30x30

CCIH 30×30 Annual Progress Report 2023

November 21, 2023

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by CCIH

Background

The 30×30 Health Systems Initiative, launched in 2019 by CCIH, aims to strengthen 30 health systems globally within which faith-based health services operate by 2030. Faith-based organizations (FBOs) frequently collaborate with governments and private providers to deliver healthcare across complex health systems in low- and middle-income countries (1). They contribute towards the provision of preventative, promotive, and curative services, and are often the only health services available to economically marginalized groups in both rural and urban settings. As shown in Figure 1, various types of organizations provide faith-based health services, each of which plays a distinct role. Similar to other health sectors, FBOs are often faced with health systems challenges including capacity building, governance, and infrastructure.

Figure 1 Types of FBOs and their key activities

The 30×30 initiative seeks to describe and measure the efforts of faith-based health services to strengthen health systems across the world between 2020 and 2030. The 30×30 initiative
demonstrates CCIH’s commitment to working through its members, affiliates, and other organizations to improve one or more of the World Health Organization (WHO) health systems
building blocks, namely health workforce, leadership and governance, service delivery, access to essential medicines and supplies, health information systems, and financing. Additionally, CCIH
includes “community services” as an additional block, recognizing that a strong health system is contingent on the interconnectedness between the community and health facilities.

At the core of the 30×30 initiative is the “commitment,” a public statement made by organizations, where they commit to work with CCIH and report data to measure the progress of
their planned or ongoing activities.

The key objectives of the 30×30 initiative are to:

1. Increase global attention to the work of faith-based health services.
2. Work alongside faith-based health services to improve resource mobilization and improve programs and policies.
3. Gather evidence of stronger health systems for FBOs.

CCIH anticipates that through the process of making public commitments and measuring commitment makers’ planned or ongoing activities, we will promote dialogue that facilitates
learning exchanges and increases the presence and visibility of faith-based health services in global initiatives. This should, in turn, translate to stronger partnerships among FBOs and
between FBOs and other sectors through strengthened capacity to deliver quality services. Additionally, external stakeholders will gain a deeper understanding of FBOs’ value and the
potential impact of investing in FBO work. This Theory of Change framework is demonstrated in Figure 2.

Figure 2 Theory of Change 

Progress Thus Far

Call for Commitments

Following the launch of the initiative, CCIH issued the first call for commitments from member organizations and affiliates in late 2019. This first cohort of commitments (Y1 cohort) were
published in a report in April 2020. The second, third, and fourth calls for commitments were made in January 2021, 2022, and 2023, respectively, and these were aggregated in a
commitments webpage on CCIH’s website. Moving forward until 2027, a call for commitments will be made annually at the beginning of each year, as depicted in the timeline in Figure 3.

Figure 3 30X30 Timeline

Commitment Refinement

After commitments were submitted, they underwent a review process by the CCIH 30×30 team. During this stage, the CCIH 30×30 team worked with commitment makers to clarify and refine
the goals, objectives, and specific activities of each new commitment maker. In addition, the CCIH 30×30 team worked with each commitment maker to develop and refine the program indicators for the planned activities.

Building on this experience, the CCIH 30×30 team developed a document of common indicators for each health systems strengthening block which will be a reference document for future
commitment makers. This indicator document was included in the commitment submission form for years 2, 3, and 4, referred to as the Y2, Y3, and Y4 cohorts of commitment makers. It guided
the commitment makers to select the right indicators during the submission stage itself, facilitating a streamlined commitment-making process. Thus, the commitments, activities, and
indicators were all reviewed by the 30×30 team in a singular submission, and then refined through individual sessions with the commitment makers.

Technical support by CCIH 30X30 team

To date, over 1000 hours have been spent by project staff in refining project activities, selecting indicators, and analyzing the data for outcomes and impacts of the public commitments. This
represents the large capacity building component of the 30×30 initiative as technical training and resource sharing are undertaken by the stakeholders. Furthermore, to ensure the quality of data
and uniform understanding among the commitment makers in the data submission process (outlined below), a Monitoring, Evaluation, and Learning (MEL) forum was conducted in
July 2022, which was attended by 37 participants from 21 organizations from the 33 commitment makers. The event focused on providing guidance and building the capacity of
commitment makers on data collection, collation, and submission processes in the online data submission platform. A recording of this session was shared to all commitment makers during
the 2023 data submission period. In addition, the CCIH 30X30 team regularly interacted with the commitment makers to discuss the committed activities, data collection, and processing.

Data Submission

All commitment makers submit their annual performance indicators (July to June) in the online database platform that was launched in September 2021, and all four cohorts (Y1-Y4) of
commitment makers used this platform to submit data in 2023. In addition to quantitative data, optional qualitative data was also requested from the Y1-Y4 cohort commitment makers.

Purpose and Objectives

The purpose of this report is to present a summary of the progress made through the 30×30 initiative towards achieving the intended objectives of the project since its launch in 2019. The
specific objectives of this report are:

1. To present the health systems strengthening efforts by faith-based health services
2. To summarize the scale, scope, and reach of 30×30 since the launch of the initiative
3. To assess the key gaps and challenges in the implementation of 30×30 and recommend strategies for the upcoming years of the initiative.

Methodology

The report is based on the analysis of quantitative and qualitative data submitted by the commitment makers. Data from all four cohorts of commitment makers (Y1-Y4) was used for analysis.

Data Analysis

The submitted data that includes the geographic focus, health system strengthening areas, and annual achievements were downloaded, collated, and analyzed using Microsoft Excel to describe
the characteristics of the commitments and trends of the progress since the inception of the initiative. The indicators for each of the commitments were aggregated, by identification of common activities and further grouped into sub-categories of activities. Common activities were generated by one of the CCIH 30×30 team members and reviewed and verified by a second team member for coherence. A given indicator cannot be assigned to more than one common activity, thus efforts were made to assign indicators to the most appropriate common activity. As some indicators were highly specific to a single activity and couldn’t be aggregated, they were excluded from tables/figures and instead were outlined under the Key Findings below.

Current Status of Commitments

Over the past four years 44 commitments to the 30×30 initiative have been received and accepted: 21 in Y1, 10 in Y2, 6 in Y3, and 7 in Y4 of the initiative. Four of them have either completed their commitments or opted to withdraw their commitments. During year 4 of the initiative, 25 commitment makers including Y4 commitment makers were able to submit 2022-2023 data by the deadline for inclusion in this report. Thus, we present a synthesis of 25 commitments in this report compared to 33 commitments in 2022-23. The absence of 2022-23 data for 15 commitment makers (38%) created a major challenge for the 30×30 initiative and accurate presentation of the progress. Additional information on this obstacle is provided in the challenges section below.

Key Findings

As of 2023, the 30×30 health initiative has 40 active commitments across 36 countries. The sub-Saharan Africa (SSA) region represents the most commitments (24, 60%), followed by global operations (9, 23%), the Asian region (5, 12%), and the Caribbean region (2, 5%) as shown in Figure 4 below.

Figure 4 Commitment makers by geographic presence of operations

(SSA refers to sub- Saharan Africa)

The activities and focus areas of the commitment makers were classified under health systems building blocks as defined by the World Health Organization, in addition to our additional
category of Community Services, which WHO now calls People. We present in Figure 5 the number of commitments seeking to address each of the blocks. Health workforce was the most
common commitment area (24, 60%), followed by service delivery (18. 45%), community services (17, 42.5%), leadership and governance (16, 40%), access to essential medicines (13, 32.5%), and financing (10, 25%). Health information systems was the least common focus area with (7,17.5%) commitments. In Y4, the activities and focus areas of commitment makers were more evenly distributed across the health system building blocks, compared to the previous three years. Additionally, it can be seen that there is an increased focus on community services when compared to the previous three years, which moved from a fourth position in Y3 to a third position in Y4.

Figure 5 Commitments by Health System Strengthening Block

(HW- Health Workforce, SD – Service Delivery, LG – Leadership & Governance, CS – Community Services, ACC – Access to essential medicines and supplies, FIN – Financing, HIS – Health  Information Systems)

Considering the different number of commitments under each of the health systems building blocks, a common public health framework – the socio-ecological model, is used to examine the commitments at a broader level, thus facilitating aggregation of indicators.

Analysis of the indicators revealed that commitments were made at multiple levels of the socio-ecological model, targeting individuals, institutions, communities, and the health system as a whole.

Individual Level

The commitments targeting the individual level were predominantly related to capacity building on a variety of subject areas and improving access and utilization of health services. The specific activities were training programs and provision of health-related services through health programs including inpatient services and outpatient services.

Training/Capacity Building

Training Programs

In the first four years of the 30×30 initiative, 6,087 training programs were delivered by commitment makers. In Y1, 600 programs were delivered, followed by 910 programs in Y2, 3,173 programs in Y3, and 1,404 training programs in Y4 (Figure 6). Training programs largely focused on strengthening the health workforce to improve leadership and governance, service delivery, health  information systems, health financing, and community services. These programs were delivered to a wide range of health care professionals including medical officers, nurses, laboratory technicians, pharmacists, community health personnel, and administrators which covered twelve subject areas namely (alphabetically listed):

• Basic/General Health Services
• Clinical Practice
• Document Management
• Equipment Management
• Financial Management
• Leadership and Governance
• Maternal, Newborn and Child Health
• Pharmacy Management/Practice
• Civil Society
• Critical Health Issues
• Emerging Health/Well-being Issues
• Surgery

Figure 6 Training Programs by Year

(Y1 – 2019-20, Y2 – 2020-21, Y3 – 2021-22 and Y4 – 2022-23)

Figure 7 Number of Training Programs by category (Cumulative of Y1, 2, 3 and 4)

(MNCH – Maternal, Child and Neonatal Care. ‘Pharmacy management’ includes Pharmacy practice.)

The considerable increase in training programs delivered in Y3 (Figure 6) is the result of the training programs delivered by one commitment maker (n=2974). The number of training programs delivered in Y3 would have fallen from 3,173 to 199 if their data had not been included, indicating a considerable decrease in the number of training programs delivered by commitment makers in Y3 compared to the two years prior (Figure 6). As Year 4 data includes only 60% of commitment makers, the Y4 training numbers were lower than Y3.

Personnel Trained

Commitment makers trained personnel intending to strengthen the health workforce in different technical areas. In the first four years of the initiative, 41,941 personnel were trained; of which 11,832 personnel were trained by 16 commitment makers in Y1, 8,936 personnel were trained by 23 commitment makers in Y2, and 12,403 personnel were trained by 21 commitment makers in
Y3, and 8,770 personnel were trained by 17 commitment makers in Y4 (Figure 8). Personnel, who belong to various healthcare professional cadres, were trained in a wide range of subject areas as indicated in Figure 8 and Table 1.

Figure 8 Number of Individuals Trained by Year

(Y1 – 2019-20, Y2 – 2020-21, Y3 -2021-22 and Y4 – 2022-23)

Figure 9 Number of Personnel Trained by Category (Cumulative of Y1,2, 3 and 4)

(‘Pharmacy management’ includes Pharmacy practice. QMS – Quality Management System)

The number of personnel trained in health training methods (individuals trained to become trainers) accounts for the highest proportion of personnel trained across the four years of the initiative (Figure 9), despite being carried out by a single commitment maker. Leadership & Governance and MNCH services were found to be the most common training subject areas across all  commitment makers.

Table 1: Number of Personnel Trained by Year

People Reached through Health Programs

Commitment makers delivered various health programs to improve the access and utilization of health services primarily, with a few programs also seeking to strengthen community services. During the first four years of 30×30, more than 2 million (n= 2,308,487) people were reached by various health programs. In Y1, 147,714 people were reached. Following this, 338,996 people in Y2, 839,417 people in Y3, and 982,360 people in Y4 were reached (Figure 10). The types of programs covered a range of subject areas, as laid out in Table 2.

Figure 10 Number of People reached through Health Programs by year

(Y1 – 2019-20, Y2 – 2020-21, Y3 –2021-22 and Y4 – 2022-23)

Table 2: Number of People Reached through Health Programs by Year

In Y4, there was an increase in MNCH program coverage from two separate commitment makers when compared to the previous three years (Table 2). Additionally, indicators on community health have seen a rise when comparing Y1-Y3 to Y4 from the contributions of six separate commitment makers (Table 2).

Inpatient and Outpatient Services

In the first four years of the initiative, 41,558 inpatient and 207,503 outpatient services were provided by two commitment makers. In Y1, 858 inpatient and 125,544 outpatient services were provided by one commitment maker. In Y2, 293 inpatient and 34,271 outpatient services were delivered by two commitment makers. In Y3 25,623 inpatient and 27,254 outpatient services were delivered by one commitment maker (Figure 11a). In Y4 14,784 inpatient and 20,434 outpatient services were delivered by two commitment makers. An additional commitment maker delivered a total of 7,024,809 combined inpatient/outpatient services in Y3 (reflected in Figure 11b), and 4,349,580 combined inpatient/outpatient services in Y4. All inpatient and outpatient services were related to general health services and focused on enhancing service delivery at health facilities in sub-Saharan African regions.

Figure 11a Number of Inpatient/Outpatient services provided by year

(Y1 – 2019-20, Y2 – 2020-21, Y3 –2021-22 and Y4 – 2022-23)

Figure 11b Number of combined Inpatient/Outpatient services by one commitment maker provided by year

(Y1 – 2019-20, Y2 – 2020-21, Y3 –2021-22 and Y4 – 2022-23)

Institution Level

At this level, commitment makers focused on supporting institutions, including health facilities, drug supply organizations and non-profit organizations. Efforts to support institutions were  undertaken to strengthen all seven building blocks, with access to essential medicines and supplies being the most popular area, followed by financial management. In total, 4,103 institutions were supported: 541 in Y1 by 14 commitment makers, 892 in Y2 by 21 commitment makers, 1,400 in Y3 by 13 commitment makers, and 1,270 in Y4 by 8 commitment makers (Figure 12). Support was provided over a range of nine subject areas namely (alphabetically listed):

• Data Management
• Funding
• General Supplies
• Human Resource Management
• Leadership & Governance
• Medicines, Medical Supplies and Equipment
• Quality Management Systems (QMS)
• Technical Support
• Water, Hygiene and Sanitation (WASH)
• Community Health Activities
• Financial management
• Hospital management
• Safe Water and electricity
• Service delivery (specifically to vulnerable populations)

Figure 12 Total number of Institutional supports provided by year.

(Y1 – 2019-20, Y2 – 2020-21, Y3 –2021-22 and Y4 – 2022-23)

Table 3: Institutional Support Provided over the Years

Community Level

In Y4, 16 commitment makers focused their activities at the community level, seeking to strengthen the community services building block of the health system. Community activities included health promotion of general well-being (NCD prevention, maternity care, child immunizations, nutrition promotion), increasing awareness/reducing stigma around communicable diseases, vaccine awareness/provision, and community leadership development. To achieve this, commitment makers established community groups and church groups and trained them in various health-related areas. For instance, 999 community groups were trained by one of the commitment makers during the first four years of the initiative. In addition, commitment makers provided support to create 3,334 church groups for health-related community activities over the first four years of the initiative (Figure 13).

Figure 13 Community level activities – (Cumulative of Y1,2, 3 and 4)

Figure 14 Number of Community Level Activities by year

(Y1 – 2019-20, Y2 – 2020-21, Y3 –2021-22 and Y4 – 2022-23)

“When children with treatable disabilities have access to surgical and rehabilitative care, their functionality, mobility, and independence are restored, they can return to school, their future  prospects for gainful employment increase, there is a reduction in poverty, and they can fully participate in the life of the community.” – 30×30 Commitment maker

Systems Level

At the systems level, commitment makers focused on establishing partnerships and resource mobilization initiatives. These efforts were largely to strengthen leadership and governance, with
a few targeting financing, service delivery, and health information systems of the health system blocks. In Y1, 20 partnerships were established by seven Y1 commitment makers. In Y2, 67 partnerships were fostered by 11 Y1 and Y2 commitment makers, and in Y3, 99 partnerships were fostered by 7 Y1, Y2, and Y3 commitment makers, and In Y4, 92 partnerships were fostered by 7 Y1, Y2, Y3, and Y4 commitment makers (Figure 15). Partnerships were largely with government, NGOs, and development agencies as depicted in Figure 15.

Figure 15 Number of partnerships by year

(Y1 – 2019-20, Y2 – 2020-21, Y3 –2021-22 and Y4 – 2022-23)

“Because of our presence and support in complementing the efforts of Government in hard-to-reach communities, there is great trust and reliance by the Ministry of Health ensuring that our  concerns are tabled (addressed) during high level technical and health implementing partners meetings. In addition, there has been increased interest of other health implementing partners expressing  interest to partner or collaborate.” – 30×30 Commitment maker

Figure 16 Types of partnerships across the years

(NGO – Non-Governmental Organization; Y1 – 2019-20, Y2 – 2020-21, Y3 –2021-22 and Y4 – 2022-23)

In Y2, there were 17 resource mobilization initiatives by two commitment makers. In Y3, there were 24 resource mobilization efforts by 4 commitment makers. In Y4, there were 29 efforts to mobilize resources by 3 commitment makers (Figure 16). Resource mobilization efforts were carried out through funding infrastructure projects at health facilities (providing direct technical
support) in Y1, Y2, Y3, and Y4, supporting applications for grants to support programs (indirect technical support) in Y1, Y2, Y3, and Y4, and supporting other technical areas in Y2 and Y3. Throughout the first four years of the initiative, resource mobilization efforts have addressed the Service Delivery and Health Financing health system building blocks.

“There were many days we felt our efforts were in vain, but we remained consistent never losing faith. The result of our hard work has been to have direct contact with decision makers within the UN and the ability to share the impact the current crisis has had, and continues to have, on the healthcare sector as a whole. Sharing true impact data and personal stories, collected through our relationships with healthcare facilities has had a powerful impact.” – 30×30 Commitment maker

Figure 17 Types of Resource Mobilization efforts across the years

“In addition to providing supply chain supports, we are helping small mission hospitals in rural locations to arrange healthcare camps with the help of large hospitals. This helps small hospitals to serve the local community with the help of expert doctors from large mission hospitals”- 30×30 Commitment maker

Gaps, Challenges & Recommendations

1. Monitoring and Evaluation capacity:
   1. Challenge:
      Commitment makers had varied levels of experience and capacity for monitoring and evaluation of their activities. Hence, the CCIH 30×30 team worked closely with them to finalize commitments and refine appropriate indicators. Some FBOs did not have formal processes for data collection and reporting and therefore had not instituted such a process for their 30×30 commitment. This made defining indicators and submitting data for the annual report on time challenging.
   2. Actions/Recommendation:
      1. CCIH further refined and published revised standard indicators in May 2023 based on commitment maker’s experience with the former indicators and utility to the 30×30 project. This should make future rounds of data submission and collation more streamlined.
      2. CCIH will continue to work with commitment makers to ensure that activities included in their commitment can be measured with quantitative indicators.
      3. CCIH will continue to provide technical assistance to build the MEL system and capacity of commitment makers.
2. Data management logistics:
   1. Challenge:
      1. As the initiative expands in scope, some commitment makers had challenges accessing and navigating the online database, requiring extra support from the CCIH 30×30 team.
      2. The 30×30 database site crashed in October 2023 due to a hard disk failure, which led to a loss of all data that was submitted between September 9 – October 3. We were able to identify most of the commitment makers that submitted during that period, and a few of them were able to resubmit data in time for inclusion in this report but others will need to be recovered separately. Additionally, staff turnover (loss of the main POC responsible for submitting data to the 30×30 project) resulted in at least two organizations not submitting on time.
   2. Actions/Recommendations:
      1. A video tutorial from the 2022 MEL workshop was shared with commitment makers. This supplemented the written database user guide that includes screenshots with navigation instructions.
      2. The database will be refined based on feedback from commitment makers and the CCIH 30X30 team for a smoother data submission process in upcoming years.
      3. CCIH will seek technical assistance from the database creator to support data management and program coding.
3. Commitment Maker Interaction
   1. Challenge:
      1. Connecting 30×30 commitment makers in strategic ways to exchange ideas about successes, challenges, and key learning.
      2. In March of Y3, the CCIH 30×30 team started the 30×30 Google Group to create a forum for exchange. It has been useful for the CCIH 30×30 team to share updates and reminders about the program but commitment makers have not used it to share and connect with each other.
      3. In January of Y4, the CCIH 30×30 team started a 30×30 WhatsApp group to boost engagement but it has not been used by commitment makers to share and connect with each other.
      4. In Y4, a lack of response to emails and not adhering to data submission deadlines were factors that negatively affected data analysis.
   2. Action/Recommendation:
      1. In August of Y4, the CCIH 30×30 team held a capacity building workshop that was requested by Y1-Y3 commitment makers on advocacy. The purpose of the workshop was to increase awareness and comfortability with the advocacy tools provided by CCIH, improve understanding of how 30×30 is utilized in advocacy with US policymakers, learn from fellow peer examples on local advocacy in their regions, and exchange advocacy knowledge with fellow 30×30 commitment makers.
      2. CCIH 30×30 to facilitate a brainstorming session as part of the 30×30 annual meeting in December of Y4 to discuss methods of engagement that would interest commitment makers and encourage shared learning.
      3. CCIH shared the advocacy toolkit and 30×30 advocacy brief with commitment makers.

Way Forward

One of the key objectives of the 30X30 Health System Initiative is to capture comprehensive information about the planned and ongoing activities of CCIH members and affiliates in health
systems strengthening. Findings from this report indicate that over the first four years of the initiative, 30X30 commitment makers have prioritized strengthening of the health workforce,
expansion of service delivery, and leadership and governance.

To map the way forward, we assessed the progress of the 30×30 initiative towards its objectives thus far.

1. Increase global attention to the work of faith-based health services
   1. Through submission of a public commitment that includes planned and ongoing efforts to strengthen the health systems in which they work, the commitment makers have highlighted the work of faith-based health services. Furthermore, the summary of their efforts in this report emphasizes the scope, scale and reach of FBO work in health systems.
   2. Moving forward, the CCIH Communications team will publicize the new advocacy brief among various stakeholders, including those external to the faith-based space.
   3. An advocacy plan has been developed with support of the CCIH Advocacy team, with the plan to review quarterly with various stakeholders.
2. Work alongside faith-based health services to improve resource mobilization, and improve programs and policies.
   1. The CCIH 30×30 team worked closely with commitment makers to refine the commitments and discuss the MEL system including the finalization of indicators to measure their program activities, thus indirectly improving the monitoring and evaluation of programs and systems. In addition, the publishing of commitments and this annual report may indirectly facilitate resource mobilization. The suggested strategies to achieve the objective include:
      1. Regular exchanges where commitment makers can share experiences, lessons learned, and best practices, which may facilitate the planning of better policies and programming.
3. Gather  evidence of stronger health systems for FBOs
   1. The online database and annual tracking of the performance of the commitment makers provide evidence on the contribution of FBOs to the local health systems and population. As it has been institutionalized and streamlined, it will be a key resource to establish FBOs’ role in health system strengthening across the world. However, this database access is limited to the CCIH 30×30 team and commitment makers.

Looking forward to 2024, Y5 of the 30×30 initiative, CCIH is preparing for a midterm evaluation. This is critical as this will help us to further explore and answer the questions related to the effectiveness of CCIH’s 30X30 health system initiative, the changes that have happened in terms of overall health systems and policy improvement and the lessons learned for future programs and sustained advocacy. The midterm evaluation will include secondary data analysis of quantitative and qualitative data submitted so far by the commitment makers and primary data collection and analysis through key informant interviews and focus group discussions which would lead to increased learning and relevant adaptations of the 30×30 initiative.

References

1. Christian Connections for International Health (CCIH). Market share of Faith-Based Organizations (FBOs) in the health care of developing countries [Internet]. Washington, DC; 2018 [cited 2021 Nov 18]. Available from: http://dx.doi.org.ezproxy.liberty.edu/10.1371/journal.pone.0128389
2. Agency for Toxic Substances and Disease Registry. Principles of Community Engagement [Internet]. Second. CDC; 2015 [cited 2021 Nov 18]. Available from: https://www.atsdr.cdc.gov/communityengagement/pce_models.html

 

 

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