According to Gavi, “community-based monitoring” or “CBM” is a process where service users collect data on various aspects of health service provision to monitor program implementation, identify gaps, and collaboratively develop solutions with providers.
- Community-based monitoring (CBM) has emerged as a promising strategy for enhancing immunization program performance and equity.
- CBM interventions have been implemented across different settings and populations, including remote rural areas, urban poor, fragile/conflict-affected regions, and marginalized groups such as indigenous populations and people living with HIV.
By engaging service users, CBM aims to foster greater accountability and responsiveness to local needs.
- However, realizing CBM’s potential in practice has proven challenging.
- Without a coherent approach, CBM risks becoming just another disconnected tool.
The Geneva Learning Foundation’s innovative learning-to-action model offers a compelling framework within which CBM could be applied to immunization challenges.
The model’s comprehensive design creates an enabling environment for effectively integrating diverse monitoring data sources – and this could include community perspectives.
Health workers as trusted community advisers… and members of the community
A distinctive feature of TGLF’s model is its emphasis on health workers’ role as trusted advisors to the communities they serve.
The model recognizes that local health staff are not merely service providers, but often deeply embedded community members with intimate knowledge of local realities.
For example, in TGLF’s immunization learning initiatives, participating health workers frequently share insights into the social, cultural, and economic factors shaping vaccine hesitancy and uptake in their communities.
- They discuss the everyday barriers families face, from misinformation to transportation challenges, and strategize context-specific outreach approaches.
- This grounding in community realities positions health workers as vital bridges for facilitating community engagement in monitoring.
When local staff are empowered as active agents of learning and change, they can more effectively champion community participation, translating insights into tangible improvements.
Could CBM fit into a more comprehensive system from local monitoring to action?
TGLF’s model supports health workers in this bridging role by providing a comprehensive framework for local monitoring and action.
Through peer learning networks and problem-solving cycles, the model equips health staff to collect, interpret, and act on unconventional monitoring data from their communities.
For instance, in TGLF’s 2022 “Full Learning Cycle” initiative, 6,185 local health workers from 99 countries examined key immunization indicators to inform their analyses of root causes and then map out corrective actions.
- Participants began monitoring their own local health indicators, such as vaccination coverage rates.
- For many, this was the first time they had been prompted to use this data for problem-solving a real-world challenge they face, rather than just reporting up the next level of the health system.
They discussed many factors critical for tailoring immunization strategies.
This transition – from being passive data collectors to active data users – has proven transformative.
It positions health workers not as cogs in a reporting machine, but as empowered analysts and strategists.
By discussing real metrics with peers, participants make data actionable and contextually meaningful.
Guided by expert-designed rubrics and facilitated discussions, health workers translated this localized monitoring data into practical improvement plans.
For an epidemiologist, this represents a significant shift from traditional top-down monitoring paradigms.
By valuing and actioning local knowledge, TGLF’s model demonstrates how community insights can be systematically integrated into immunization decision-making.
However, until now, its actors have been health workers, many of them members of the communities they serve, not service users themselves.
CBM’s focus on monitoring is important – but leaves out key issues around community participation, decision-making autonomy, and strategy.
How could we integrate CBM into a transformative approach?
TGLF’s experiences suggest that CBM could be embedded within comprehensive learning-to-action systems focused on locally-led change.
TGLF’s model is more than a monitoring intervention.
- It combines structured learning, rapid solution sharing, root cause analysis, action planning, and peer accountability to drive measurable improvements.
- These mutually reinforcing components create an enabling environment for health workers to translate insights into impact.
In this framing, community monitoring becomes one critical input within a continuous, collaborative process of problem-solving and adaptation.
Several features of TGLF’s model illustrate how this integration could work in practice:
- Peer accountability structures, where health workers regularly convene to review progress, share challenges, and iterate solutions, create natural entry points for discussing and actioning community feedback.
- Rapid dissemination channels, like TGLF’s “Ideas Engine” for spreading promising practices across contexts, enable local innovations in response to community-identified gaps to be efficiently scaled.
- Emphasis on root cause analysis and systemic thinking equips health workers to interpret community insights within a broader ecosystem lens, connecting localized issues to upstream determinants.
- Cultivation of connected leadership empowers local actors to champion community priorities and navigate complex change processes.
TGLF’s extensive digital network connects health workers across system levels and contexts, enabling them to learn from each other’s experiences with no upper limit to the number of participants.
By contrast, CBM seems to assume that a community is limited to a physical area, which fails to recognize that problem-solving complex challenges requires expanding the range of inputs used.
Within a networked approach that connects both community members and health workers across boundaries of geography, health system level, and roles, CBM could become an integral component of a transformative approach to health system improvement – one that recognizes communities and local health workers as capable architects of context-responsive solutions.
Fundamentally, the TGLF model invites a shift in mindset about whose expertise counts in monitoring and driving system change.
CBM could provide the ‘connective tissue’ for health workers to revise how they listen and learn with the communities they serve.
For immunization programs grappling with persistent inequities, this shift from passive compliance to proactive local problem-solving is critical.
As the COVID-19 crisis has underscored, rapidly evolving public health challenges demand localized action that harnesses the full range of community expertise.
TGLF’s model offers a tested framework for actualizing this vision at scale.
By investing in local health workers’ capacity to learn, adapt, and lead change in partnership with the communities they serve, the model illuminates a promising pathway for integrating CBM into immunization monitoring and beyond.
For epidemiologists and global health practitioners, TGLF’s approach invites a reframing of how we conceptualize and operationalize community engagement in health system monitoring.
It challenges us to move beyond tokenistic participation towards genuine co-design and co-ownership of monitoring processes with local actors.
Realizing this vision will require significant shifts in mindsets, power dynamics, and resource flows.
But as TGLF’s initiatives demonstrate, when we invest in the leadership of those closest to the challenges we seek to solve, transformative possibilities emerge.
Further rigorous research comparing the impacts of different CBM integration models could help accelerate this paradigm shift, surfacing critical lessons for the immunization field and global health more broadly.
TGLF’s model not only offers compelling lessons for reimagining monitoring and improvement in immunization programs, it also provides a pathway for integrating CBM into a system that supports actual change.
CBM practitioners are likely to struggle with how to incorporate it into existing practices.
By investing in frontline health workers as change agents, and surrounding them with an empowering learning ecosystem, the model offers a path to then bring in community monitoring.
Without such leadership from health workers, it is unlikely that communities are able to participate.
The journey to authentic community engagement in health system monitoring is undoubtedly complex.
But if we are to deliver on the promise of equitable immunization for all, it is a journey we must undertake.
TGLF’s model lights one promising path forward – one that positions communities and local health workers as the beating heart of a learning health system.
While Gavi’s evidence brief affirms the promise of CBM for immunization, TGLF’s experience with its own model suggests the full potential of CBM may be realized by embedding it within more comprehensive, digitally-enabled learning systems that activate health workers as agents of change – and do so with both physical and digital communities implementing new forms of peer and community accountability that complement conventional kinds (supervision, administration, donor, etc.).