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.


Reflections on Women Deliver: From Stories to Action

By Claire Hitchcock, GSK

Eva looked beautiful in a long pink dress, tied with a white sash. But her serene smile belied hardship. Speaking at a Frontline Health Workers Coalition-led side session at the Women Deliver conference in Copenhagen, Eva described her difficult and determined journey to become a midwife in Uganda.

Eva Nangalo, a midwife from Nakaseke Hospital in central Uganda (left), speaks to Frontline Health Workers Coalition Chair Julia Bluestone of Jhpiego (right) at FHWC’s Women Deliver side session focused on frontline health workers’ stories. Courtesy Cole Bingham, Jhpiego.

Eva Nangalo, a midwife from Nakaseke Hospital in central Uganda (left), speaks to Frontline Health Workers Coalition Chair Julia Bluestone of Jhpiego (right) at FHWC’s Women Deliver side session.  Courtesy of Cole Bingham, Jhpiego.

Now a fully-fledged midwife, she shares what little money she has with the mothers. That explains why her closely cropped hair is not braided. The health facilities are poor too, and Eva has had to deliver babies by the light of a mobile phone when the power goes out. But for Eva, the challenges are worth it: mothers love her because she helps them deliver.

The three-day summit in Denmark’s capital – which focused on women’s health and economic empowerment – was brimming with powerful tales like Eva’s. These stories all demonstrate why health workers count, and why it’s vital to step up investment in these frontline staff and the systems they work within. Not only will this benefit health workers the families they care for, but communities and businesses also stand to gain from healthier societies.

If the energetic discussions in Copenhagen are anything to go by, there are signs of increasing investment in primary health systems. In Ethiopia, more than 38,000 health extension workers are supporting families and communities to improve their health. This fleet of health workers focus on vital frontline services such as malaria prevention and control, family planning, and newborn care.

In Burkina Faso, the government has recently removed user fees, meaning that women and children under-5 can now get free health services. Valerie, a manager with Save the Children in Burkina, campaigned with advocates for women and children’s health for the government to remove user fees. The determination of Valerie and her colleagues is already having a real impact on mums and children.

In the remote, flood-prone Sunamganj area of Bangladesh, CARE International is working with local authorities and communities to train up a cadre of skilled birth attendants. This is funded through GSK’s commitment to reinvest 20% of our profits from the least developed countries back into strengthening those regions’ health systems. CARE has supported the training of more than 150 skilled birth attendants in Sunamganj, who have managed almost 9,000 deliveries. Fewer women need face childbirth alone.

Rina, a program manager with CARE Bangladesh, told Women Deliver that she was passionate about improving education for women and girls so that even more of them can go on to be health workers. We want that too. That’s why we’re expanding our health worker training programme in Sunamganj and also working in urban areas. Along with CARE and our two other partners – Amref Health Africa and Save the Children – GSK has already helped train more than 40,000 health workers across 35 countries. By the end of 2017, we hope that number will have risen to more than 70,000.

Dr. Rina Rani Paul of CARE Bangladesh (left) speaks to FHWC Chair Julia Bluestone of Jhpiego at the Coalition’s Women Deliver side session. Courtesy of Cole Bingham, Jhpiego.

Dr. Rina Rani Paul of CARE Bangladesh (left) speaks to
FHWC Chair Julia Bluestone of Jhpiego at the Coalition’s Women Deliver side session. Courtesy of Cole Bingham, Jhpiego.

Stories of women like Rina, Eva, and Valerie inspire a renewed sense of purpose. Working in partnerships across business, government and civil society to swell the ranks of frontline health workers is not always straightforward. But it is necessary. Women and girls are counting on us to take action so that they can access the health services they need to survive and thrive.

Women Deliver Starts with Stories from Health Care’s Front Lines

By Maeve Halpin,
IntraHealth International

“If we can empower frontline health workers, we empower women, we empower families, and we empower the whole community.”
 Dr. Marjorie Makukula, Lecturer at the Department of Nursing, School of Medicine, University of Zambia

COPENHAGEN – Sunday night, before Women Deliver 2016 officially opened this week, a full house of conference attendees came early to the Bella Center—and for good reason. Three women working on the front lines of health from Bangladesh, Uganda, and Zambia were telling their stories: stories of struggle, stories of opportunity, stories of empowerment.


Frontline Health Workers Coalition Chair Julia Bluestone (right) of Jhpiego speaks with Dr. Marjorie Makukula (left), a nurse and Lecturer at the University of Zambia. Courtesy IntraHealth International.

“What saves a mother?” Eva Nangalo, a midwife from Nakaseke Hospital in central Uganda, asked the audience. “We do. We know what to do, and we shall save many. Invest in us!”

Nangalo joined fellow storytellers Dr. Rina Rani Paul, who is working diligently to train community health workers in rural Bangladesh, and Dr. Marjorie Makakula, a nurse who has brought her experience working in rural Zambia to developing a national curriculum for frontline health workers in her country.

“When we’re talking about human resources, we’re talking about human beings,” said Excellency Toyin Ojora-Saraki, president and founder of Wellbeing Foundation Africa, during the opening of the reception. “And this is what we must remember going forward in policy discourse: human beings and their stories.”

The Women behind the Stories

“I was born to be a midwife,” a woman named Eva told the audience. “But the journey to become one was not easy.”

Against the wishes of her father, Eva entered a Ugandan midwifery school and learned that out of the 103 new entrants, she was the only one who did not have an advanced level of secondary schooling. But what she lacked in qualifications, she made up for in passion and hard work.

“The other students used to leave me alone on the ward and go home or to the disco,” she said. “I would stay on to learn and help the midwives.”

Two-and-a-half years later, her hard work paid off. Only 26 of the 103 students completed the course, and Nangalo was second in her class. Since then, she has helped countless mothers deliver babies.

Dr. Rina Rani Paul has devoted her career to helping health workers in the most remote stretches of Bangladesh, a country that has less than one skilled provider per 1,000 people. Doctors like her are important, she told the audience, but frontline community health workers are essential to reach the lowest quintile. “Frontline health workers in insolated communities reach women both geographically and socioeconomically,” Rina said.

At age 19, and fresh out of nursing school, Dr. Makakula was assigned a post in rural Zambia.

“At first I was so scared and lonely,” she said. “I was away from my family and friends for the first time. And we had limited resources. When you have limited resources, it is hard to help.” This experience, however, showed her the importance of frontline health workers for the economic empowerment of women, especially in remote, rural settings.

Marjorie decided to further her education in a doctorate program and research the role of nurses in providing primary health care to those communities and to develop curricula that would build the capacity of frontline health workers in those rural low-resourced areas.

“When you have a skilled health worker in a village, you empower every person in that village to live a healthy life,” Marjorie said. “Women who are healthy are empowered.”

Frontline Health Workers Coalition Chair Julia Bluestone of Jhpiego speaks with Dr. Rina Rani Paul of CARE Bangladesh.

Frontline Health Workers Coalition Chair Julia Bluestone (right) of Jhpiego speaks with Dr. Rina Rani Paul (left) of CARE Bangladesh. Courtesy IntraHealth International.


Participants of Sunday’s reception were also reminded of the rights issues that must be addressed in order to unleash the potential for economic empowerment of women on the front lines of care.

“Becoming a frontline health worker can economically empower women only if their human, economic, and labor rights are respected, promoted, and protected in the health systems in which they work,” said Constance Newman, senior team leader gender equality and health at IntraHealth International. Women in the health workforce are underpaid, with less opportunity for advancement and decision-making, and have less opportunity for career advancement. International agreements such as the Sustainable Development Goals target the changes needed, and civil society must hold governments accountable for those commitments, she said.

To do so, the advocates at Women Deliver must join efforts to advocate for frontline health workers, said Vince Blaser, director of the Frontline Health Workers Coalition.

“If you’re a women’s advocate or a gender equality advocate,” he said, “you should be a health workforce advocate too.”

Julia Bluestone, chair of the Frontline Health Workers Coalition and senior technical advisor of Jhpiego’s Global Learning Office, moderated the discussions at a reception hosted by the coalition, CARE, GlaxoSmithKline, IntraHealth International, Jhpiego, and Johnson & Johnson.

I Am a Midwife and These Are Our Stories

By Stembile Mugore, IntraHealth International

Olga Richardson—Ritchie, as we fondly called her—was my supervisor and mentor when I was a newly qualified midwife. And she taught by example.

She reminded us over and over that compassion and empathy are two of the most important characteristics of being a midwife. Always assess, monitor, anticipate, and plan for what a woman will need during her pregnancy and labor, she said, by seeing each situation through her eyes.

The experience of childbirth makes a big difference in whether women seek care during future pregnancies.

As a practicing midwife and technical advisor on global health programs, I have met midwives throughout Africa, Southeast Asia, and beyond in very low-resource settings and challenging circumstances, working hard every day to ensure women and newborns receive the high-quality care they deserve.

I want to share some of our stories because midwives can greatly reduce morbidity and mortality of women and newborns, and because the experience of childbirth makes a big difference in whether women seek skilled birth attendants for future pregnancies, delivery, and postpartum care.

In East Africa, I came across Jane.* She was the only midwife at her rural health center, and was on call 24/7. On this particular morning, her shift had started at 3:00 AM. Five hours later, she had already assisted two normal deliveries, was preparing to transfer a woman to the hospital due to complications, had two additional women in labor, and was preparing to provide antenatal care. In between, she had decontaminated and sterilized the few delivery instruments she had and cleaned the delivery room. Jane exuded so much confidence and professionalism and had an infectious smile despite what must have been great fatigue. Ritchie would have approved.

Imagine being the only midwife or person with midwifery skills in such a setting.

Does Jane even know that May 5 is International Day of the Midwife?

There are many Janes all over the world. They are unsung heroes—my heroes—who should be celebrated every day. I often ask myself whether Jane even knows that May 5 is International Day of the Midwife. And if she does, what difference does it make to her world?

Then there is Ann, one of the many midwives I’ve seen shine during a near-death experience. A vivid memory of her is etched in my mind: there she was, steady, with no obvious panic, providing emergency care to a woman who was bleeding immediately after giving birth. Quickly and efficiently, Ann called out instructions to us while she manually applied compression to the woman’s uterus.

To Ann and many like her, this is, unfortunately, a fairly common occurrence—she is used to it and has acquired the skills and experience to know exactly what to do, despite the paucity of resources.

In my travels I’ve also come across Mary, a well-trained midwife who had been practicing for years as well as working in teaching hospitals. Mary shouted at women. Her abuse could be heard all the way from the entrance to the clinic. She would not allow any male partner into the antenatal clinic, let alone the delivery room.

I have seen fear on women’s faces when a midwife like Mary is on duty—they are afraid to ask questions, to speak, or to return for antenatal visits.

I know firsthand how traumatic such an experience can be. When I had to have a caesarian section, the doctor booked the procedure for 8:00 AM. At 8:30, he called from the operating room to find out what the delay was. A midwife quickly told me to get on the trolley, and on the way to the operating room pushed the trolley so hard I almost fell head-first.

My crime was that I was a private patient who was paying this doctor who’d had the cheek to ask the midwives why I was late getting to the operating room. I would never go to that hospital again. And for quite some time, I was afraid of midwives, despite being one myself.

I know firsthand how traumatic an abusive experience can be.

I have heard stories from many women who have been abused and vow, as I did, never to return to a particular health facility. For many in rural areas, this might be the only facility and the alternative is home delivery with an unskilled birth attendant.

While abusive midwives can tarnish the reputation of our entire profession, they are a minority. And we must not shy away from talking about abuse or make excuses for mistreatment. As a midwife, I am resolved to talk about this issue openly and advocate for change.

The International Day of the Midwife gives us the opportunity to stand up as a reputable, compassionate profession that strives for excellence, and to address issues such as staff shortages, low salaries, and poor working conditions around the world.

It’s an opportunity to call for more mentors and supervisors like Ritchie who look at every situation from the client’s perspective and model empathy, good interpersonal relationships, and understanding.

It’s an opportunity to make almost every antenatal, childbirth, and postpartum care experience a positive one and boost women’s confidence in seeking skilled birth attendance.

This is how we will make a lasting impact on preventable maternal and newborn mortality.

The world needs more midwives like my heroes, Jane and Ann, if we are to achieve the World Health Organization’s vision of a world where every pregnant woman and newborn receives high-quality care throughout pregnancy, childbirth, and the postnatal period. Midwives can also help us achieve the goals of the Global Strategy for Women and Children.

The world needs more midwives like my heroes, Jane and Ann.

But the world must support every Jane and Ann with greater resources and better working environments. Those who succumb to the pressures of this difficult job and become negligent or abusive need just as much help, so that they can become the midwives they aspire to be.

So as I work with midwives around the world I dispense more than just clinical advice. I show them how to help a mother breathe through a contraction, to make sure a woman in labor is covered and not lying there naked on a delivery bed that is separated from other clients by only a thin curtain, to talk to a client and her family respectfully.

Because I am a midwife and this is what I do.

*All names (except for Ritchie’s) have been changed for privacy.

This post originally appears on IntraHealth’s Vital Blog

World Malaria Day: Celebrating frontline health workers and the programs that support them

By Cornelia Lluberes, ONE

There are 7.3 billion people living in our world today, and nearly half of them are currently at risk for malaria. Caused by parasites that are transmitted through the bites of female mosquitos, malaria is one of the most dangerous and life-threatening diseases, infecting 260 million people and killing nearly half-a-million people each year (the vast majority of whom are young children or pregnant women). Nowhere is malaria’s burden greater than in sub-Saharan Africa, home to 89% of cases and 91% of deaths.

CDC/James Gathany

CDC/James Gathany


Despite the tremendous burden that malaria still poses, much progress has been made over the past decade. The collective efforts of the global community have helped to reduce malaria mortality by 60% since 2000, effectively saving the lives of 6.2 million people – most of them children – since the launch of the Millennium Development Goals (MDGs). Over half (57) of the countries that had ongoing malaria transmission in 2000 have reduced malaria by 75% or more, and a record 33 countries reported fewer than 1,000 cases in 2015 (up from only 13 in 2000).

Much of the progress in the fight against malaria is attributable to U.S.-supported programs like the President’s Malaria Initiative (PMI) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Both PMI and the Global Fund have worked hard to build robust and sustainable health systems needed to fight malaria, particularly by investing in frontline health workers (FHWs), individuals who provide services directly to communities where they are most needed, especially in remote and rural areas. In regards to malaria, FHWs have played a pivotal role in educating communities, distributing insecticide-treated nets (ITNs), conducting rapid diagnostic tests, and administering effective treatments, like artemisinin-combination therapy (ACT). In northeastern Nigeria, the two FHWs pictured below, Salamatu Mohammed and Sadiq Baba Wakasau, protect children and pregnant women from malaria in their communities by distributing ITNs and instructing women and families on the importance of sleeping under them every day; they also work to link pregnant women and families to health facilities so they can be appropriately diagnosed and treated.



Programs like PMI and the Global Fund are instrumental in advancing progress against malaria by training and continually supporting FHWs. In FY 2015 alone, PMI supported the training of more than 77,000 health workers in malaria case management; 54,000 clinicians and laboratory technicians in diagnostic testing; and 31,000 health workers in the prevention of malaria in pregnancy. In addition, PMI has supported training for more than 36,000 people in the implementation of indoor residual spraying (IRS), which helps to kill mosquitos when they come in contact with common home surfaces. The fruits of these FHWs have been extraordinary:

President’s Malaria Initiative

President’s Malaria Initiative

Training health workers is also a critically important feature of the Global Fund. In Ethiopia, the Fund has supported integrated training for 32,000 health workers, resulting in a 57% increase in the number of pregnant women with at least one antenatal visit, a 70% reduction in malaria incidence, and an increase of over 30% of case notifications of smear positive TB. In Zimbabwe, the Global Fund has trained nearly 20,000 critical health workers in an effort to reverse the enormous “brain drain” of health staff from the country due to economic decline; in doing so, the Fund has helped to motivate staff to return to work, decrease vacancy rates, improve retention rates of nurses and doctors, and greatly improve coverage of health services. All across the Global Fund’s focus countries, these and other programs have helped the Fund distribute over 600 million ITNs distributed to individuals and families, 30% of which have been  disbursed to high-impact countries including Cote d’Ivoire, Democratic Republic of Congo, Ghana, Nigeria and Sudan. As of mid-2015, the Global Fund had also sprayed 61 million protected with IRS and treated 560 million malaria cases.


The Global Fund

The Global Fund


In the face of all the good that FHWs have to offer, they remain continually deprioritized as a component of global health policies and programs. It is estimated that our world currently faces a 7.2 million shortage of doctors, nurses, and midwives needed to deliver basic services. If we filled this gap and fully utilized community health workers on the frontlines, it is moreover estimated that 3.6 million additional children’s lives could be saved each year.


one 5

Now is the time to champion FHWs, as well as the programs that so strongly support them. Sign ONE’s Global Fund petition to lend your voice to the fight today!

The Frontline Health Workers Coalition is an alliance of United States-based organizations working together to urge greater and more strategic U.S. investment in frontline health workers in developing countries as a cost-effective way to save lives and foster a healthier, safer and more prosperous world.

Study: How Do Incentives Affect Community Health worker Performance in Madagascar And Malawi?

By: Colin Gilmartin & Uzaib Saya, Management Sciences for Health

This article originally appears on the MSH website:

Throughout sub-Saharan Africa, community health workers represent the foundation of the health system, addressing priority health areas ranging from maternal and newborn health to family planning and Ebola prevention. Not only do community health workers extend access to health services for the underserved and those living in hard-to-reach areas, they help countries accelerate certain health outcomes, and achieve the Sustainable Development Goals and related targets for universal health coverage.


A vast majority of community health workers are unpaid volunteers. Despite increasing calls by global development partners and national governments for expanding the number of community health workers and strengthening community health systems, questions remain on how such investments can maximize the performance and impact of this health worker cadre in the face of systemic challenges. Many community health worker programs are under-funded and disease-focused, lack long-term financing, and suffer from high attrition. Community health workers may receive a mix of financial and non-financial incentives, among them per diems for trainings; equipment; certifications; user fees from the sale of commodities; and public recognition.

To better understand and document the impact of incentives on community health worker performance and retention and service delivery, the US Agency for International Development (USAID)-funded African Strategies for Health (ASH) project, led by Management Sciences for Health (MSH), conducted in-depth research in Madagascar and Malawi. MSH staff with the ASH project analyzed a range of quantitative and qualitative programmatic data and conducted interviews with 123 people, including nine cadres of community health workers supported by international NGOs, ministries of health, and UNICEF. Using a set of performance measurements, as discussed by Naimoli and colleagues and Kok and colleagues, including the quality and number of services provided, utilization of health services, and job satisfaction, the study found that both financial and non-financial incentives have considerable impact on community health worker performance.

Financial incentives affect motivation and can improve participation in trainings, increase knowledge and capacity, and ensure availability of heath commodities for preventive and curative services. Non-financial incentives, such as training and education opportunities, mentorship and supervision, public recognition, and opportunities for job advancement, can also improve motivation and capacity. Likewise, insufficient incentives, delays in payments, heavy workloads, and volunteering “opportunity costs” (i.e. time commitment) contribute to lower motivation, poor performance, and in some cases, interruptions in the delivery of health services to the community.

Study findings suggest three ways to improve the performance of community health workers and the delivery of community-based services:

  1. Community health worker incentives must reflect the context: workload, opportunity costs, and the environment in which they work. Consistent incentives, whether for salary, allowances, or per diem payments, can help encourage accountability, commitment, and motivation, and, in many cases, facilitate an uninterrupted provision of health services.
  2. Non-financial incentives must be included as essential components of any community health program, including paid and volunteer programs. Such incentives, including regular training, supervision, public recognition, and opportunities for advancement and professional development, improve the capacity of community health workers and ensure high-quality service provision.
  3. Implementing agencies, government partners, and donors supporting community health worker programs must harmonize incentives, trainings, reporting, and supervision, to reduce duplicative costs and improve capacity, use of services, and limit frustration related to inconsistent incentives.

This study is unique in that it examined specific incentives within community health worker cadres of two countries using program data, and related such incentives to performance. If program implementers know how certain features of an intervention affect performance, such interventions can be shaped and adjusted to yield optimal performance. Recommendations from this study are useful for countries considering introducing, modifying, or scaling up a community health program.


Led by MSH, USAID’s African Strategies for Health (ASH) project improves the health status of populations across Africa by identifying and advocating for  best practices, enhancing technical capacity, and engaging African regional institutions to address health  issues in a sustainable manner. ASH provides information on trends and developments on the continent to USAID and other development partners to enhance decision-making regarding investments in health.

#WHWWeek: Thank Your Pharmacist, A Cornerstone of the Health System

By Rachel Hassinger, Management Sciences for Health (MSH)

This article originally appears on the MSH website:


“Medicines are a key component of treatments to save lives”

~ Kwesi Eghan, trained Ghanian pharmacist and MSH portfolio manager for the US Agency for International Development (USAID)-funded Systems for Improved Access to Pharmaceuticals and Services (SIAPS) program in South Sudan and Afghanistan

A child in Tanzania has a fever for three days. A pregnant woman in Namibia is taking antiretroviral therapy (ART) to treat HIV and prevent transmission of HIV to her baby. A man in Swaziland suffers from drug-resistant TB and struggles to adhere to treatment.

Who helps ensure they take the right drug, at the right time, and for the right reason?

A pharmacist.

In many developing countries, pharmacists are primarily responsible for medicines selection, procurement, distribution, and explaining rational use of these medicines to their patients. But, many low- and middle-income countries suffer shortages of trained pharmacists. MSH and partners are helping countries and communities ensure that pharmacists and related health workers are equipped with the skills, systems, and support to provide quality services every day.

Below, meet some of these trained pharmacists, pharmacy assistants, and accredited medicine shop dispensers from five countries: Ethiopia, Namibia, South Africa, Swaziland, and Tanzania.

This World Health Worker Week, we honor and celebrate them, one of the cornerstones of the health system. If you’re on social media, share the links to their stories or add your own using hashtags #WHWWeek and #TYpharmacist (thank your pharmacist).


Dagnachew Hailemariam, head pharmacistPhoto credit: MSH staff/Ethiopia

“We have come a long way,” says Dagnachew Hailemariam, head pharmacist of Bishoftu General Hospital in Ethiopia. “Six years ago, we followed a tiresome and unreliable system of counting and tracking bin cards and prescription information manually. … We had no procurement system for medicines—we  bought medicines that were not essential; many of those expired; and disposing of them was a challenge.”

Through the support of a drug and therapeutic committee, systems and guidelines have been established at the hospital that empower individual health workers and teams to improve service delivery. “I can take accountability for what I do now since there is a system that enables me to do that,” he says. “Now, we have a drug list; and we use the ABC/VEN reconciliation mechanism to determine which drugs are needed the most and which drugs to order in large amounts. … I can handle complaints, respond to inquiries, and carry out my duties with confidence.”