Health system stakeholders must define which patients they will contact for proactive population outreach. However, it may not be feasible to provide proactive population outreach to all patients initially. Implementers can begin the process of proactive population outreach by identifying segments of the population that have specific needs that can be addressed and managed in community settings. This strategy is also discussed in the empanelment module as it may be a useful strategy for beginning the process of full empanelment while also identifying and targeting populations in need of specific services based on national or international targets (such as the SDGs). All of these activities require that providers have actively updated patient registers to track the specific health needs of these sub-populations. As discussed in the empanelment module, this rests upon the presence of a civil registration and vital statistics (CRVS) system. More information on CRVS is available through the WHO. Some strategies for selecting segments of the population include: targeting by specific or acute health need, targeting by preventive need, targeting by chronic disease, and targeting by risk strata.
Targeting by specific or acute health need
Patients within any given catchment will have diverse and specific health needs. For example, health needs differ significantly between pregnant or post-partum women, post-discharge patients, and children, and all of these groups are often recipients of community-based outreach. One example of targeting by specific health need is in Mali where Muso Health collaborated with the Malian Ministry of Health in 2008 to deliver a multifaceted intervention to improve community based care in Mali.4 Community health workers engaged in active case finding among children under 5 years old by focusing on the identification of 16 danger signs. While results cannot be mapped to these activities alone, researchers observed a significant decrease in childhood illness and under-five child mortality. Additionally, the intervention targeted pregnant women and connected them with prenatal care. More details on the intervention can be found here.
There are many programs that focus on the treatment of acute needs in communities. Integrated Management of Childhood Illness (IMCI), a WHO/UNICEF initiative, has been implemented in many countries across the world and can be integrated into population outreach activities. The steps for implementing IMCI include: adopting an approach to child health in national health policy, adapting clinical guidelines to country needs, upgrading care by training health workers in local clinics, ensuring availability of necessary equipment and medicines, strengthening hospital care for children who cannot be treated in communities or clinics, and developing concurrent initiatives to strengthen preventive care.30 Rwanda is among many countries that have introduced integrated community case management of childhood illness. Evaluations found that IMCI in Rwanda resulted in a decrease in child mortality and health facility use.31 Information on the implementation of these services in Rwanda can be found here.
Targeting by preventive need
Preventive services are particularly strong opportunities for community-based outreach because they often do not require significant diagnostic knowledge or training and can be carried out by community-based providers with specific but limited knowledge. The specific preventive services that should be delivered in a given community will differ between groups and should be determined through consideration of demographics and burden of disease within the catchment. For example, preventive care may be specific to age, gender, vulnerability such as poverty or malnourishment, or tuberculosis contact. Vaccines or routine care such as cervical cancer screenings are examples of preventive services that may be delivered to target populations during population outreach.
Targeting by chronic disease
Population outreach may be an effective strategy for ensuring that patients with chronic diseases have necessary support and medications. For instance, community health workers may facilitate anti-retroviral treatment adherence for HIV-positive patients or provide medication for diabetes management. In 2005, a program implemented by the Rwandan Ministry of Health and Partners in Health in southeastern Rwanda supplemented national program guidelines for HIV care with a community-based program.7 Patients received daily visits that included social support, monitoring, identification of barriers to adherence, and observed ingestion of medications. Additionally, patients received a food ration and transportation stipends as well as accompaniment to clinic visits for a patient’s first four monthly visits. This comprehensive community-based component was associated with higher retention and suppressed viral load at one year after implementation. More details on this intervention can be found here.
Targeting by risk strata
Determining target groups for population outreach according to risk profile (for morbidity or mortality) can improve coordination of care and direct resources towards those in the greatest need. Essential activities for ensuring comprehensive care for these patients include: developing a method for risk stratification, working as a team to assess patient needs, building care treatment plans, and coordinating care among all providers. After defining target outcomes of interest, stakeholders can conduct risk stratification using a variety of methods including algorithm based tools using data from health records, referrals from providers, or a combination of these approaches.8