Increasing the Use of Social and Behavior Change in Health Systems Strengthening: Evidence and Recommendations to Improve Primary Health Care

"Integrating social and behavior change - including community engagement - into health systems strengthening frameworks and activities increases the accountability, affordability, accessibility, and reliability of health services."

There is increasing recognition of the critical role social and behaviour change (SBC) - in particular, community engagement, as part of SBC - plays in achieving global primary health care (PHC) goals. Despite the potential, gaps remain in understanding the overlooked links between SBC and health systems strengthening (HSS) work and its support and documentation. From Breakthrough ACTION, this brief summarises findings from a 2022 literature review and expert consultations: The Effects of Integrating SBC within HSS in Low- and Middle-Income Countries [PDF]. The brief provides: evidence, potential operational frameworks for increased integration between SBC and HSS, operational challenges, evidence gaps, and concrete recommendations for increasing the use of effective SBC in HSS programming.

The literature review [PDF] identified 65 published and gray literature sources published between January 2012 and August 2022 that addressed the nexus between SBC and HSS. The project then invited 18 global SBC and HSS experts from Breakthrough ACTION's partner networks to a series of three virtual technical working sessions from September to October 2022 to explore the literature review findings and share their practical experiences working at the nexus of SBC and HSS.

The literature review and corresponding technical working sessions identified 4 key findings that support increased investment in and collaboration between SBC and HSS implementers, including potential pathways and interventions for maternal, newborn, and child health (MNCH) and family planning (FP)/reproductive health (RH) impacts. High-level findings include the following:

1. Compelling evidence shows the potential positive impact of integrating SBC into HSS efforts to improve the accountability, affordability, accessibility, and reliability of PHC. For example, increased community engagement can improve health system functioning, responsiveness, and equitable policy development, and social accountability initiatives can increase the acceptability and quality of health services and shape the goals and values of the health system.
2. Layering individual-level SBC interventions onto HSS or social determinants of health (SDOH) interventions increases positive FP/RH and broader PHC outcomes. For example, interventions combining mass and local media with engaging community and faith leaders and other forms of intensive community engagement have demonstrated positive impacts on FP/RH. The literature review and consultations identified more than 15 promising examples of effective, multi-tiered SBC approaches that go beyond individual-level interventions to address SDOH, including with interventions addressing actors and collective action at different levels of the health system.
3. Community engagement plays a critical role in strengthening local health systems in several ways. To cite only one: Involving strong community systems, actions, and voices in health system activities strengthens community capacity and fosters trust and shared accountability for health system performance. Community participation in audit processes, such as a perinatal death audit, can contribute to health service delivery actions that improve the quality of care.
4. Some HSS frameworks consider SBC and can expand to encourage the adoption of healthy behaviours. Emerging health systems and policy research literature demonstrates that health system performance depends in part on whether there are conducive social interactions, decentralised decision making, and high levels of trust, teamwork, commitment, and collaborative teamwork - all factors that support greater integration of SBC into HSS frameworks.

The literature review found a small but growing number of HSS-related frameworks that incorporate behaviour change and community engagement at multiple levels, in areas including demand creation, health promotion, service delivery, governance, advocacy, and policy development. Similarly, several current SBC frameworks presented by participants explicitly address how SBC supports HSS by using a systems lens for behaviour change. Summarised in the brief (with additional potential frameworks described in Annex 03 of the literature review), these frameworks can serve as an entry point for collaboration by identifying specific behaviours that contribute to improved health outcomes, demonstrating the interaction and interplay of SBC and HSS in improving PHC, and identifying resources needed to improve health service planning and governance for policymakers.

Working session participants agreed that practitioners should consider the following potential challenges when working in the cross-sector "gray area" at the nexus of SBC and HSS:

• SBC and HSS use different technical terminology and need to identify common entry points.
• SBC and HSS use highly complex frameworks that need simplification.
• Local stakeholders are often not engaged in HSS frameworks and intervention design.

The brief also outlines knowledge gaps remain that prevent effective integration of SBC into HSS, such as the need for more evaluations of SBC interventions that integrate local or community priorities through community participation and social accountability to identify most effective and sustainable approaches of such integration.

Finally, the brief offers action steps to strengthen SBC and HSS integration and collaboration:

• Develop an improved operational framework for SBC and HSS that builds on and extends the models identified in this brief.
• Engage SBC practitioners to support the design and implementation of SBC components of HSS intervention, such as approaches to strengthen trust, teamwork, shared values, and leadership styles to improve health system functioning.
• Document the potential benefits of integrating SBC into HSS beyond service delivery - e.g., increasing the reach of interventions.
• Leverage multi-sectoral SBC and service delivery platforms to advance integrated PHC service delivery in recognition of the fact that, for instance, integration can potentially introduce new health services not initially demanded by the community, increase men's participation in health services, improve cost efficiency, increase service uptake and retention, and address SDOH.
• Continue the dialogue and documentation of what works in integrating SBC and HSS. As suggested here, the Social and Behavior Change for Service Delivery Community of Practice, led by the United States Agency for International Development (USAID) and Breakthrough ACTION, offers a platform for fostering ongoing conversations and operationalising recommendations, including through the participation of HSS practitioners.

In conclusion, the brief provides guidance on the individual questions that drove the literature review and consultation: recommendations to integrate SBC into HSS frameworks; recommendations to strengthen SBC and community engagement approaches; and recommendations to promote the use of SBC beyond the individual level in support of SDOH approaches.