Sacks Emma, Morrow Melanie, Story William T, Shelley Katharine D, Shanklin D, Rahimtoola Minal, Rosales Alfonso, Ibe Ochiawunma, Sarriot Eric
Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA.
Community Health Team, USAID Maternal and Child Survival Program/ICF, Washington, District of Columbia, USA.
BMJ Glob Health. 2019 Jun 22;3(Suppl 3):e001384. doi: 10.1136/bmjgh-2018-001384. eCollection 2018.
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.
实现宏伟的健康目标——从“每个妇女每个儿童”战略到可持续发展目标的健康指标，再到重申人人享有健康的《阿拉木图宣言》承诺——需要强大、高效且包容的卫生系统。改善并维持社区卫生是加强整体卫生系统努力的不可或缺的一部分。然而，尽管卫生系统与社区卫生在概念和操作上相互关联，但为卫生系统政策制定者和资助者提供指导的内容——尤其是著名的世卫组织“构件”框架——只是间接涉及有效开展社区卫生所需的基础要素。尽管与基于机构的战略相比，包容社区和由社区主导的战略可能更困难、更复杂，且需要更广泛的资源，但将其排除在卫生系统框架之外导致对那些需要事前努力和投资以便在系统内有效确立社区卫生的要素关注不足。本文建议扩展世卫组织的构件框架，首先要认识到健康产出的基本决定因素。它提出了一个扩展框架，阐明了社区层面所需的专门人力资源和优质服务；将在卫生系统背景下组织和调动社区社会资源的战略置于其中；将健康信息作为一个更大的、致力于信息、学习和问责的构件的一部分；并将社会伙伴关系视为与公共卫生部门的关键联系。该框架明确了社区卫生方面常常被忽视的投资需求，旨在为将社区卫生纳入国家卫生系统及全球指导以实现人人享有健康的努力提供信息。
