Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all.

Achieving ambitious health goals-from the Every Woman Every Child strategy to the health targets of the sustainable development goals to the renewed promise of Alma-Ata of 'health for all'-necessitates strong, functional and inclusive health systems. Improving and sustaining community health is integral to overall health systems strengthening efforts. However, while health systems and community health are conceptually and operationally related, the guidance informing health systems policymakers and financiers-particularly the well-known WHO 'building blocks' framework-only indirectly addresses the foundational elements necessary for effective community health. Although community-inclusive and community-led strategies may be more difficult, complex, and require more widespread resources than facility-based strategies, their exclusion from health systems frameworks leads to insufficient attention to elements that need ex-ante efforts and investments to set community health effectively within systems. This paper suggests an expansion of the WHO building blocks, starting with the recognition of the essential determinants of the production of health. It presents an expanded framework that articulates the need for dedicated human resources and quality services at the community level; it places strategies for organising and mobilising social resources in communities in the context of systems for health; it situates health information as one ingredient of a larger block dedicated to information, learning and accountability; and it recognises societal partnerships as critical links to the public health sector. This framework makes explicit the oft-neglected investment needs for community health and aims to inform efforts to situate community health within national health systems and global guidance to achieve health for all.

Scale-up of adolescent contraceptive services: lessons from a 5-country comparative analysis.

BACKGROUND: Poor sexual and reproductive health outcomes among adolescents aged 10-19 years are indicative of the barriers this group faces in accessing health services and highlights a gap in the availability of appropriate services, including adolescent-friendly contraceptive services (AFCS). The HIV Investment Framework identifies contraceptive services as an entry point for HIV counseling, testing, and treatment, and as a component of HIV prevention. To effectively meet the needs of adolescents, greater understanding of effective scale-up strategies for adolescent-friendly services is needed. METHODS: The authors conducted a retrospective analysis of AFCS scale-up experiences in Ethiopia, Ghana, Mozambique, Tanzania, and Vietnam using the ExpandNet/World Health Organization framework for systematic scale-up. The authors analyzed the type of scale (expansion or institutionalization), dissemination and advocacy, organizational process, costs and resource mobilization, and monitoring and evaluation. RESULTS: The analysis showed that all programs simultaneously pursued expansion and institutionalization, contributing to sustainable scale-up. Advocacy complemented by intensive capacity building at all levels of the health system contributed to adoption of AFCS in national and district work plans and budgets as well strengthening collection of age-disaggregated data. DISCUSSION: To achieve scale-up of AFCS, the authors identified the importance of institutionalization and expansion in tandem for synergy and reinforcement, empowering adolescents to be agents of change and hold government accountable to its commitments, and strengthening health systems to sustain AFCS. CONCLUSIONS: This article contributes to a growing body of evidence around scale-up of AFCS, which can inform the implementation and sustainable scale-up of HIV and other services for adolescents.

Sexually transmitted infections treatment and care available to high risk populations in Pakistan.

Limited literature exists on the quality and availability of treatment and care of sexually transmitted infections (STIs) in Pakistan. This article aims to document existing services for the care and treatment of STIs available in Pakistan's public and private sectors to high risk groups (HRG), particularly the transgendered population. We conducted a cross-sectional survey to document STI services in Lahore, Karachi, Rawalpindi, Peshawar, and Quetta. Seventy-three interviews were administered with health service providers at the 3 largest public sector hospitals in each city, as well as with general physicians and traditional healers in the private sector. Twenty-five nongovernmental organizations (NGO) providing STI services were also interviewed. Fewer than 45% of private and public sector general practitioners had been trained in STI treatment after the completion of their medical curriculum, and none of the traditional healers had received any formal training or information on STIs. The World Health Organization (WHO) syndromic management guidelines were followed for STI management by 29% of public and private sector doctors and 5% of traditional healers. STI drugs were available at no cost at 44% of NGOs and at some public sector hospitals. Our findings show that although providers do treat HRGs for STIs, there are significant limitations in their ability to provide these services. These deterrents include, but are not limited to, a lack of STI training of service providers, privacy and adherence to recommended WHO syndromic management guidelines, and costly diagnostic and consultation fees.