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Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all
  1. Emma Sacks1,
  2. Melanie Morrow2,
  3. William T Story3,
  4. Katharine D Shelley4,
  5. D Shanklin5,
  6. Minal Rahimtoola6,
  7. Alfonso Rosales7,
  8. Ochiawunma Ibe2,
  9. Eric Sarriot8
  1. 1 Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
  2. 2 Community Health Team, USAID Maternal and Child Survival Program/ICF, Washington, District of Columbia, USA
  3. 3 Department of Community and Behavioral Health, University of Iowa, Iowa City, Iowa, USA
  4. 4 Health Systems Innovation and Delivery, PATH, Seattle, Washington, USA
  5. 5 CORE Inc, Washington, District of Columbia, USA
  6. 6 Independent Health Systems Consultant, Boston, Massachusetts, USA
  7. 7 Health Unit, World Vision, Federal Way, Washington, USA
  8. 8 Global Health, Save the Children Federation Inc, Washington, District of Columbia, USA
  1. Correspondence to Dr Emma Sacks; esacks{at}


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.

  • health systems
  • health system strengthening
  • community health
  • frameworks
  • maternal, newborn and child health
  • primary care
  • health for all, Alma-Ata
  • SDGs

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  • Handling editor Stephanie M Topp

  • Contributors E. Sacks, M. Morrow, W. Story, M. Rahimtoola, D. Shanklin, and E. Sarriot conceptualised the paper. E. Sacks wrote the first draft. W. Story oversaw the literature review, with support from K. Shelley and E. Sacks. M. Morrow, W. Story, O. Ibe, and E. Sarriot researched and drafted the case studies. All authors reviewed and approved the final text.

  • Funding This study was supported by USAID/Maternal and Child Survival Program, Cooperative Agreement AID-OAA-A-14-00028.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No additional data are available.

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