applications, or provide support to other applicants to increase their impact and sustainability.