The Intellectual Framework

The Co-Investment Model

Six traditions in development, governance, and technology converge in a single framework for building health systems that communities own, operate, and sustain.

The Pattern

What gets built does not stay built

Outside organizations deploy systems, train small teams, and fund operations for a fixed period. When funding ends, maintenance and governance often do not transfer. The technology becomes an artifact instead of an asset.

The co-investment model starts from a different premise: communities that invest in their health infrastructure will protect it, govern it, and sustain it.

Scholarly Lineage

Six traditions. One framework.

The model draws together primary care delivery, community financing, commons governance, digital public goods, asset-based development, and blended finance. Each thread contributes a layer of practice.

Primary Health Care and the CHW Tradition

The care delivery architecture

Alma-Ata Declaration (1978) · Walsh & Warren selective PHC debate · Ethiopia Health Extension Program (2003) · WHO CHW Guidelines (2018)

Community Health Workers are not a workaround for absent infrastructure. They are a design choice that places trusted community members at the center of health delivery, connected by digital tools to clinical systems.

What AHN takes

AHN trains and connects CHW networks to open-source clinical systems so community care and facility care share one record.

Community Health Financing

The ownership and sustainability thread

Bamako Initiative (1987) · Rwanda Mutuelles de Santé · User fee abolition debates (2000s–2010s)

Community financing works when it confers ownership, not when it creates barriers. Health cooperative memberships and village health savings groups are structured to build stake, not extract fees.

What AHN takes

AHN structures co-investment so communities hold real financial stake in facilities and systems.

The Commons and Collective Governance

The governance thread

Elinor Ostrom, Governing the Commons (1990) · Hess & Ostrom, Understanding Knowledge as a Commons (2007) · Health commons applications

Community health boards, transparent dashboards, and community scorecards are Ostromian design patterns applied to health infrastructure. Clinics and digital systems are commons requiring active, structured community governance.

What AHN takes

AHN designs governance for health data and facilities as shared commons.

Digital Public Goods

The technology thread

UN Roadmap for Digital Cooperation (2020) · Digital Public Goods Alliance · OpenMRS (2004) · DHIS2 · Community Health Toolkit

Open-source platforms are the infrastructure layer, but open source alone is not enough. The co-investment model adds local digital stewardship: communities trained to configure, customize, and maintain their own systems.

What AHN takes

NexusEMR and partner platforms are deployed with local stewardship plans from day one.

Asset-Based Community Development

The agency thread

Kretzmann & McKnight, Building Communities from the Inside Out (1993) · Cooperrider & Srivastva, Appreciative Inquiry (1987) · Amartya Sen, Development as Freedom (1999)

Communities contribute labor, land, materials, governance capacity, and financial investment. These are assets, not needs. The model starts from what communities have, not from what they lack.

What AHN takes

AHN assessments begin with assets and governance capacity, not deficit lists.

Blended Finance and Social Enterprise

The sustainability thread

Social impact bonds · Development impact bonds · Cross-subsidization models · Convergence Blended Finance

Sustainability is designed in from the start. Revenue-generating clinical services, community health subscriptions, and adjacent enterprises fund operations. Digital infrastructure is what makes this operationally possible.

What AHN takes

AHN helps partners design blended pathways that keep systems running after grants end.

The Synthesis

What the co-investment model integrates

No single tradition covers community delivery, financing, governance, technology, agency, and sustainability. The co-investment model aligns them so investment, infrastructure, and governance reinforce each other.

Thread 01

CHW networks

Trusted community delivery linked to open clinical systems.

Thread 02

Community financing

Ownership through savings, cooperatives, and transparent fees.

Thread 03

Commons governance

Boards, scorecards, and shared stewardship of infrastructure.

Thread 04

Open-source infrastructure

Deployable platforms with local configuration and maintenance.

Thread 05

Asset-based framing

Partnerships built from community strengths and governance.

Thread 06

Tiered sustainability

Blended revenue streams and enterprise where appropriate.

The distinctive contribution

No single tradition covers all six layers. The co-investment model brings them together into a single operational framework where community investment, digital infrastructure, commons governance, and financial sustainability reinforce each other.

Health systems built this way do not depend on the next grant cycle. They belong to the communities they serve.

How the Framework Maps to the Work

Three focus areas. Six traditions.

Digital Public Goods

NexusEMR is built on OpenMRS by Open Source Harbor. Deployments pair open platforms with local stewardship and community governance.

Digital Public Goods Commons Governance Asset-Based Development

Co-Investment and Ownership

Shared financing, transparent governance, and planned revenue blend into a single ownership strategy for facilities and systems.

Community Health Financing Commons Governance Blended Finance

Consulting and Advisory

Strategy, platform selection, and financing design for governments and organizations adopting the co-investment model.

Primary Health Care Digital Public Goods Blended Finance

The traditions behind the work

Primary Health Care

Declaration of Alma-Ata

WHO & UNICEF, 1978

Primary Health Care

WHO Guideline on Health Policy and System Support to Optimize CHW Programmes

WHO, 2018

Commons Governance

Governing the Commons

Elinor Ostrom, 1990

Commons Governance

Understanding Knowledge as a Commons

Hess & Ostrom, 2007

Asset-Based Development

Development as Freedom

Amartya Sen, 1999

Asset-Based Development

Building Communities from the Inside Out

Kretzmann & McKnight, 1993

Digital Public Goods

Roadmap for Digital Cooperation

UN Secretary-General, 2020

Community Health Financing

Removal of User Fees and System-Wide Effects

The Lancet, 2009

Build With Us

Engage

Partner, collaborate, or support work that builds health systems communities can own.

Health organizations

Deploy open-source health platforms in your setting. We provide technical support, training, and adaptation assistance for local administration.

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Governments and NGOs

Advisory services on health informatics strategy, open-source technology selection, digital governance, and sustainable financing.

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Funders

Invest in sustainable, community-owned health infrastructure. We pursue blended finance pathways including grants, impact investment, and operational revenue.

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