Female Health Workers for the Prevention of Malaria

By Hawa Camara, Abt Associates

Courtesy of Abt  Associates.

Courtesy of Abt Associates.

Since 2011, the United States President’s Malaria Initiative’s (PMI)  Africa Indoor Residual Spray (AIRS)  Project has protected millions of men, women, and children in Sub-Saharan Africa against malaria by spraying insecticide indoors on walls, ceilings, and other resting places of vector mosquitoes.  The project  ensures safe and hospitable working environments for their employees, who are on the frontline of the fight against the deadly infectious disease. 

The PMI AIRS Project saw an opportunity to promote gender equality and women’s empowerment among its frontline health workforce by employing more women and providing them with an environment that would ensure their safety and availability to needed resources.

The project aimed to protect the safety of workers, especially women, by posting sexual harassment guidelines at each operational site, and providing gender and sexual harassment trainings to key stakeholders. Furthermore, female privacy has been a priority of this initiative: the project provides changing areas, separate washrooms and showers, to name a few, to ensure female health workers’ safety. Spray campaigns do not begin unless operational sites are verified as meeting these and other environmental compliance standards.

Additionally, to accommodate traditional norms that might prevent women from working all day alone with men to whom they are not related, the project instituted a buddy system for female spray operators. If there are female spray operators, there must be at least two women on the team.

The PMI AIRS Project also provided professional growth opportunities to their qualified returning workers. To date, the project has trained more than 21,000 women to support indoor residual spraying (IRS). The project is working with the National Malaria Control Program (NMCP) in each country to recruit and hire more women, ensuring a sustainable approach to gender-integrated IRS after the project ends. The project trained 7% more women to deliver IRS in 2015 compared to 2014.

Focusing on identifying women with potential for supervisory positions, these women receive mentorship and training and many return to work as team leaders or supervisors in the following year. While 25% of supervisors in 2013 were women, 2015 figures show an increase to 46%.

The PMI AIRS Project’s gender-focused initiatives have led to increased hiring of female frontline health workers and a dramatic increase in the number of women in supervisory roles, all while meeting or exceeding the project’s IRS targets.

Loan Program Brings Peace of Mind to Kenya’s Aspiring Frontline Health Workers

By Peter Abwao, IntraHealth International

Asthma remains the most common chronic disease among children and affects 235 million people worldwide. In Africa, myths associated with the condition mean children and adults struggle not only with the health challenges associated with asthma but also from societal stigma. Bringing up an asthmatic child is a challenge for the parents, and very humbling for the child.

It is from her experience growing up as an asthmatic child that Mercy Wangui Kariuki draws her passion for becoming a nurse.

“The tender care and support that I received from nurses and other health workers during those critical moments of my illness made me develop the desire to care,” she said at the launch event for the Afya Elimu Fund, a low-interest student loan program that helps aspiring frontline health workers afford the schooling they need and address Kenya’s health workforce shortage.

“As I grew up, all I wanted was to be a nurse,” Mercy said. “I knew this would give me an opportunity to know how to care for myself and also other patients with similar and other health needs.”

Mercy told this to a crowd of over 300 delegates in Nairobi last month, including United States Ambassador to Kenya Robert Godec, Health Cabinet Secretary Dr. Cleopa Mailu, other government officials, corporate executives, trainers, and fellow students. Kenya’s Cabinet Secretary for Education Dr. Fred Matiangi, representing Deputy President H.E William Ruto, presided over the event.

Mercy Wangui Kariuki speaks at the launch event for the Afya Elimu Fund in Nairobi, Kenya. Courtesy of IntraHealth International.

Mercy Wangui Kariuki speaks at the launch event for the Afya Elimu Fund in Nairobi, Kenya. Courtesy of IntraHealth International.

When Mercy took the stage on behalf of over 9,000 students who have been funded through the Afya Elimu Fund, her mission was to tell the senior government bureaucrats and private-sector functionaries—as clearly and simply as possible—that there is enough passion for health care work among Kenya’s youth to eliminate the country’s shortage of health workers, but that the fees associated with schooling are a major obstacle.

Mercy’s father died when she was only three years old, leaving her and her elder brother under the care of her mother. Her mother brought the two up living off peasant farming on less than one acre of land.

Growing up in the volatile Kuresoi Constituency in the Rift Valley meant that her family was not spared the instability caused by the ethnic clashes of the 1990s and early 2000s. More tragedy came for Mercy’s family when her elder brother died in a freak accident in Kenya’s Indian Ocean just after he had gotten a job with the Kenya Airports Authority.

“I was very depressed because my brother had brought so much hope to me,” Mercy said. “He had assured me that if I got admission to a nursing school, he would pay my fees. At this point I saw my dream literally go up in smoke.” 

But Mercy enrolled at the AIC Kijabe Hospital School of Nursing in February 2014. And like many students from underprivileged backgrounds, she soon discovered that enrolling in college was the easy part.

“The challenge of school fees became a major cause of anxiety, since my mother could only raise a small amount—barely enough to feed the family from farming,” she said. “It reached a point where I felt like hiding every time I saw the principal.

“Then when I was informed of the Afya Elimu Fund, I saw hope. AEF came to my rescue.”

Mercy appealed to those gathered at the event to increase funding for the program, so more students like her could have peace of mind as they prepare to work on the front lines of health care in Kenya.

“This launch gives a lot of hope to thousands of students out there,” she said.

Mercy is enrolled at the AIC Kijabe Hospital School of Nursing in Kenya. Courtesy of IntraeHealth

Mercy is enrolled at the AIC Kijabe Hospital School of Nursing in Kenya. Courtesy of IntraeHealth

 

The fund plans to raise 1.5 billion Kenyan shillings (KES) by 2018 to train 20,000 health workers and help bridge Kenya’s health workforce shortage, which currently stands at a ratio of 15 health workers per 10,000 people. (The World Health Organization recommends a minimum of 23 doctors, nurses, and midwives per 10,000 people.)

The Afya Elimu Fund has received more than KES 522 million (US$5 million) from various organizations, including the US Agency for International Development, the Ministry of Education through the Higher Education Loans Board, the Ministry of Health, IntraHealth International, the Standard Chartered Bank, the Family Group Foundation, I&M Bank, and the Ratansi Educational Trust.

Students repay the low-interest loans to the Higher Education Loans Board after graduation, which creates a revolving fund to support more students.

“Ladies and gentlemen, this is not just about getting my family out of poverty,” Mercy said. “Saving the lives of the vulnerable in society the way other health workers did for me is a better way to get out of poverty.” 

The Afya Elimu Fund was established by IntraHealth International’s FUNZOKenya project, which is funded by the US Agency for International Development, in partnership with the Higher Education Loans Board and the Kenya Healthcare Federation.

Inclusive data collection on CHWs, all health workers required to meet new global compacts, new analysis finds

By Vince Blaser and Michelle Korte, Frontline Health Workers Coalition secretariat and IntraHealth International

As researchers, practitioners and policymakers gather this week in Vancouver, Canada, for the Fourth Global Symposium on Health Systems Research in Vancouver , momentum for action has never been greater to address the gaps in the global health workforce that prevent universal access to essential health services and stymy inclusive economic growth. In the last 14 months alone, targets on strengthening the health workforce were prioritized in the Sustainable Development Goals, the first ever Global Strategy on Human Resources for Health: Workforce 2030 was unanimously approved by World Health Organization member states, and the report of the UN Secretary-General’s High-Level Commission on Health Employment and Economic Growth presented a robust multisectoral case for urgent investment in the health workforce.

chws_report_2016 To turn the momentum into results, several steps from all levels of policymaking are urgently required –one of the first is a firm commitment to better data on the current state of health workforce, data that is most severely lacking among community health workers.

Today, the Frontline Health Workers Coalition (FHWC) has released a new policy analysis, Prioritizing Community Health Worker Data for Informed Decision-Making, aimed at highlighting this acute need for data on health workers on the frontlines of care. This is not a new topic of analysis for FHWC – in fact this report is a direct follow up to our September 2014 report A Commitment to Community Health Workers: Improving Data for Decision-Making.

The new report aims to capture the urgent need to address prioritization of data for CHWs and all health workers in light of the new compacts reached since our last report was published in 2014. Among our recommendations, are for:

  • Countries to recognize CHWs as a formal cadre in their national health strategies and to clearly define their roles and responsibilities.
  • Countries to adopt the minimum data set for health workers recommended by the WHO to integrate into their health workforce registries, including National Health Workforce Accounts.
  • Countries to increase investments in mHealth technologies.
  • The International Labour Organization to update its 2008 definition of health workers, including CHWs, to include an updated set of core tasks and competencies.
  • Donors and partners to make coordinated investments in strengthening the capacity of countries to collect and analyze standardized and consistent health workforce data.

Discussion of these recommendations will be a crucial piece of a satellite session in Vancouver on Tuesday about the role of non-governmental organizations in ensuring harmonizing CHW programs – an ongoing conversation stemming from the commitment by several NGOs, donor agencies and other stakeholders at the Third Global Forum on Human Resources for Health in Recife, Brazil. We hope you will join us for that discussion and ones to follow.

Put simply, ensuring adequate access to essential health services, ensures global health security, empowers women and youth, and promotes worldwide inclusive economic growth. Investing in health workers, including in workforce data collection and analysis needed to address the most acute gaps in access to trained and supported health workers, is a crucial step along the way to ensuring such access.

You can read the new FHWC policy analysis at Frontlinehealthworkers.org/CHWReport.

Investing in health workers: the business case

Daryl Burnaby, GSK

“For too long countries have seen health workers as just another cost to be managed,” said Dr Margaret Chan, WHO director-general, as the High-Level Commission on Health Employment and Economic Growth published their final report.

Instead of draining resources, health workers in fact deliver a triple return for health, economic growth and global health security, added Dr Chan. Investing in swelling the ranks of skilled health staff is therefore pivotal to achieving the ambitious Global Goals to improve health, prosperity and sustainable development by 2030.

The Commission made 10 recommendations for strengthening the global health workforce – ranging from maximising women’s economic participation to scaling up high quality education and advancing international recognition of health workers’ qualifications. As the Commission made clear, there’s no time to lose on implementing these recommendations and it outlined immediate actions for political leaders, governments and bodies such as the International Labour Organization.

Of course governments lead the charge in strengthening health systems, but there is a clear ethical and business case for the private sector to also play its part. Building capacity among health workers leads to healthier communities, which can in turn lead to stronger economies – creating an environment in which business can thrive. According to the WHO, the returns on investment in health are estimated to be 9 to 1. Given those numbers, the private sector has an obvious stake in helping translate the Commission’s recommendations from words into reality.

There are various ways the private sector can contribute to a stronger health system – from providing mobile apps to micro insurance, to supporting training and development. At GSK, one of the biggest contributions we can make to society is to innovate and drive access to healthcare. We seek to bring health benefits to more people around the world through an open and collaborative approach. We have health workers among our own ranks – from doctors to scientists working in researching and developing medicines.We also train and equip community health workers in the poorest countries to provide basic prevention and treatment, with the dual goal of positively impacting  the communities where we deliver program as well as helping develop the infrastructure needed to enable access to medicines and vaccines.

Courtesy of IntraHealth International.

Courtesy of IntraHealth International.

One mechanism that we use to support these frontline health workers is reinvesting 20% of the profits we make in the Least Developed Countries (LDCs) back into their health systems. We’ve been doing this since 2010 and have so far reinvested approximately $26 million. The funds help to train frontline health workers; educate communities on health; build local capacity to deliver health worker training; and advocate to governments for increased investment in human resources for health. These programare delivered through three NGO partners – Amref Healthcare Africa, CARE International and Save the Children – and are well aligned to government priorities and plans.

Over the last six years, we have seen tangible results from these program. More than 40,000 health workers have been trained and 11 million people reached. Moreover, we have seen a fall in mortality and morbidity rates in the communities we serve – for example, there has been a drop in maternal and neonatal deaths in the Nepal programme area – and increased demand for essential medicines and vaccines. While one cannot draw a direct line between our program and these changes, we hope that our work is contributing. And such evidence is beginning to catalyse investment in human resources for health from other quarters, including governments.

Seeing these kinds of results has given us the confidence to extend our investments in the health workforce. By 2017 we aim to have expanded our health worker training program to all non-LDC countries in sub-Saharan Africa including Nigeria, Ghana and South Africa; we’re already supporting training and education for health workers managing diabetes and asthma in Kenya. Central to these programmes will be a continued support for advocacy to generate the evidence base needed to demonstrate the impact of investing in human resources for health.

With a growing gap between actual and required numbers of frontline health workers – a shortfall of 18 million health workers, primarily in low- and middle-income countries, is anticipated by 2030 – the economic and employment need to be developed to create a compelling case for investment in health staff. Similar to the health benefits to the communities we serve, and the business benefits GSK will realise from our investment in frontline health workers, viewing investing in human resources for health as more than a ‘cost’ is critical to translate the recommendations in the report to implementation of programmes.

As such, GSK welcomed the Commission’s report on the global health workforce and particularly the emphasis on the economic benefits and employment opportunities to countries through governments investing in their health workforces. And we were delighted that three of our scientists played a part in a short film made by the WHO to highlight the power of health workers. We are fully aligned with the 10 recommendations and our programmes already directly address all of them. As the Commission’s plans are implemented, we stand ready to support.

Access to safe and affordable surgical and anesthesia care when needed: A global promise that must be fulfilled

By Dr. Ross “Rusty” Segan, Johnson & Johnson

A surgical colleague of mine once offered  a hypothesis to his group of eager medical students: everyone lives in at least one of three states – pre-op, intra-op and post-op.  At first, I thought this was simply an attempt to grab the attention of these young men and women, but over the last several years I’ve come to appreciate the wisdom of this statement.

We inhabit this earth with approximately 7 billion fellow humans, of which as many as 5 billion lack access to safe and affordable anesthesia and surgical care.  With approximately 28-32% of the world’s global burden of disease being potentially addressable through surgery, lack of access to surgery represents the single largest aggregate global public health challenge in the world today. Considering the range of surgically treatable conditions  –  appendicitis, hernia, cholecystitis, malignancy, obstructed labor, maternal hemorrhage, open fracture, trauma, cleft lip, club foot, hydrocephalus, and cataract – it is easy to see the possible broad impact of everyone having access to surgery for these conditions alone.  Although this problem has been known in many circles, only in the past few years has it grabbed mainstream attention.

Perhaps the most impactful contributors to the elevation of Surgery to the forefront in Global Public Health were the 2015 publication of DCP3 Volume 1-Essential Surgery and the special report of the Lancet Commission on Global Surgery, entitled “Global Surgery 2030: evidence and solutions for achieving health, welfare and economic development.” Both clearly articulate the global surgery access story, the magnitude of the challenge, what we know about scalable interventions and the economics of surgery.

Dr. Mulu Maleta performs fistula surgery at Gondar Fistula Hospital in Gondar, Ethiopia. Courtesy of Johnson & Johnson.

Dr. Mulu Maleta performs fistula surgery at Gondar Fistula Hospital in Gondar, Ethiopia. Courtesy of Johnson & Johnson.

Despite the incredible unmet need, solves for surgical access have proven elusive, largely due to the complexity of the surgical ecosystem. In low and middle income countries, this ecosystem is a network of varying degrees of connection between frontline health workers, local clinics, a first-level district hospital (the core facility for essential surgical procedures) and a tertiary medical center.  Within this ecosystem, having a health worker with the right training, equipment and resources is, insufficient to meet needs. Patients need to have physical access to care, reasonable assurance of quality of care and be able to afford that care. Within many countries, frontline health workers are crucial to the identification of patients with surgically treatable conditions, referral for care, and assistance during post-operative care.

One of the most clear recommendations from the Lancet Commission, is that solutions are most likely to be successful if they are part of a coalition supporting a country-level national surgical plan with targeted policies and actions that address: infrastructure, workforce, care delivery, finance and information management.  Frontline health workers are a cornerstone of any credible national surgical plan.

To illustrate this, let’s walk down the road of a patient with obstetric fistula. Obstetric fistula is a complication of a usually prolonged labor and unassisted childbirth, which is often physically, emotionally and socially unbearable for the women themselves and/or their families. These women and their children are often marginalized, ostracized and abandoned.  Any tangible sense of normalcy, positive self-worth and role in the community is threatened the minute this complication occurs.

The road to healing is long and challenging, but comprehensive programs, including  the Fistula Foundation, UNFPA, and the Campaign to End Fistula, have led to successful outcomes for these women .  And it is clear that the role of the frontline health worker is critical, not only to treating these complications and road to recovery, but to preventing them:

  1. Empowerment of girls and young women with the education to delay pregnancy until maturity may help decrease the risk;
  2. The majority of fistulae occur due to prolonged or obstructed labor. Increasing the presence and access of women to skilled birth attendants and midwives, as well as surgical c-section, can help reduce the likelihood of fistula;
  3. Appropriate prenatal care and identification and repair of birth trauma at the time of delivery;
  4. Early identification of fistula in the community by trained individuals with knowledge of fistula and where to seek help;
  5. Referral to safe, qualified surgical care; and
  6. Post-operative rehabilitation and community reintegration.

At every stage, the frontline health worker plays a vital part in this preventable and surgically addressable condition. 

As I reflect on the work of the Lancet Commission and DCP3 along with the journeys patients will follow along their pre-op, intra-op and post-operative care, I appreciate just how integral surgery is to any reasonably functioning healthcare system.  

At the inaugural Lancet Commission Meeting, Jim Kim, President of the World Bank aptly stated, “Surgery is an indivisible, indispensable part of healthcare” and “can help millions of people live healthier, more productive lives.”  The increased awareness and advocacy led to a passage of the World Health Assembly Resolution WHA 68/15 to strengthen emergency and essential surgical care and anesthesia as a component of universal health coverage – a meaningful first global step in a promise to provide broader access.  With frontline health workers being such a critical part of solving this challenge, I am hopeful we will keep this promise.

 

 

Improving Emergency Obstetric and Neonatal Care in Zambia through Pre-Service Training

By Maura Christopher, American College of Nurse-Midwives

Imagine being a novice midwife in rural Zambia. You’re working in a peripheral health center in a remote area where you are the only health worker. You are totally alone except for a cleaner and a guard. You regularly confront emergency obstetric and newborn care cases where there is no time for referral. You must act in the moment alone and do the best you can under sometimes dire circumstances.

“Some emergencies cannot be referred without causing maternal and newborn mortality and morbidity,” says Patrice White, CNM, DrPH, interim director of the Department for Global Outreach for American College of Nurse-Midwives (ACNM). “For example, if a midwife doesn’t know how to recognize and competently manage postpartum hemorrhage—the leading cause of maternal mortality worldwide—a newborn with asphyxia, or a woman with eclampsia, the woman or baby may die.” 

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Patients waiting outside an antenatal clinic in Zambia. Courtesy of American College of Nurse-Midwives

Ten years ago, committed to addressing its maternal and newborn mortality and morbidity rates, Zambia’s Ministry of Health conducted an emergency obstetric and newborn care assessment. Then, as now, Zambian midwives and nurses provide approximately 87% percent of prenatal care and assist with 41% of deliveries (as compared with 4.5% of deliveries assisted by doctors or clinical officers). Among the assessment’s conclusions was a recommendation to emphasize building the skills of health providers in emergency obstetric and newborn care, with a priority placed on strengthening pre-service midwifery training to prepare them for their real-world role.

ACNM stepped up to help achieve this goal. A Frontline Health Workers Coalition partner, ACNM is the professional association of midwives that sets the standard for excellence in midwifery education and practice in the United States and has worked globally to strengthen the capacity of midwives in developing countries for more than 30 years.

Beginning in 2010, ACNM and its partner and subcontractor, the USAID-funded Zambia Integrated Systems Strengthening Program (ZISSP) and its follow-on project, Systems for Better Health (SBH) have worked with the Zambian Ministry of Health and the country’s General Nursing Council to strengthen clinical simulation, a teaching method that depicts real-life situations for students to address, in the skills lab. ZISSP and SBH partnered with ACNM staff who trained midwifery tutors and clinical instructors at 13 of country’s 18 midwifery schools. Guided by ACNM, the tutors and clinical instructors created a variety of simulation scenarios and learned to run the skills labs. Additionally, the projects, with the help of ACNM, equipped each school with four to ten simulation stations.

In the skills lab, students can practice various scenarios repeatedly before they go into clinical situations. They focus first on the management of normal birth, and then on infant resuscitation, postpartum hemorrhage, and other conditions such as breech delivery and shoulder dystocia, which seriously impact maternal and newborn mortality and morbidity. “We’re teaching students how to handle complications and how to handle them, if needed, alone,” White stresses. 

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A clinical instructor (in white) and a tutor simulate a normal delivery using the Mama Natalie model in Zambia. Courtesy of American College of Nurse-Midwives.

This process optimizes students’ time in the hospital. First, they learn the clinical skills more quickly because they’ve practiced them in the simulation lab. This leads staff members at clinical sites to permit the students to perform procedures on clients sooner, which builds the students’ confidence and skills. Additionally, as their confidence grows, their patient interaction improves, which increases their diagnostic ability.

“We’ve had feedback from the doctors and staff in the clinical areas, asking, ‘where did you find these students; they are so good.’” White adds. “Additionally, educators tell us the students themselves, all alone in their first posting, say they feel strong in their skills and more prepared.”

Anecdotally, the improved training is having a genuine impact. Though it’s difficult to accurately measure infant and maternal mortality and morbidity and almost impossible to assign causality, what’s clear is, in Zambia, infant and maternal mortality and morbidity is decreasing–one confidently handled birth at a time.

Ghana’s new CHW program also platform for eHealth innovations

By One Million Community Health Workers Campaign

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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.

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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.

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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.