title: Supporting close-to-community providers through a community health system approach: case examples from Ethiopia and Tanzania.
abstract: BACKGROUND
  Close-to-community (CTC) providers, including community health workers or volunteers or health extension workers, can be effective in promoting access to and utilization of health services. Tasks are often shifted to these providers with limited resources and support from CTC programmes or communities. The Community Health System Strengthening (CHSS) model is part of an improvement approach which draws on existing formal and informal networks within a community, such as agricultural or women's groups, to support CTC providers and address gaps in community-based health services. The model offers a framework for bringing representatives from existing community networks, CTC providers, and health facility staff together to form a community team charged with identifying challenges in service delivery, testing solutions, and monitoring changes. CTC providers draw upon fellow community team members to disseminate health messages and refer community members in need of services.
  
  
  METHODS
  Two cases are presented. In Ethiopia, the CHSS model was applied in 18 communities to increase HIV testing among pregnant women and antenatal care service utilization and improve sanitation. Prior to implementation, representatives from community groups were unaware of health extension workers or were uncomfortable making referrals. By participating on the community team, representatives became familiar with and comfortable referring people to health extension workers and spreading health messages. During implementation, more pregnant women registered for antenatal care and tested for HIV; health extension workers conducted more postnatal visits; and more households had functioning latrines and proper latrine use increased. In Tanzania, the CHSS model was applied in five communities to improve HIV testing and retention into care. Community team members talked to their families and social networks about HIV testing and, when they identified someone who had dropped out of treatment, they referred those individuals to the home-based care volunteer. Increases in HIV testing and a reduction in patients lost to follow-up were observed.
  
  
  CONCLUSIONS
  The CHSS model brings together existing networks within communities to support and lend legitimacy to CTC providers. This approach may result in sustainable community-based programmes, especially in HIV where the continuum of care extends beyond the facility and into the community.
authors.affiliation: EnCompass LLC, 7200 Wisconsin Ave., Bethesda, MD, 20814, USA. ssmith@urc-chs.com.
authors.forename: Sarah Smith
authors.initials: SS
authors.lastname: Lunsford
authors.affiliation: University Research Co, LLC, 7200 Wisconsin Ave., Bethesda, MD, 20814, USA. kfatta@urc-chs.com.
authors.forename: Kate
authors.initials: K
authors.lastname: Fatta
authors.affiliation: University Research Co, LLC, 7200 Wisconsin Ave., Bethesda, MD, 20814, USA. kethier@urc-chs.com.
authors.forename: Kim Ethier
authors.initials: KE
authors.lastname: Stover
authors.affiliation: University Research Co, LLC, 7200 Wisconsin Ave., Bethesda, MD, 20814, USA. rshrestha@urc-chs.com.
authors.forename: Ram
authors.initials: R
authors.lastname: Shrestha
mesh_terms: D018672:Community Health Planning; D003153:Community Health Services; D003150:Community Health Workers; D019058:Community Networks; D003695:Delivery of Health Care; D005002:Ethiopia; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000175:diagnosis; D006801:Humans; D008297:Male; D008427:Maternal Health Services; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis; D012111:Residence Characteristics; D013636:Tanzania; D000078329:Workforce