Malawi Struggles in Providing Quality and Accessible Maternal Care

By Enock Mnyenyembe, White Ribbon Alliance, Malawi
Introduction by Elena Ateva, White Ribbon Alliance

Midwife from Mapale Health Centre - Mzuzu City,Mzimba North District, Malawi. Courtesy of White Ribbon Alliance

Midwife from Mapale Health Centre – Mzuzu City,Mzimba North District, Malawi. Courtesy of White Ribbon Alliance

The vital contributions of midwifery for women and newborns to survive and thrive is well recognized. The 2014 Lancet Series on Midwifery proved the case for a renewed commitment to midwifery that is often overlooked in healthcare systems. The Lancet research supports “a shift from fragmented maternal and newborn care provision that is focused on identification and treatment of pathology to a whole-system approach that provides skilled care for all.”

According to the UNFPA “State of the World’s Midwifery 2014” report, midwives can provide up to 87% of the care needed by women and newborns. Evidence shows that care provided by midwives is cost-effective, affordable and sustainable. According to the Lancet, the “return on investment from the education and deployment of community-based midwives is similar to the cost per death averted for vaccination.” Midwifery care is thus crucial to the successful achievement of the Sustainable Development Goals (SDGs), and midwives are an important resource which has been underutilized globally in securing better outcomes for mothers and babies.

As such, White Ribbon Alliance (WRA) is working with partners HP+, USAID and others to raise awareness about the importance of midwifery. As part of that, WRA recently trained 30 midwives in Malawi as citizen journalists with the goal of having a stable of midwives who could report on the issues facing them as health professionals and the mothers and babies they care for. This story comes from WRA Malawi Communication Officer Enock Mnyenyembe, who helped train the midwives and continues to collaborate with them to raise awareness in Malawi.

Malawi Case-study:

The Government of Malawi committed to achieving the SDGs by 2030 at the United Nations General Assembly in September 2015, but is struggling in its efforts to achieve quality and accessible health services in accordance with the SDGs. A number of challenges exist, including the need for women to travel long distances to health facilities, shortages of drugs and trained staff, and an inability to retain staff due to poor pay and basic motivations.

A survey commission by WRA Malawi revealed an acute shortage of bedside midwives, defined as midwives who spend more than 75% of their time working in their midwifery capacity. The survey revealed there are only 3,420 bedside midwives in the country to serve about four million childbearing women and called for an additional 20,217 midwives to reach the World Health Organization (WHO) recommended ratio of 175 pregnant women to one midwife.

Mapale Health Centre - Mzuzu City,Mzimba North District, Malawi. Courtesy of White Ribbon Alliance

Mapale Health Centre – Mzuzu City,Mzimba North District, Malawi. Courtesy of White Ribbon Alliance

According to Mtondera Munthali, the Safe Motherhood Coordinator for Mzimba North District Health Office, only 43% births are attended by skilled birth attendants in the district. Another way to look at that startling figure: 57% of women are putting their lives and the lives of their babies at risk, delivering at home or on their way to the health facility. Georgina Phiri is one such mother.

For Georgina, who lives in Mzuzu City, which is part of Mzimba North District, the Mapale Health Centre is the only public health facility in her surrounding area that offers primary health care. This small facility typically has 300 deliveries per month. Its midwives are often doing the work of a large district hospital, overseeing pre- and post- natal care, outpatient care and deliveries. Munthali and her fellow midwives have an increased workload due to conditions like this, that exist throughout the country.

Georgina, like many women, lives far from the health facility – about 10 kilometers – and began her long journey as soon as her labor pains started. She did not make it and ended up delivering her baby on her way to the facility, where she lost a lot of blood and fell unconscious, leaving her accompanying family in a panic to get her to the clinic. Georgina would’ve gone earlier, but the facility does not have the capacity to keep women overnight, compromising care and creating dangerous scenarios, like Georgina’s, who was lucky: she and her baby survived. But many others do not.

WRA Malawi is leading the multi-year campaign “Happy Midwives for Happy and Healthy Women” that focuses on advocacy for increased midwifery positions throughout the country and to ensure that no matter where a woman lives, she can expect and receives quality, respectful care, and ultimately, improved health outcomes for mothers and babies.

A Strategy to Deliver a Fit-For-Purpose Global Health Workforce

By Vince Blaser, Frontline Health Workers Coalition

This post was originally posted on the Global Health Council blog.

The placards went from horizontal to vertical—indicating their nation wished to speak. One after another—from Guinea to Switzerland, Thailand to the United States—they spoke with impassioned tones about the centrality of strategically addressing the health workforce gaps exasperatingly standing in the way of the enormous progress we know can be achieved in global health in the next 15 years.

And then, after civil society chimed in with similar calls of praise and pleas for vigilance – the chair called for objections. There were none, and the first ever Global Strategy on Human Resources for Health: Workforce 2030 went from draft to reality.

Working in global health advocacy, you rarely see such a vivid display of the collective work that leaders of the Frontline Health Workers Coalition (FHWC) witnessed in Geneva this past May when the world’s health ministers unanimously approved Workforce 2030 at the World Health Assembly.

Flashback two-and-a-half years across the Atlantic Ocean in Recife, Brazil. Fifty-seven member states had just made five-year commitments of variable muster in addressing their country’s health workforce challenges—nearly all of the commitments coming from low- and middle-income countries. Over a dinner with health workforce policy leaders from around the world that FHWC, USAID, and others help organize, a conversation began about the acute need for a global consensus on a strategic direction to address the most severe human resource-related barriers to ensuring everyone worldwide has access to essential health services.

The Global Health Workforce Alliance carried forward a two-year, multipronged consultation process with stakeholders from all sectors in all regions that delivered a framework for the World Health Organization to work with member states to draft Workforce 2030, which was strongly championed by USAID and across the U.S. government.

Member states debate adoption of the Workforce 2030 strategy at the World Health Assembly in May 2016. Photo by Vince Blaser, Frontline Health Workers Coalition.

Member states debate adoption of the Workforce 2030 strategy at the World Health Assembly in May 2016. Photo by Vince Blaser, Frontline Health Workers Coalition.

So what does the strategy say? In brief, it sets out a vision of “accelerating progress towards universal health coverage and the UN Sustainable Development Goals by ensuring equitable access to health workers within strengthened health systems” and a series of milestones by 2020 and 2030 to achieve this vision.

And why is this important for global health progress? Consider this:

We are encouraged that the strategy provides a common framework for all countries and stakeholders to ensure a robust and resilient global health workforce; however, a strategy is just a piece of paper if not backed by a fervent effort to ensure the right investments and policies are in place.

On that front, we are hopeful that the report due this month by the United Nations High-Level Commission on Health Employment and Economic Growth, and commissioned by UN Secretary-General Ban Ki-moon in March, will have bold recommendations on how countries, donors, and civil society can work together for a fit-for-purpose health workforce we need to achieve the SDGs.

We at the Frontline Health Workers Coalition celebrate the passage of  Workforce 2030, but the global health community must be vigilant to ensure its promise becomes reality.


WASH on the Front Line

By Assumpta Nantume, Global Health Council

South Sudan is one of several conflict regions today that face a grave scarcity of human resources for health. The recent surge in violence last month has worsened the humanitarian crisis and taken a huge toll on refugee camps, where individuals are experiencing malnutrition and diarrhea at high rates.

Courtesy: IntraHealth International

Courtesy: IntraHealth International

The UN Protection of Civilians Mission in South Sudan and other refugee camps throughout the country currently shelter a combined population of over 933,000 refugees. Ensuring access to water, sanitation, and hygiene (WASH) is a major priority.

The effects of WASH have far-reaching impacts that enhance infant, child, and maternal health; reproductive health; nutrition; and protection from parasitic infection and water-borne diseases. As a result, WASH is one of the most cross-cutting public health interventions, especially in a humanitarian crisis.

Through concerted efforts with UNICEF and other WASH partnerships, frontline health workers play a central role in accelerating and sustaining delivery of WASH services to vulnerable communities in South Sudan, providing not only access to safe drinking water during emergency responses, but also encouraging WASH standards and guidance as sanitary officers within the camps. Most recently, as dozens of suspected cholera cases were reported across the country in July, community health workers worked with NGOs and the government to coordinate a quick and effective response to prevent an outbreak.

As part of South Sudan’s Ebola Preparedness Campaign, UNICEF’s frontline workers played a key role in raising awareness about how hand washing can help prevent the spread of Ebola and similar viruses among the community. Where soap was not readily available, communities were educated on washing their hands with ash—a suitable alternative.

Situations like these are not unique to South Sudan. As it stands today, the global population is facing the largest humanitarian crisis in history, with over 65.3 million forcibly displaced people. Frontline health workers in these resource-constrained settings must often rely on adaptiveness and innovation to meet the surging demands for potable water, soap, toilet paper, water basins, and other commodities central to WASH. This raises the question of the dangers that they as individuals are exposed to when challenged with limited access to WASH services. Whether they are attending to refugees within camps or to patients at health care facilities outside the camps, frontline health workers have a right to serve in sanitary, hygienic, and dignified conditions, along with the patients they serve.

Ensuring access to WASH services plays an important role in safeguarding the health and well-being of individuals and communities. It plays an equally important role in protecting the health workers who protect our communities. A lack of basic WASH services compromises the ability to provide safe care and presents serious health risks to both those who seek treatment and those who provide it.

A recent report by the World Health Organization (WHO) found that out of 54 low- and middle-income countries surveyed, only 25% had established policies or targets for basic coverage of WASH in health care facilities. Global Health Council (GHC) is working to increase awareness and action around the pressing need for adequate WASH services in all health care centers.

Earlier this year, GHC cohosted a World Health Assembly side event with WaterAid and other partners to discuss barriers to WASH access in health service delivery and how to close these gaps in vulnerable communities. Local government officials, the private sector, international NGOs, and other stakeholders explored different leadership opportunities and highlighted efforts already underway across the health sector. Both the global health and WASH communities are unequivocally invested in providing WASH services for people in crises and the frontline health workers that serve them.

As refugees flee crises all across the globe and a severe scarcity of health workers in these regions persists, a host of actors—including governments, NGOs, and public-private partnerships—must strengthen WASH strategies to combat disease before it strikes.

On World Humanitarian Day, Remember Local Health Workers

by Michelle Korte, IntraHealth International

When you think of a humanitarian, what image comes to mind? A foreign aid worker? A group of missionaries? Maybe a few American celebrities stirring trans-Atlantic compassion? (Just Google the term “humanitarian” and you’ll see a lot of Angelina Jolie, after all.)

Here’s another picture: local health workers, on the front lines of care in the communities where they grew up, providing humanitarian services every single day.

At a monthly Accredited Social Health Activist (ASHA) meeting at Sunhati Khadkhadi community health center, ASHAs conduct a group exercise and present their findings about handling newborn babies. ASHAs are effective at communicating and changing behaviors at the community level because they are from communities they serve. Photo by Trevor Snapp, IntraHealth International

At a monthly Accredited Social Health Activist (ASHA) meeting at Sunhati Khadkhadi community health center, ASHAs conduct a group exercise and present their findings about handling newborn babies. ASHAs are effective at communicating and changing behaviors at the community level because they are from communities they serve. Photo by Trevor Snapp, IntraHealth International

Humanitarians, by definition, actively engage in promoting human welfare and social reforms—both in emergency settings and for the long-term. While Western media often portray the image of expat aid workers flown in to save the day, only about 8% of humanitarian workers on the ground are international hires.

Local workers account for the vast majority of the humanitarian workforce, and 4 of every 5 organizations providing humanitarian aid are local nongovernmental organizations operating exclusively in-country. Despite these numbers, local workers often go unrecognized in their service on the front lines.

Millions of humanitarians across the globe are working to improve the human condition. They are community health assistants providing last-mile care to the most remote and vulnerable villages in Liberia. They are hair dressers imparting vital family planning knowledge to their clients in Guinea. They are drivers risking their personal safety to collect information on food security for Syrians under siege from their own government.

They are the indispensable connections between the aid budgets we debate in Washington and the realized mitigation of human suffering.

Today, on World Humanitarian Day, we must not forget that when the planes come in to evacuate foreigners from crisis settings, many local workers are left behind to continue the work, while continuing to face dangers on the ground.

The Humanitarian Situation

Today, there are at least 28 ongoing conflicts worldwide. A record 130 million people depend on humanitarian assistance for their very survival. “Grouped together, these people in need would comprise the tenth most populous nation on Earth,” writes UN Secretary-General Ban Ki-moon. The need for humanitarian assistance is urgent.

In their laudable efforts to deliver this assistance, frontline humanitarians too often end up victims of violence themselves. Compared to the 74 attacks on aid workers in 2005, 2013 saw a peak of 265 attacks—a 250% increase.

On July 11 of this year, South Sudan witnessed one of the worst targeted attacks on aid workers in its three-year civil war. Earlier this month, the few remaining doctors in the besieged city of Aleppo pleaded for President Obama’s help in ending the five-year Syrian conflict, noting that an attack on a medical facility occurs every 17 hours.

Just this Monday, an airstrike on an MSF-supported hospital in Yemen killed at least 15 people, including 3 staff members. And the examples don’t stop there.

The Aid Worker Security database found that last year 217 aid workers were victims of major attacks including bodily assaults, shootings, kidnappings and bombings. Ninety percent of these victims were local staff. While they may not make international headlines, these local humanitarians are the ones who often bear the brunt of risk in conflict settings.

As we move forward in the post-MDG era, let us better support the critical work that they perform.

A pharmacist delivers drugs at a clinic in Mali. Photo by Trevor Snapp, IntraHealth International

A pharmacist delivers drugs at a clinic in Mali. Photo by Trevor Snapp, IntraHealth International

Paying our Respects Through System Reform

At the global level, we must continue to fund a robust, coordinated humanitarian system while encouraging greater respect for humanitarian law. Investment in the health workforce is not only a cost-effective strategy to accomplish this, but also a moral imperative in crafting a better, healthier world.

We must ensure that our investments in the humanitarian system are smart, bridging the gap between high-quality evidence and humanitarian practice. Oxfam concludes that the international humanitarian system is not saving as many lives as it could, because its design perpetuates unsustainable dependencies on international donors.

To more adequately advance the humanitarian goals of saving lives and reducing suffering, we must restructure our aid mechanisms so that funding is channeled where it’s needed most—and often, that’s in the hands of local actors.

Already we’re seeing more examples of the international community embracing the idea of aid localization. Donors and aid agencies launched the “Grand Bargain” at the first-ever World Humanitarian Summit in Istanbul this May. Through this pact, 25% of humanitarian spending will be channeled to local organizations by 2020—a drastic increase from the 0.3% in 2015. USAID, for its part, has already committed to channeling 30% of its funding to local partners.

While progress unfolds on the global stage, everyone has a role to play in supporting frontline humanitarians at the grassroots level. Become a messenger of humanity and encourage leaders to maintain the commitments expressed at the World Humanitarian Summit. Write to your representatives and urge them to support legislation that empowers frontline humanitarian actors to more effectively deliver needed assistance—the Frontline Health Workers Resolution and the Reach Every Mother and Child Act, for instance, lay out plans for US leadership to strengthen global health commitments and workforce to achieve enormous returns on investment.

We cannot meet the needs of 130 million people without a reliable supply of frontline health workers who are present, ready, connected, and safe. So let’s expand our conception of what a humanitarian looks like, does, and needs, and get creative about ways to support the life-saving work they perform.

The End of Polio in Nigeria

By Tyler Marshall, International Medical Corps

Courtesy: International Medical Corps

Courtesy: International Medical Corps

A milestone global health victory has been achieved in the war against disease: Nigeria—and with it, all of Africa—is now polio-free. It is an accomplishment that has brought the world to the brink of eradicating the crippling virus, with only Afghanistan and Pakistan still struggling to conquer the disease.

“This is a tremendous achievement,” said International Medical Corps Senior Health Advisor Paul Robinson, who has provided technical support to the project since his organization joined the CORE Group Polio Project (CGPP) in 2015. “In the history of the world there has been only one other human disease eradicated globally and that is smallpox. Now we have a chance to add polio to that list.”

Working in northern Nigeria as part of the CGPP – which is supported by USAID– International Medical Corps drew on our highly respected training expertise to join the fight against polio. We provided local government workers, non-government staff, and volunteers, with the skills needed to increase polio vaccination rates—rates that had seriously lagged behind due to terrorist attacks and atrocities in a region that includes Boko Haram’s home areas.

We began in Kano State in March 2015 and six months later expanded our polio and other vaccine efforts to Borno State, where Boko Haram is active. Our local partners in these two states are Nigerian NGOs, Community Support and Development Initiatives (CSADI) in Kano and African Healthcare Implementation and Facilitation Foundation (AHIFF) in Borno. Despite the violence, we were successful in lifting vaccination rates from the 20-30% range to an impressive 99.96% rate in Kano and 96.8% in Borno.

Such high vaccination rates don’t just happen.

They are the result of careful planning, organization, and coordination—all skills that require a variety of training curricula. For example, supervisors are trained on how to use smart phones for tracking project activities at neighborhood and community levels; on how to use registers filled out by volunteer community mobilizers (VCMs) to assure no households are missed. VCMs are trained on how to find and engage pregnant women and new mothers, encouraging them to bring their children to immunization sites for vaccinations, and also on how to find and report young children suffering from paralysis—and possible polio.

Local government staff and volunteers were also supported and mentored on ways to address community suspicions about the vaccination campaigns, which generate outright resistance to immunization.

One such incidence occurred when, for two subsequent rounds of monthly campaigns, community residents in one district area did not allow any of its children to be immunized, significantly increasing the likelihood of children contracting polio.

In response, the local government formed a team with UNICEF, Rotary Club, International Medical Corps and local government health officer to meet with community health officials, local council members as well as community leaders and engage in dialogue to address the causes for resistance and ease concerns.

Residents at the meeting resented that the polio campaign had been prioritized over other neglected community needs. The community lacked essential services, including clean water, and treatment and prevention against other diseases such as malaria and cholera that also killed children. Medicines were either not available or too expensive to purchase.

IMCorps - VaccinationPolioNigeria

Courtesy: International Medical Corps

These concerns expressed by residents were genuine and had to be dealt with honestly. The team initiated a dialogue under the leadership of a local traditional leader, to resolve the complaints.

Once community residents could see their complaints being addressed, the resistance ended. With an action plan agreed, a house-to-house polio immunization campaign followed that reached every child in that community.

It was only with countless similar dialogues, with explanations and persuasion on both sides, along with effective immunization strategies that those involved in the effort managed to rid Nigeria of polio—one child at a time.

Today, International Medical Corps, as all CGPP partners, remain vigilant in Nigeria, focused on the steps needed to consolidate the public health victory once the World Health Organization certifies the country polio-free in 2017—a triumph that would not have been possible without the tireless efforts of frontline health workers.

AIDS2016: Opening One Door to Chronic Care

By Dr. Sanele Madela, Director Expectra Health Solutions, South Africa

NOTE: This post was written in collaboration with – Jessica Daly and Belinda Ngongo of FHWC member Medtronic Foundation

'Thinking Collectively on Integrated Healthcare in Communities' panel at 21st International AIDS Conference (AIDS 2016). Courtesy: Medtronic Foundation.

‘Thinking Collectively on Integrated Healthcare in Communities’ panel at 21st International AIDS Conference (AIDS 2016). Courtesy: Medtronic Foundation.

“I am a mother, and my question is why was it so hard to diagnosis my baby?” The question – asked at the end of a session I attended at the 21st International AIDS Conference (AIDS 2016) in Durban, South Africa, July 18-22 – was striking.

This mother told the story of her daughter falling ill, time and time again, and her multiple visits to clinics and hospitals. The baby received numerous HIV tests, all of them negative. It wasn’t until her daughter nearly fell into a coma and had to be rushed to the hospital that the attending physician ordered a glucose tolerance test. Only then was her daughter diagnosed with type-1 diabetes.

Frontline health workers and their patients worldwide have been educated about how to test for HIV, how to seek and provide complex care to achieve viral-load suppression, and how to live healthy lives without shame or stigma – an irrefutable necessity and a moral mandate to fight the HIV/AIDS pandemic. Focused, targeted investment and urgent action remains imperative to achieve an AIDS-free generation.

But as the HIV response addresses millions of people of all ages, and as health systems supporting them mature, there is an increasing need to examine how these systems work for the whole person. How do they work for the HIV-positive mother with a child with diabetes, for the HIV-positive adolescent, or for the care-taking granny with high blood pressure?

The South African district hosting AIDS 2016 not only has an HIV prevalence of 40%,but also a 46% prevalence of hypertension. How do the health systems work for those without HIV, as well as those managing other chronic conditions in the same community? How do we create demand for comprehensive care, as well as provide care for the range of conditions communities face, in the context of fragmented systems?

Robust dialogue at the AIDS 2016 made clear evidence is evolving, and there is no silver bullet solution. But we do know frontline health workers will be key to bringing care to communities and homes and putting patients at the center of care. Not only will frontline health workers, including community health workers, continue to drive HIV screening and diagnosis, they will also be critical in the management of  other chronic conditions like hypertension and diabetes. These health workers must be linked to supportive supervision in primary care centers, and successfully integrated into care teams as they are the lynchpin to transformative change for people like the woman who boldly stood to ask her question about her baby.

Nquobile’s Story

Jessica Daly (left) and Dr. Sanele Madela at the AIDS 2016 Conference. Courtesy of Medtronic Foundation.

Jessica Daly (left) and Dr. Sanele Madela at the AIDS 2016 Conference. Courtesy of Medtronic Foundation.

At the same session, we also heard the story of Nqobile – a mother who learned she was HIV-positive status while pregnant, well after she had been diagnosed with diabetes, and years before she was diagnosed with asthma. Nqobile also had trouble getting to a diabetes diagnosis – requesting the test herself after reading a pamphlet on its symptoms. But now with the support of her family and frontline health workers in her community, she is successfully managing her conditions.

Fellow clinicians like myself need a paradigm shift in our approach – we can make a significant impact on our communities if they partner with us. Exemplifying this approach was a rotation at my medical school called “medicina general integral” – directly translated as “integrated general medicine.” It emphasized that the patients’ needs to be assessed holistically. Frontline health workers must be ready to manage multiple conditions, a one-stop shop. And we must empower communities to better prevent and manage their health issues.

The rural doctor must work effectively and share tasks with nurses, community health workers and other frontline providers, as well as assist in fostering community organizations and in promoting good health practices and self- and family-care. Frontline health workers must also advocate and mobilize the resources from within and outside the community to deliver essential health services.

Nqolbile is the model of empowerment, for what we collectively look to achieve at global scale. She is taking multiple daily medications, including antiretroviral drugs for HIV and insulin for diabetes, and practices good self-care – supported by frontline providers.

Her advice to other consumers of care: “Know whether it’s diabetes, HIV, or asthma – it’s not a death sentence. Think of yourself as any other person. You can live happily, with life and with hope.”




Health workers: The unattended resource

By Melissa Wanda Kirowo, FCI Program of Management Sciences for Health

NOTE: This post was originally published in the FCI program of MSH blog Rights and Realities

At Women Deliver 2016 conference in May, I had the opportunity to talk with one of a number of young midwives attending the conference. Clementina IIukol, a 22 year-old Ugandan midwife, represents the commitment of health care providers as they work, often under very difficult conditions, to provide essential services to women, newborns, children, and adolescents in the communities they serve. “I walk for miles before daybreak,” Clementina told me, “to fetch water for use at the clinic where I work.”

Courtesy FCI Program at MSH

Courtesy FCI Program at MSH

A week after Women Deliver, global health security was the top subject of discussion at the World Health Assembly, as member states recognize that sustainable development will be unattainable if resilient health systems cannot withstand epidemics like the Ebola, MERS, and Zika viruses. Ultimately, global health security requires individual health security; we must not only support rapid detection and response to cross-border infectious disease threats, but we must also guarantee that every individual has access to safe and effective health care.

And what this requires, in turn, is an adequate, equitably distributed, skilled, and well-equipped health workforce. Health workers, like Clementina, turn aspirations into actions. They constantly ‘innovate,’ building bridges to work failing health systems so that everyone facing a health emergency can get the treatment they need.

The newly approved Global Strategy on Human Resources for Health: Workforce 2030 aims to support achievement of Sustainable Development Goal (SDG) target 3C, to “substantially increase health financing and the recruitment, development, training and retention of the health workforce,” by ensuring equitable access to high-quality health workers and filling a global shortage of health-care workers that is estimated to exceed 14 million in 2030.

This global Human Resources for Health strategy lays out the minimum density of doctors, nurses, and midwives needed to meet the SDG health targets and deliver universal health coverage (UHC) — 4.45 per 1,000 population. We need to develop clear strategies and make conscious investments in building the health workforce to achieve this target.

A 2013 WHO report, A universal truth: No health without a workforce, identified key causes for the critical shortage of healthcare workers: an ageing health workforce, recruitment and retention challenges, inadequate training, population growth, emerging and re-emerging pandemics, and increasing risks of non-communicable diseases.  Inequality in distribution is exacerbated by internal and international migration of health workers, leading to regional imbalances.

To overcome these challenges and fulfill the promise of Workforce 2030, countries must invest in health workers and devote resources to implementation, monitoring, evaluation, accountability, and learning.

After Women Deliver, I returned to Kenya inspired by the sacrifice of Clementina and her fellow midwives, and was met by yet another example of dedication, as I witnessed a healthcare worker wading through the floods–which have recently covered many Kenyan communities–to take measles vaccines to villagers in Busia County.

Like Clementina and this Kenyan woman confronting inhospitable environments, skilled health professionals are our communities’ first line of defense. Health workers are the key to individual health security, and thus also to global health security. Without them, no health system can function well and serve its users effectively and equitably. Meeting our health goals means investing in the health workforce.


Frontline health workers: The missing link to making the data revolution work for global health

By Laura Hollod, Johnson & Johnson

“You want a revolution? I want a revelation.” – Angelica Schuyler, Hamilton the musical

There is no denying a data revolution is underway in global development.

The Millennium Development Goals (MDGs) agreed to in 2000 represented a breakthrough moment when for the first time, the development community agreed upon and tracked key targets for 2015. For the Sustainable Development Goals (SDGs) agreed to last year with 2030 targets, the multidisciplinary Global Partnership for Sustainable Development Data has been established “to convene, connect, and catalyze” effective use of data to track progress. The World Bank, USAID, and WHO last year set forth a Roadmap for Health Measurement and Accountability.

And just last month at the World Health Assembly, health ministers unanimously voted to ratify the first ever Global Strategy on Human Resources for Health called Workforce 2030, which includes milestones and a strong call to strengthen data for the health workforce.

Global initiatives and strategies like these rightly call for high-level standardization, disaggregation, and infrastructure support for better access to data at the country level, all of which are essential to inform policy and resource allocation.

However, here is a revelation from the frontlines of health: the data revolution is weakened until those responsible for delivering care can fully participate. Only when all health workers have the timely, accurate, and useful data they need to provide the best care to their communities can global health goals be realized.

On the frontlines, health workers are often responsible for so much more than just delivering care. In places like Zambia’s rural communities, many of the daily tasks of nurses and midwives rely on data – monitoring staffing, overseeing service delivery, following up with patients, and tracking health outcomes. These frontline health workers often lack the support, capacity, or infrastructure needed to interact with data in a meaningful way.

JnJ photo

Johnson & Johnson supports the H4+ program at Mkoani Hospital, Pemba Island, Zanzibar, that focuses on capacity building, health system strengthening, and monitoring and evaluation to ensure that healthy mothers give birth to healthy babies. © Johnson & Johnson

How can the global health community help frontline health workers to fully participate in the data revolution?

The first step is to listen and understand the data challenges of the frontlines from those who are experiencing it. Building on a long-standing partnership with IntraHealth International, Johnson & Johnson and several other partners including the University of Zambia, mPowering Frontline Health Workers, International Council of Nurses, and Dalhousie University WHO Collaborating Center recently engaged with Zambian health leaders to help strengthen Zambia’s community frontline health teams and the nurses who lead them. To start, we spoke with many nurses, community health workers, and other key stakeholders, who candidly told us about the key gaps in information flow, and specific challenges to getting the right data to the right people at the right time. Conversations like these help to reveal the real gaps and barriers to effective use of data.

With barriers identified, we can tailor capacity-building efforts to address these needs, better empowering those on the frontlines to be emissaries of the data needed to grasp realities on the ground. This means that in addition to going beyond clinical skills to train frontline health workers in topics such as leadership and management, we must include basic data skills development – how to record data, how to interpret data visuals, and how to use data to help make decisions. While “data intermediaries” can potentially help interpret and translate data at certain levels, the reality is that in many rural communities, it is frontline health workers who must work to understand and use data daily as they strive to provide effective care. While continuing the global effort to improve data, we cannot loose sight of improving the capacity of those gathering the data to do it well and with meaningful benefits at the local level.

The data revolution will not yield lasting, transformative results for global health unless those on the frontlines of delivering care are engaged, empowered, and leading the way. Our global efforts to achieve the SDGs with better and more insightful data at the global level will fall short if those at the community level, leading in implementation, are not a key part of the process. By improving the capacity and skills of frontline health workers, we engage them not only on the frontlines of care but also on the frontlines of the data revolution. And they are the revelation we need.

A Colleague Lost, and the Unknown Devastation of Attacks on Health Care

By Margarite Nathe, IntraHealth International

NOTE: This blog was originally published in the Huffington Post.

We know very little about what happened to our dear colleague Sister Veronika Rackova, a physician and Catholic nun who was loved by her community in Yei, South Sudan.

We know she was driving the St. Bakhita Medical Centre’s ambulance on May 16. We know she was on her way back from the neighboring Harvester’s Health Centre, to which she had rushed a pregnant woman in the midst of a medical emergency. And we know it was late at night, about 1am.

Most people in the region know the roads aren’t safe at that hour. Checkpoints that may be benign in the daylight grow more and more volatile as the night goes on and the soldiers manning them get rowdier or drunker. People get hurt.

But of course, medical emergencies are not restricted to safe hours or safe places.

We know that someone shot at Sister Veronika’s ambulance, and that she was hit in the stomach. We know she was evacuated from Yei to a hospital in Nairobi, Kenya.

And we know that four days later, she died.

But so many details are still missing. Who shot her? Was it one of the four members of the security forces now in custody? But why? Was it because she was driving an ambulance or was that just a coincidence?

And what will become of the many people who relied on Sister Veronika’s care?

Health care under attack

Sister Veronika was one of more than a thousand people killed in the last 15 months as a result of attacks on health care. According to the Safeguarding Health in Conflict Coalition’s new report, No Protection, No Respect: Health Workers and Health Facilities Under Attack, 19 countries have seen continuous assaults on ambulances, frontline health workers, patients, and health facilities.

Hospitals are being looted, burned, and bombed. Ambulances are being attacked. Infants in incubators are dying as hospital generators are destroyed or run out of fuel.

Like many of the other 18 countries in the report, South Sudan is in the midst terrible violence and warfare, which the United Nations estimates have killed at least 50,000 people there since the fighting began in 2013 (and among those, Sister Veronika was the fifty-fourth aid worker killed). Both sides of the conflict have taken to obstructing access to medical facilities, stealing medical supplies, and kidnapping or murdering health and humanitarian workers.

Trevor Snapp for IntraHealth International
A nurse at the Saint Bakhita Health Centre in Yei discusses family planning and HIV counseling and testing with clients before their routine antenatal visits. IntraHealth has worked with the health center since 2007 to train and support Sister Veronika’s staff of health workers.


Sister Veronika’s death is a tragic microcosm of the ongoing assault on health care in war-torn regions around the world—all are marked by unanswered questions, impunity for perpetrators, and health consequences that will echo within affected communities for generations to come.

Here is one of the most striking revelations within the report’s pages: No one knows exactly how many attacks like the one that killed our colleague occur. No one knows how many health workers have died, how many people are left without care as a result, or who is responsible for many of the attacks.

Usually, there is no prosecution, because there are little or no data.

For years, the Safeguarding Health in Conflict Coalition has been calling on the United Nations and the World Health Organization to change this by putting in place a mechanism to monitor attacks and punish perpetrators.

And the agencies have begun to respond. Last month, the UN Security Council unanimously passed a resolution condemning attacks on health workers and facilities. And now for the first time, the WHO is calling for an information hub on health care attacks and gathering data to quantify the scope of the problem.

So far, WHO officials say they have found that between 2014 and 2015, attacks on health workers and facilities killed 959 people and injured 1,561. But the coalition believes this is a gross underestimate and is based on insufficient data. It continues to advocate for the WHO to refine its methodology to reach a more comprehensive calculation of what—and whom—we’ve lost in ongoing conflicts throughout the world.

The night she was shot, Sister Veronika had just transported a pregnant woman from St. Bakhita to Harvester’s Medical Centre for the specialized care the woman needed during her medical emergency. Without Sister Veronika’s quick action and devotion to her clients, the woman and her baby might have died that night. But instead, the mother safely delivered a healthy baby boy, and both are alive today.

“I worked with Sister Veronika very closely at St. Bakhita Medical Centre,” says Patrick Buruga, HIV prevention technical manager at IntraHealth International in South Sudan. “I knew her as a joyous and welcoming person, loved by her staff. She was dedicated to her work, and met her death while in service taking a mother to deliver where there were better facilities. Her death is a big loss for us and for the people she served in Yei.”


Trevor Snapp for IntraHealth International
Clients wait outside the Saint Bakhita Health Centre in Yei. The health repercussions of losing a highly skilled frontline health worker such as Sister Veronika could affect this community for generations.


As director of St. Bakhita, Sister Veronika worked with IntraHealth’s South Sudan office as they trained and supported her team of health workers. She helped many HIV-positive mothers in and around Yei to deliver their babies free of the virus. She was an invaluable health worker, neighbor, and friend.

And no amount of data will bring her back.

But knowing what happened matters. It affects how we move forward, how we prevent future attacks, and how—or if—anyone is held accountable for these ongoing atrocities.

IntraHealth has partnered with St. Bakhita Medical Centre in South Sudan since 2007. Our work in South Sudan is funded by the US Centers for Disease Control and Prevention and by the US Agency for International Development. IntraHealth serves as the secretariat for the Safeguarding Health in Conflict Coalition.

World’s Health Ministers Approve Historic Global Health Workforce Strategy: Workforce 2030

By Scott Weathers, IntraHealth International

GENEVA – The world’s health ministers last week at the 69th annual World Health Assembly approved an unprecedented resolution on health workforce that included approval of the first ever global health workforce strategy called “Global Strategy on Human Resources for Health: Workforce 2030.”

The resolution acknowledges the importance of health workforce to achieving the Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC), calling on member states to strengthen their health workforces.  Although the resolution carries no binding actions, statements from member states including the United States reaffirmed the high-level priority given to health workforce and health systems strengthening.

Frontline Health Workers Coalition and IntraHealth International leaders and other global health experts hailed the resolution’s approval as a milestone moment in the effort to ensure sustainable and resilient health workforces that can save lives and respond to global threats:

Also during the Assembly, the United Nations High-Level Commission on Health Employment and Economic Growth began a call to build the evidence base for investing in health workforce. The expert panel is seeking contributions from all sectors, which can be accessed here.   Meanwhile in Japan, the G7 issued a new Vision for Global Health, that also highlighted action on supporting frontline health workers as a key area of focus.


Damali Inhensiko, Midwife from Uganda, receives a 2016 International Health Workforce Award from Dr. Ariel Pablos-Mendez, USAID Assistant Administrator for Global Health. Photo courtesy : United States Mission Geneva

Amidst the policy dialogue during WHA, the Global Health Workforce Alliance awarded several global health leaders for their achievements in health workforce, including Damali Inhensiko, a midwife and frontline health worker working alone in her clinic in rural Uganda. Inhensiko’s rousing speech culminated a watershed week for frontline health workers workforce, ensuring that the issue remain at the top of the global health agenda.