Ghana’s new CHW program also platform for eHealth innovations

By One Million Community Health Workers Campaign


103 newly trained community health workers from the Amansie West District of Ghana at their graduation ceremony. Courtesy One Million Community Health Workers Campaign.

In June 2015 the One Million Community Health Workers Campaign hosted a workshop on collaboration between countries in sub-Saharan Africa and international development partners on financing the scale-up of community health workers (CHW) programs. The workshop culminated in the signing of a Joint Call to Action to the international community for increasing funding for national CHW programs, with representatives of ministries of health and finance from 15 African countries as signatories.

During that meeting, Columbia University Prof. Jeffrey Sachs and his team met with Ghana His Excellency President John Mahama, who decided to take on this challenge as a step toward ensuring universal health coverage (UHC) in the country.  Ghana’s program is a partnership of the Ghana Health Services (GHS), the Ghana Youth Employment Agency  within the Ministry of Employment and Labour Relations, and Ministry of Health, conducted with the support of World Vision International and the 1mCHW Campaign.

The program has recruited, trained and deployed 20,000 CHWs and 1,000 eHealth Technical Assistants (eTAs) across the country. The CHWs have been trained to provide community education on nutrition, hygiene and sanitation, and the prevention of malaria, diarrhea, respiratory and other diseases. They will also undertake community mobilization and support the community-based management of childhood illnesses by serving as adherence counsellors, defaulter tracers, initiators of community-based telemedicine, and following up on progress of patients and providing additional health education to families. The eTAs will provide data support to the Community Health Officers (CHOs) and CHWs, strengthening Ghana’s eHealth and data collection system.

Both CHWs and eTAs have been integrated into Ghana’s health system.  CHWs work under the direct supervision of Community Health Officers, who work in the Community-based Health Planning and Services (CHPS) zones; while eTAs work under the direct supervision of the District Health Information Officers of the GHS. Tools, equipment, and supplies for the work of CHWs have also been seamlessly mainstreamed through the Ghana Health Service, in a decentralized manner.

With the financial support of GlaxoSmithKline (GSK), the Campaign is supporting the training and deployment of 1,800 CHWs in the Ashanti region in partnership with Millennium Promise and the GHS. These CHWs will be equipped with smart phones and/or tablets, with an outreach focused software application made by Dimagi that will complement the facility based e-tracker of Ghana’s District Health Information Management System (DHIMS2), integrating the two into an overall eHealth system. This pilot interface system is known as ‘Cetracker’

The Cetracker system serves multiple functions including (1) decision-support tool for the CHWs, (2) an audio-visual device for education purposes for the clients, and (3) real-time GIS-enabled data collection facilitating longitudinal tracking of cases, disease mapping, surveillance for new diseases, and birth and death registrations. In the Cetracker, real-time household and community data are presented as customized reports, dashboards, and maps to allow easy visualization and quick decision-making. With Cetracker, the quality of the performance of CHWs can be electronically monitored with the aim of continuous, databased quality improvement of health care delivery.

The Ashanti region is serving as a national demonstration site for Ghana’s scale-up and will be evaluated using a variety of indicators. The program will map essential community infrastructure for health services – such as health facilities, water points, road network, internet connectivity, and emergency referral services. This helps to tailor health services to communities and guides the prioritization of interventions. The Ashanti regional scale-up is also integrated with the telemedicine initiative to improve the continuity of care from households to the health system.

There is also potential to leverage the CHWs and the eHealth technical assistants to address issues on non-communicable diseases (NCDs) and to contribute to meeting the UNAIDS 90-90-90 goal of getting 90% of people living with HIV to know their status; 90% of those diagnosed on treatment; and 90% of those on treatment as virally suppressed.

This initiative will strengthen Ghana’s health services and provide employment opportunities for the country’s unemployed youth and will in turn help Ghana accelerate its progress towards achieving the Sustainable Development Goals (SDGs) on health and youth employment (SDGs #3 and #8). The 1MCHW Campaign is very excited and committed to continue working with Ghana as it builds its pioneering cadre of professionalized CHWs supported by mHealth and telemedicine, improving the quality of life and health of Ghanaian rural communities.

On International Day of the Girl Child, nursing student Dibyashree Behara reminds us of the power to dream – and the means to fulfill it

By Indrani Kashyap, Jhpiego

In her coastal farming village in eastern India, Dibyashree Behara knew that getting sick meant visiting a local healer or traditional medicine practitioner.

“In my village, there is no doctor. One has to walk many miles before they can show themselves to a doctor or a nurse,” she said.

She told herself, “When I become a nurse, I will change that.”

Young Dibyashree Behara.

Young Dibyashree Behara.

It was the dream of a young girl, the daughter of a farmer and homemaker neither of whom ever had a chance to finish school. But Dibyashree’s parents wished for her and their two other children what they could not achieve themselves—an education and a profession.

“Health is a very precious thing, and when one is unwell, they need someone who can diagnose their problem and help them recover,” said Dibyashree. “I feel nursing is such a profession. I feel it will give me the ability to be there for people in need and be of use to them.”

An uncle encouraged her to realize her dream. At 18, with his support, Dibyashree applied to a nursing school some 250 miles away from her remote village in the coastal state of Odisha, sending her application from a computer in a small shop in her village.


Photo by Rashmi Kochuveetil and Manaswini Biswal, Jhpiego.

For a teenager with limited means, the online application process eliminated several hurdles to achieving her dream. “Every student doesn’t have great economic power to undertake the cost of travelling again and again. The online admission process saved a lot of trouble for me and my family,” said Dibyashree.

Young girls face immense barriers in achieving their dreams, starting with lack of basic education and health care. Sixty-two million girls around the world are not in school. These girls have diminished economic opportunities and are more vulnerable to HIV/AIDS, early and forced marriage, and domestic violence. When girls are educated, they have better control over their future and can lift up their families and transform their communities. A World Bank study found that every year of secondary school education is correlated with an 18% increase in a girl’s future earning power.
After a few more steps and a trip to a processing center at the school, Dibyashree was admitted to the nursing school in Brahmapur. She is one of more than 6,700 students who gained admission to general nursing schools through an online process developed for the government of Odisha with technical assistance from Jhpiego. More than 50,000 students applied online, a milestone in the state’s efforts to expand educational opportunities for girls.

Increasing the ability of young women to become nurses will help reduce the gap in frontline health workers in India and elsewhere. The World Health Organization estimates a shortage of at least 17 million health workers worldwide, including at least 9 million nurses and midwives.

In September, Dibyashree received her student nurse’s uniform and began classes. “We are studying the fundamentals of nursing, and I love it,’’ she said. “I am really grateful to have the chance to get into this profession. I want to do everything in my capacity to be of help and make valuable use of my education to help my community and my family in the future.”

Dibyashree Behara at nursing school.

Dibyashree Behara at nursing school. Photo by Rashmi Kochuveetil and Manaswini Biswal, Jhpiego.

Over the past four decades, Jhpiego has helped educate, train or mentor hundreds of thousands of frontline health workers to deliver lifesaving care to women and their families.

Dibyashree represents the potential of each and every girl throughout the world. We believe that where women live should not limit their worth, value or ability to live up to their full potential. It should not limit their access to basic health care and education. By educating girls, we empower them to fulfill their dreams and increase women’s participation in the health workforce force so they can advance economically and socially – and prevent the needless deaths of women and families.

HealthRise Lessons from the Field: Creating “Coordinated Care Hubs” to Serve Underserved Populations in Minnesota

By Chanza Baytop, Abt Associates

HealthRise is a five-year, $17-million global effort with funding and thought leadership from the  Medtronic Foundation designed to expand access to care for cardiovascular disease (CVD) and diabetes among underserved populations in Brazil, India, South Africa and the United States. Led by Abt Associates and partners, including global evaluation partner, IHME, HealthRise aims to contribute to the World Health Organization’s goal of reducing premature mortality associated with chronic, non-communicable diseases (NCDs) by 25% by 2025 through the implementation and evaluation of innovative, scalable, and sustainable community-based demonstration projects. These projects empower patients, strengthen frontline health workers and advance policies to increase the detection, management and control of CVD and diabetes. The projects address key barriers to care faced by underserved populations by strengthening health care delivery and extending care into community and home-based settings.  In this interview, Charlie Mandile, executive director of HealthFinders Collaborative (HFC) in Minnesota shares his experiences as one of the first local partners to implement HealthRise demonstration projects.


Charlie Mandile. Courtesy of Abt Associates

Please describe the work that HealthFinders Collaborative (HFC) conducted prior to HealthRise.

Since it began, HFC has worked with local health systems to provide care to marginalized and underserved populations. We are a community health center that provides care for those who are without health insurance, underinsured, or otherwise falling through the cracks. For a long time we’ve been viewed as the safety net for our community and have picked up where traditional medical care has left off. We were able to build from this position of working across the health system to identify gaps and provide people with access to the health system. It was a natural next step to participate in HealthRise because it fills a critical community need to coordinate care and support patients in their context, in ways that none of the providers are able to do alone.

Describe the most innovative feature of your program.

We are combining frontline health workers (and all that we define them as – community health workers, community paramedics, patient advocates, and community organizers) with medical teams to create a “coordinated care hub” that exists in the community, unites all of their work, and facilitates communications across the team and the community. This strategy of partnering emerging, community-based professionals with traditional medical teams to extend their reach in a coordinated, efficient and reliable way makes for a potentially innovative model. We are hoping we can contribute to the broader conversation on population health in a way that transcends insurers, health systems, and organizational partnerships and allows many different perspectives to come together to support patient health in communities.

How did you engage clinical facilities to support the HealthRise Program?

It was an interesting, natural evolution. We were already caring for their patients in the community, supporting them in their neighborhoods, and going out to patients with services. We had longstanding partnerships and were interested in how we could work together more. When HealthRise arose to address diabetes and hypertension, it gave us an opportunity to build on the capacity that we already created so we could see an effective extension of their reach beyond their walls.

What do you think motivated your clinical partners to participate in this partnership and what keeps them involved in HealthRise?

HFC is grounded in the belief and practice that it is our communities, our patients, and their families that really know what is best for their health. We committed to organizing our care and services around that principle, and in a way that is beneficial to health systems. Collaborating with us allows the clinical partners to get connected to the community and to capitalize on the trust and relationships that HFC has established. We were able to structure partnerships and engage in conversations in ways that allowed the community to give feedback to the healthcare providers, and I think the care providers found a lot of value in that. In working with the population, we connect community leaders and clinical partners so they can enhance their services. The other important element is the idea that HFC and HealthRise are extensions of their reach beyond the clinical partner’s walls. Clinical partners are aware that what matters in the treatment of chronic diseases, like cardiovascular disease and diabetes, is happening outside of their exam rooms. HFC has prioritized being an easy, efficient, and reliable extension for our clinical partners into the community so the doctors, nurses, and care team view us as a resource. This is a critical relationship that has allowed us to build these partnerships with the health systems.

Did you experience some hesitation with those you invited to participate in HealthRise? If so, where did it come from and how did you deal with those issues?

We did encounter some reservations and found out very quickly that there were a lot of groups working on some form of coordinated care or patient-centered approach. I think they initially found us duplicative or figured we were offering something that they were already embarking upon. Care coordination from a hospital or healthcare system perspective is very different from the way HFC interprets it to be. We spent a lot of time educating them on how HealthRise could be an effective tool for their existing patient-centered care projects and as way to extend their reach and capacity into the community. It was a lot about showing them the gaps that existed and explaining to them how we could build on their existing efforts.

Please describe how you educated clinical partners on the gaps between the care coordination services that they provide vs. the care coordination services provided in HealthRise.

From a clinic perspective, their care coordination focused on things like ensuring patients made it to the pharmacy to pick up medication, barriers to making lab appointments, comprehensive support for referral services, etc., and challenges faced by the patients are handled on a case-by-case basis. HFC’s expanded definition of care coordination includes providing resources that patients can tap into immediately (e.g. access to community health workers who are well-versed on both health and non-health related issues impacting their communities) which can be a benefit to them as they manage their diabetes or cardiovascular disease. This involved introducing the community-based aspect of care coordination to clinical partners in a way that was accessible, reliable, and effective.

Please share any technical challenges that you may be facing in the program.

We’ve learned that the key to our HealthRise program is sharing information. We’ve spent a lot of time and resources in figuring out ways to accurately and efficiently share information across partners. I think one of the innovative things about HealthRise is that it transcends payors, healthcare systems, and organizations. Getting everybody to go in the same direction around a patient is critical and difficult. We’ve faced some challenges but I think we have good systems in place, both technology and otherwise, to make sure we can serve the patients that we service through the coordinated care hub.

Is there anything else that you’d like to share with other HealthRise local partners about your planning experiences?

We’ve designed HealthRise to be of value and service to our clinical partners. Whether it’s pitching the care coordination hub in a certain way, or modifying elements of the program, a lot of our early work sought to emphasize HFC’s desire to be an effective extension of the work being conducted by the clinical partners. We wanted them to view us as a resource for their care team which was crucial in the early phases of the project. Clinics and hospitals are busy with their own work, and when someone from the outside offers them another program that they intuitively understand and want to be a part of, they have to ensure that it is in line with their resources and priorities. For the first several months, we not only spent a lot of time understanding the needs of our clinical partners, but also educating them on how we could plug into their existing systems in order to build their capacity.

How is HealthRise designed to ensure successful elements?

HFC is developing the capacity to make the HealthRise care coordination financially viable and billable. Furthermore, we are explicitly engaging community health stakeholders such as the Department of Public Health, hospitals, and health systems to collaborate in a way that returns value to them.

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.