Improving Health Services and Facilities through WASH

By Lisa Bos, World Vision

In 2015, the World Health Organization (WHO) and UNICEF released the first multi-country review of water, sanitation and hygiene (WASH) access in health facilities.  The report looked at 54 low- and middle-income countries.  The results were staggering.

According to the report, 1 in 3 health facilities in low-resource settings do not have any access to water at all. When the reliability, safety, and distance of the water supply is taken into account, that ratio increases to 1 in 2.  Nearly 1 in 5 facilities do not have toilets, and more than 1 in 3 do not have soap for handwashing.

Adequate water, sanitation, and hygiene are essential for frontline health workers to provide basic health services. WASH helps prevent infections and the spread of disease, protects staff and patients, and ensures the dignity of those who are vulnerable including pregnant women and those with disabilities. Yet, an unacceptable number of health facilities have massive gaps in WASH access. 

As a result of the findings of their report in 2015, WHO and UNICEF launched a global action plan to ensure that all health facilities in all settings have adequate water, sanitation, and hygiene services by 2030. They launched global task teams established to drive progress in four main areas: advocacy, leadership and policy; monitoring; evidence; and facility-based improvements. Advocacy is often left out of conversations on how to improve health facilities, yet it can be a great driver of change in communities.

Dr. David Mayengo, a doctor at Ntwetwe Health Center IV in Kiboga Cluster, Uganda, has stayed in his community in part because of how advocacy led to improved health services. When he arrived at the health center, there was no power or water. “We cried out through advocacy,” he says. 

And things improved. Through a partnership with the Ugandan government and World Vision, new latrines and a water system were built. Not only have these improvements led to better health outcomes but patients and staff are happier. “Mothers have a better experience here. The hospital is well staffed with 49 professionals. It’s like a different world,” shared Dr. Mayengo.

Having satisfied patients and staff is a key indicator of a well-run and strong health system.  By improving access to WASH, through advocacy and other means, both can be achieved.

Health clinic latrines and water put in by World Vision at Ntwetwe Health Center IV, next to the old system on the left.
Photo Credit – Jon Warren, World Vision, 2016

Happy Birthday! Online library of mHealth Training Materials ORB Turns Two.

By Alex Kellerstrass, mPowering Frontline Health Workers

Photo courtesy of mPowering Frontline Health Workers.

In the summer of 2015, the mPowering Frontline Health Workers partnership launched ORB an online library of mobile health worker training materials, along with support from their network of partners. The rising temperatures of another Washington D.C. summer marks the second birthday of ORB and this milestone serves as an opportunity to reflect on how the online library has grown over these last two years.

ORB launched with a robust platform made up of several health domains including family planning, prenatal/antenatal care, newborn care, labor and delivery, and nutrition. mPowering immediately began an advocacy campaign throughout their global network promoting the open-licensed sharing of content—specifically through the use of Creative Commons Licensing—urging others to share their existing training materials on the platform.

mPowering worked with partners including Medical Aid Films, Digital Campus, Johns Hopkins Center for Communications Programs and many others to adapt and disseminate content on the ORB platform—extending the reach of existing materials for use on community, regional, national or global levels. ORB’s foundation is grounded in several of the UN’s Sustainable Development Goals (SDGs) as it promotes quality education, partnership through content sharing, and improved health. In advocating for ORB, the message became two-fold: promoting the open-license sharing of materials as well as the benefits of using mobile learning tools in training.

All ORB content is not only open-licensed, but also mobile-optimized—meaning the materials are suitable for viewing on mobile devices such as a tablets, laptops, smart phones or feature phones. mPowering has worked with several content creators to facilitate the adaptation of materials to a mobile-ready format. Through these and other collaborations, ORB content has been used in nurse training programs in Zambia, midwife training in Nigeria, and continues to be integrated into mPowering’s country program and advocacy initiatives in Uganda, Pakistan, Sierra Leone and the Latin America and the Caribbean region.

As ORB turns 2 years old, it looks a little different than it did in the summer of 2015. The site is now completely translatable into Spanish. The platform has expanded to include two additional health domains with Zika and WASH materials, there are resources in 44 languages, and is accessed in 155 countries. mPowering has continued to add new features to streamline users’ ability to search and upload content to the site and future plans include additional features that would allow users to build simple exportable courses with ORB materials.

mPowering is committed to using ORB as a tool to train more health workers in an effort to end preventable maternal and child deaths. Frontline health workers are often relied upon for so much within the communities they serve. Supporting ORB through sharing content and using ORB materials in training programs is in turn supporting health workers and those communities they serve. As we look toward the year ahead, mPowering will continue to build ORB and advocate for the goals and principles that formed its foundation. We hope you’ll join us in this effort.

USAID’S Maternal and Child Survival Program serves as mPowering’s secretariat. mPowering is a public private partnership focused on mobile training for frontline health workers. Learn more at

The story of Allan Joel and his drive to save lives in the operating room

This story originally appeared on Touch Foundation’s news blog.

Five billion people live without access to safe, affordable surgical and anesthesia care. These operating room services are crucial to treating people with cardiovascular conditions, bone fractures, pregnancy complications, and many other health issues. If these services are inaccessible it can lead to an avoidable disability or premature death. This situation is far too common in Tanzania where surgical and anesthesia care is lacking and the country is facing a large shortage of health workers with the needed skills.

Photo courtesy of Touch Foundation.

Allan Joel is an ambitious 29-year-old nurse anesthetist trained to meet all of a patient’s anesthesia needs before, during and after surgery or the delivery of a baby. Allan developed a passion for medicine in 1989, the year his father was diagnosed with diabetes. He witnessed his father suffer from inadequate medical care and decided at a young age to pursue nursing so that he could help his father and others in need. After graduating from nursing school, he applied for a nurse midwifery position at Sengerema Hospital, a 325-bed rural hospital serving 800,000 Tanzanians. Limited funding and resources at the hospital prevented Allan from getting a position and forced him to reconsider his career.

Touch Foundation accepted Allan Joel’s application to work as a medical scribe aiding the Treat & Train program*. While Allan worked as a medical scribe, he was able to spend all of his free time volunteering in the ICU and operating theaters at Sengerema Hospital. In the ICU and operating theaters, Allan was exposed to anesthesiology and realized the impact he could have on patients’ lives in this field. Inspired to learn the skills necessary to provide life support in a safe surgical environment, Allan applied for a one-year nurse anesthetist certification at Bugando Medical Centre. With the help of a Touch-funded grant, he graduated in September 2016 and promptly returned to Sengerema Hospital to begin working in the operating room.

Mortality and morbidity related to anesthesia and surgery are all too common in Tanzania. We recognize the importance of a safe and sterile surgical environment to protect everyone, including patients, health workers and students, from infection, injury, and other harm. Touch, together with hardworking individuals like Allan Joel, is working to improve access to safe surgical care and save lives at Sengerema Hospital and our other partner health facilities.

With Touch’s help, Allan was able to start a career in the field of anesthesiology. Although Allan’s work comes with many challenges, including working with only a limited number of trained specialists and equipment, his dynamic drive to find solutions has made him an integral part of the hospital. He has already devoted seven years of his life to improving the care of patients and aims to return to school next year to qualify as an Assistant Anesthesiologist. Touch is proud to support the ambition of young health workers and improve the lives of Tanzanians by providing greater access to quality skilled providers and safe surgical care.

*The Treat & Train Program is supported by the United States Agency for International Development (USAID), Vitol Foundation, ELMA Foundation, and other partners to improve the education of health students and extend access to health services in Tanzania. Core to Treat & Train is the facilitation of external clinical rotations by nurses, medical doctors, and other health students from the main urban campus to rural health facilities. These rotations provide students with practical experience delivering care to patients in small groups under the supervision of faculty and staff. Touch Foundation develops the Treat & Train Network of healthcare and educational institutions so that scarce resources are shared and the entire health system is strengthened.

Karamoja’s Mothers and Children Reap the Benefits of Health Systems Investments

By Lindsey Freeze, IntraHealth International

This post originally appeared on Vital, IntraHealth International’s blog. 

Veronica Munges, 19, holds her newborn hours after his birth at Nadunget Health Center III in Moroto, Uganda. Photos by Tommy Trenchard for IntraHealth International.

Jane Atim smiles and smooths the skirt of her crisp blue uniform as she ushers us into the maternity ward, excited to share what the night brought.

Morning light warms the walls of the room where Veronica Munges, 19, swaddles her healthy six-pound baby—a boy, named Tatelo. Jane shows Veronica, a first-time mother, how to breastfeed before turning to the two other women who gave birth overnight—Clara, 37, and Paulina, 34. 

The first day of life is the riskiest of all for infants and mothers, especially here in Uganda’s Karamoja region. This vast area is home to a rural, mostly pastoral population of 1.2 million that suffers from high rates of poverty, fertility, and food insecurity.

In 2008, UNICEF called it the worst place to be a child. One hundred children under the age of five died every week, mostly from preventable diseases, and 17% of children would not live to their fifth birthday. Six years ago, only 27% of women in Karamoja delivered in health facilities and the regional maternal mortality rate was 750 per 100,000 live births—among the highest in the world.

The region has lagged behind national progress in improving health care and outcomes, but the joyful scene that morning was not a fluke.

Last year, 73% of Karamoja’s mothers delivered in health facilities, and medical officers say the maternal mortality rate has sharply declined as a result. The percentage of children receiving all basic vaccinations is also now the highest in the country, by wide margins, at 73%.

The evening before, we visited Nadunget Health Center III in Moroto to talk to Jane, the nurse in charge, and Dr. Abubaker Lubega, the district health officer, about improvements there that are dramatically changing health care in the district and region.

“People don’t believe we’ve done it in just a few years,” says Dr. Lubega, who oversees the seven public health facilities serving 140,000 people in Moroto.

So what happened?

The surge

A hiring surge in late 2012 laid the groundwork for improving health care throughout the country. Five years ago, Uganda’s government budgeted for and hired 7,000 of the most-needed cadres—midwives, anesthetic officers, pharmacy and lab techs, and public health nurses—and approximately 3,000 new workers have joined the country’s long understaffed health workforce since.

Jane, a midwife with 14 years of training and experience, was recruited during the surge, which brought 31 new workers to Moroto and increased staffing levels from 40% to 70%.

But staff shortages weren’t the only problem affecting health care in the region.

Perceptions of poor quality, staff absences, and negative attitudes were among the top reasons within the health sector’s control that women weren’t seeking skilled care at birth, according to a 2013 study on barriers to using institutional delivery services in two Karamoja districts.

Motivation and performance problems plague health centers across Uganda. These are incredibly complex issues with no easy fix. Leadership and supervision, workload, security, infrastructure, and so much more affect health workers’ attitudes and output.

Better performance management and supervision systems

Jane is one of just two midwives at the health center she manages, where nearly 1,000 mothers are expected to deliver this year. On top of that, she supervises a staff of 26. And until last year, she had no formal tools or processes to support and hold them accountable for their duties.

In-charges like Jane are critical to improving the quality and availability of health care in their communities. That’s why, for the past two-and-a-half years, IntraHealth International’s USAID-supported Strengthening Human Resources for Health (SHRH) in Uganda activity has worked with Uganda’s ministries to revise national service delivery standards and supervision guidelines and, at the local level, to support the country’s 112 district health management teams, like Dr. Lubega’s, in rolling out a package of tools to improve individual- and facility-level performance.

It starts with ensuring staff have clear job descriptions and regular appraisals. At Nadunget, and hundreds of other facilities in Uganda, most did not.

Jane attended a series of practical trainings that helped her develop specific scopes of work for her staff, set individual performance targets, conduct appraisals, and implement appropriate rewards and sanctions, while addressing other real problems she experienced at work. She learned the fundamentals of performance management and applied the new approaches at her facility.

“This was really an eye-opener for us,” Jane says of what came to light when she held the past few quarterly performance reviews.

The new approach forced conversations about why one nurse wasn’t adequately documenting women’s antenatal visits, for example, or why another assisted fewer deliveries than her counterparts that quarter.

Previously, there wasn’t a system for tracking attendance, either, or penalties for not showing up. Jane says the appraisal process, combined with public recognition of good and bad performance and withheld pay for unexcused absences has quickly helped establish a culture of accountability.

Districts now host community events to celebrate staff, where they recognize top performers and discipline the chronically absent by announcing and posting their names publically.

It’s working: absenteeism in Karamoja is down to 11%—from 46% in 2015.

District ownership and national coordination

The performance management toolkit is part of a package of interventions that SHRH developed to help districts address their unique health workforce challenges.

“It’s a very bright strategy,” Dr. Lubega says. “The approaches are integrated into our systems, and the district HR department has ownership over the trainings and interventions. They will sustain these changes.”

SHRH has also worked with Moroto staff to strengthen supportive supervision systems so that district health managers can assess facilities’ strengths and gaps—and budget for the resources (including staff) they need to meet national standards and community needs.

So far, SHRH has supported 73 of Uganda’s 112 district health management teams and helped 8,127 health workers in 800 facilities implement the new performance management guidelines and practices, improving health services for millions of Ugandans.

As we finished talking to Jane and Dr. Lubega the day before, the sun had started to set on Mount Moroto. Veronica was in the early stages of labor and the only patient left after a busy day. She walked the 6 miles from her village at the first sign of labor. Beyond a chain fence, children waited at wells to bring water home and cooking fires glowed across the dry landscape, sending stacks of sweet smoke into the dusk.

Jane didn’t know that two more mothers would walk to the health center overnight. Clara and Paulina delivered quickly, but Veronica struggled through a long and difficult labor.

The next morning, no words or translations are needed to understand the joy and fatigue and relief each mother feels holding her newborn. Seeing them stretch and squint in their first glimpses of sunlight is a reminder of the awe and peril of being born—and the long road to raising a healthy child, no matter where you live.

For these families, every milestone to better health care makes the journey safer and the chance of a more secure, prosperous life possible.

5.9 million women have given birth in a health facility since 2012 because of USAID investments. Read more »

To see how health systems strengthening efforts are making a difference for mothers and children around the world, read USAID’s 2017 Acting on the Call Report.

A Malawian frontline midwife speaks

By: Mtondera Munthali for White Ribbon Alliance

Mtondera Munthali in Malawi. Photo courtesy of White Ribbon Alliance.

I am Mtondera Munthali, a midwife from Mzuzu city in the north of Malawi. My job is a very busy one. I’m in charge of the labor ward where 15 to 20 babies are born every day. I’m responsible for making sure there are enough midwives with enough resources to keep those women safe. I also coordinate safe motherhood services for the district and head up nursing and midwifery services for Mzuzu health center.

We have daily prenatal clinics with 200 women and family planning clinics daily with more than 100 women. When I left Mzuzu to attend the 31st ICM Triennial Congress in Toronto this past week, a bedside midwife had to be called away to cover for me.

We face many challenges. We are short of staff and overwhelmed with work. We often don’t have sterile gloves and medicines. We only have 12 beds, and yet, there are often 40 women in postnatal so they have to share those beds – sometimes two or three women and their babies on each bed.

Midwives in Malawi get paid only $160 a month, and out of that we have to pay our rent, food, children’s school fees, and transport to work. Some midwives walk long distances to save money on fuel. It’s a hand to mouth existence. Many of my colleagues work extra jobs such as selling potatoes, or second hand clothes, just to survive.

Despite this, we do love our work as midwives. We have many successes in saving the lives of women and resuscitating newborns who would otherwise have died.

In Mzuzu we had a big problem of women giving birth at home because of travel distance and the fear of midwives being rude. This means they lack quality care at birth. There is no equity or dignity.

To change this, I called on Mzuzu city councillors and together we organized a meeting for the community leaders. The leaders are very powerful in their communities and they decided to regularly sensitize the people on safe birth. They also followed up with all the pregnant women to make sure they attended antenatal clinics, and that they gave birth in the health facility.

I also did trainings on respectful maternity care in Mzuzu Health Center for all midwives. Many of the midwives had not realized they were disrespecting and abusing women; they thought abuse was only physical. So, they committed to being polite and kind to women and their families. It was a quick result and they did change their behavior. I even heard midwives reminding each other; they would call out and ask. “Have you forgotten? Be polite to women!”

The impact on the community was also big. The number of women giving birth at home without midwifery care went down by half across Mzuzu, and in two communities it went right down to zero.

So, I am proud to be a midwife, proud to bring lives into this world, and to save women and their babies.

Fostering the next generation of health workers

By Dr Sanele Mandela, founder of  Expectra 868 Health Solutions

This blog was originally posted on the NCD Alliance website.

Dr Sanele Madela gives NCDs Health Eduction During HealthRise campaign at Gcumisa Umgungundlovu. Photo courtesy of Expectra Health Solutions.

During a 70th World Health Assembly event on access to diabetes medicines and care in underserved populations, health worker Dr Sanele Madela said “diabetes care depends on health workers able to empower patients with knowledge to participate in care.” In this blog he illustrates this importance through his experiences as a health worker in South Africa.


“Every day when I show up for work, I think – I’m glad I get the privilege today to save lives. In life, it’s all about how you want to show up. For me, showing up means serving my community.” – Dr. Sanele Mandela

When I was just a boy, my best friend died of a completely treatable illness. One day we were playing outside, the next he was simply gone. His family hadn’t recognized his symptoms quickly enough and there was no healthcare worker for miles. I never wanted this to happen again. In that moment, I committed my life to providing outstanding healthcare services for all. And I’ve never looked back.

I write this as I’m heading to the 70th World Health Assembly, the annual convening of state delegations that advise the World Health Organization on important health policies- focusing on access to healthcare, the importance of quality healthcare for all and addressing critical healthcare infrastructure needs. I’m excited to attend such a proceeding and even more excited to serve as a voice of frontline health workers amidst the policy discussions. Let me share why this matters to me.

Frontline health workers are the glue for healthcare systems to function effectively. We’re the people who sacrifice our lives to deliver difficult care, who build trusted relationships with patients to improve their quality of life and who develop innovative healthcare solutions out of necessity. We take this responsibility very seriously and need our health systems to do the same by addressing critical priorities:

Priority 1: Invest in safety and training for frontline health workers.

Young people today are witnessing their family members dying in the line of healthcare duty from exposure to infectious disease and deadly outbreaks e.g. Ebola in Congo etc. Because there are limited frontline health worker safety standards and training opportunities, many young people are not interested in pursuing a healthcare career in underserved communities. Achieving universal health coverage will not be an easy task if this continues.

Priority 2: Adequately compensate frontline health workers.

As the global burden of chronic diseases continues to rise and healthcare becomes more about the management of diseases, frontline health workers play an increasingly important role in building effective healthcare systems. We work hard to build trusted relationships with families and communities to lead cost-effective prevention efforts and to provide outstanding follow-up care when needed. We believe in the work that we do, but we also need to earn enough to take care of our families too. Without adequate compensation, frontline health worker morale is reduced which negatively affects their quality and commitment to care. Ultimately this results in top talent leaving to pursue other sectors.

Priority 3: Adapt policies and regulations to allow frontline health workers to provide more care at the local level.

In many countries, we simply don’t have enough doctors or nurses to adequately treat a population. While it makes for a challenging healthcare environment, it also presents an opportunity for us to re-think healthcare delivery, to identify opportunities for frontline health workers to deliver increasingly important health services in their communities. In my work at Expectra 868 Health Solutions, we’re excited to provide frontline health workers with blood pressure machines and glucometers used at the community level. These simple devices provide incredible confidence and motivation to these health workers, knowing that when they visit a household they’re leaving it better than it was before. Research has also proven that post-surgery patients who recover in familiar surrounding with their loved ones, recover more quickly. Therefore, empowering frontline health workers with post-surgery care skills and appropriate hospital referral linkages go a long way in patient recovery.

As a primary healthcare physician in South Africa, working at the Pomeroy Community Health Centre, I share these statements on behalf of frontline health workers everywhere. Frontline health workers who don’t have time to complain about their working conditions and in-service training required because they are busy taking care of their patients. Frontline health workers who provide patient coaching at the community level and who educate community caregivers on how to promote and prevent disease including care for their loved ones at home. Frontline health workers who are directly saving lives every day, but so often don’t have a voice in key policy conversations.

Frontline health workers – a special breed whose stories need to be shared & considered

Those working on the frontline are a special breed, their stories need to be elevated for policy makers to understand the true plight of the critical role these frontline health workers play to the overall picture of the community health status. Linkage to care of patients, meeting of health targets, giving dignity to the sick and frail and ultimate improving the overall health status of the community, country and the world would not be possible if those in the frontline are not given the platform to influence the decisions in the sector they committed their lives to.


Dr Sanele Mandela is one of the health workers trained in storytelling by the Medtronic Foundation and IntraHealth International.

Why Investments in Frontline Health Workers Matter – Preventing needless deaths through trusted healthcare relationships

By Samalie Kitooleko, Nurse In-Charge of Uganda Rheumatic Heart Disease Registry and Belinda Ngongo, Global Health Leaders Fellow, Public Health Institute

This blog was originally posted at the Global Health Council blog.

Samalie’s Story

Samalie speaking at the panel “Against All Odds: Strengthening Health Systems to Better Serve Vulnerable Women and Children” during World Health Assembly.

It all started when I nursed a young female university student with Rheumatic Heart Disease (RHD). As a teen she had received a mechanical valve replacement requiring her to take an anticoagulant daily, which she did without fail. During her third year, she became pregnant and stopped taking her anticoagulant medication without medical consultation, thinking she was looking out for the best interest of her baby. Several days later, she lost her baby and I saw her passing away on her graduation day, suffering from valve thrombosis, a condition which could have easily been prevented if she hadn’t defaulted her medication. In that moment, I vowed to never see another woman die of preventable complications. No one should die because they lack appropriate healthcare knowledge in today’s world.

I began counselling women intending to undergo mechanical valve replacement, educating them about necessary medications and lifestyle changes. Initially, I dealt with very few women however in 2013, when the RHD register was established in Uganda, the numbers become rather overwhelming so I developed novel ways of addressing them at scale, forming a patient support group on WhatsApp. Patients used this platform as a way to pose questions to the broader group and it became an incredible group to share knowledge with.

As a nurse in Uganda, I spend most of my time caring for patients affected with chronic cardiovascular illnesses such as congenital heart disease, myocardial infarction, and rheumatic heart disease (RHD). My typical day starts at 7 AM and ends at 9 PM. During this time, my work involves updating the RHD registry with new patients, those that have died and identifying those that are lost to follow-up. I then spend the day in the outpatient clinic counseling patients, enrolling patients in the RHD registry, and administering Benzathine Penicillin injections in the Coumadin clinic which I run concurrently. Due to limited staff, I also work closely with patients affected by all other noncommunicable diseases including diabetes, hypertension and cancer. I’m proud to provide a patient-centered approach during delivery of care, spending time getting to know and following up with the women I serve.

The Case for Frontline Health Workers

Like Samalie, there are many other frontline health workers (FHWs) in developing countries committed to caring for patients and pressured to work long hours under poor conditions in deplorable infrastructure and limited sundries. To make matters worse, their hard work is rarely recognized and they are compensated poorly for their incessant efforts to improve health and wellbeing of populations. The exodus of FHWs from the health sector can be attributed to some of the current chaotic and constrained environment. The pursuit of non-health related employment opportunities compromises the quality of care already aggravated by the major shortage of staff in most health care facilities.  It is therefore important that we answer these questions – Why do we need to care about FHWs? What do we need to do to retain, satisfy and support FHWs?

  • Undoubtedly, to improve service delivery and lower staff turnover, appropriate compensation and recognition of frontlines’ efforts is imperative for increased motivation and morale. Such recognition can be in form of being acknowledged as best performers of a given period, promotions and better wages and including them in critical global health and health systems conversations. FHWs need to be well equipped with knowledge and skills and understand trends and strategies to accelerate the implementation of appropriate interventions to effectively combat disease. They also need to be provided with ongoing training and career advancement opportunities in order to ensure persistent delivery of quality services.
  • One stumbling block in the health systems arises from the fact that FHWs have limited decision making power and their potential contributions are hindered by certain rules and regulations. For example, in Uganda nurses are now allowed to provide a prescription but are limited to making a nursing diagnosis and care plan. Policies need to be reviewed and where appropriate influence of frontline should to be augmented and task shifting implemented. Promising models of how FHWs are managing NCDs can be found here.
  • The gender lens aspect is important to ponder when alluding to FHWs, especially since it is recognized that 75% of global health work is done by women. Women deliver the bulk of health care worldwide in the formal and informal sectors. Most FHWs are women. They usually work under pressure to balance family and societal responsibilities in resource – limited settings, leaving their lives and those of their families at stake. Despite working tirelessly to restore the health of other people, on many occasions’ health and life of FHWs are not carted and likewise despite their important contribution to global health and the dependence on women as providers of health care, according to a recent report women have very few leadership positions in the health systems.
  • FHWs play a vital role in initiating the referral process through timely and comprehensive communication, provide ongoing support and care to patients and their families. Referral of patients may affect treatment and continuity of care and can affect clinical outcomes and costs thus clear guidance from facility staff is critical. They need to be part of the referral process.

In sum, FHWs deserve to be recognized for their dedicated and generous contribution towards the health and wellbeing of the populations they serve. In return, they also need to be healthy in all aspects, valued, respected, supported, protected, compensated adequately and work in appropriate.

This week, WHA70 gives us an opportunity to further elevate the voice of FHWs to encourage further investment and support for those saving lives on the frontline. Join us in helping to elevate their voice!

Learn More:

The Case for Frontline Health Workers in Addressing Non-Communicable Diseases Globally.” By IntraHealth

RHD Action 

What social accountability means for frontline health workers–digging into the black box

By Eric Sarriot and Karen Waltensperger, Save the Children USA

Group Village Headman Kabwangala. Nkhunga Health Center. The USAID SSDI-Services Project, Malawi, scaled up the Community Score Card approach through a consortium of partners. Photo courtesy of Save the Children.

Social accountability in health refers to a group of approaches bringing health professionals, providers or managers, together with community members, or clients, in order to improve quality of services by strengthening the accountability of the health system to the population. USAID has supported innovations and social accountability scale up efforts, as illustrated in the picture from SSDI in Malawi. Our professional community is getting a pretty good picture of what works in this approach  and little by little, some questions percolate to the surface.

Scale Professor Jonathan Fox of American University was a speaker at a recent panel organized by the DC Health Systems Board and Save the Children and brought up the topic of scale. He suggested, as did others, that there needs to be a conceptual reboot of transparency, participation, accountability, and most notably, less time spent on ‘scaling up’ and more on ‘taking scale into account’ by promoting accountability at multiple levels to affect sustainable change.

Time We still live in the world of project cycles. But social systems need to develop ongoing, adaptive processes allowing health systems to address inevitable stumbles, face dysfunctions, and shocks, which may come from staff changes, aftermaths of a strike, election cycles, and many others. Evaluation and learning processes that go beyond pre-post, then-now, and intervention-control proofs-of-concept need to be in place.

Social dynamicsAt the micro level, evidence for what happens inside communities, as between communities and health providers, has been growing. And with that a significant question: what could social accountability mean for frontline health workers?

Social accountability and the frontline worker – A frontline health worker can be anyone directly serving clients or communities – a nurse, pharmacist, district supervisor, or other. Accountability mechanisms fundamentally aim to incentivize workers to take [the right] action. In the figure below, taking action is at the very top.  Some behavioral theories suggest that a health worker needs to have the “disposition” to act above a certain unknown threshold to take action. The health worker is part of a network and a hierarchy of functions, so right action at one level may affect how this threshold is crossed at another. And when the health system does not provide basic inputs (e.g. drugs), this threshold can be seen as insurmountable. Beyond that, how does disposition to act come along?

Disposition accrues from three tracks:

  • Deliberative disposition: “I know how to do this; this is what I’m trained for; this will lead to positive outcomes for my patients / my internal clients.”
  • Emotional disposition: sense of pride, agency, ownership, meaning, perhaps even fear or shame.
  • Social disposition: expectations we attach to social encounters, be they with supervisors, colleagues, clients, or community groups and leaders.

‘Normal’ health systems functions are already affecting these three paths: we train, disseminate information, certify, and supervise to reinforce deliberative factors. We speak about ‘supportive’ supervision, to influence both emotional and social factors. We create quality teams–probably as much a social disposition driver, as a way to cognitively review data. But gaps in performance and quality remain frequent. And accountability mechanisms are proposed to palliate some of these gaps, building micro (health workers’) positive behaviors and accruing system changes through these same pathways:

  • Deliberative and cognitive factors are addressed through problem definition (“How do you understand this problem?”), followed by the recourse to measurement and assessments;
  • Initiatives often start with our proverbial ‘low hanging fruits’ [cringe] – the reason for this might lie with the emotional value of achieving some success; and
  • Finally, accountability may be one of the ways through which we perhaps unwittingly create different types of social capital within groups (providers, communities) and between these groups.

Questions need to be explored in all three pathways. How do we balance objective measures of service performance with subjective assessments and self-assessments? How much ‘demotivation’ is rooted in fatigue from business as usual, and how can initial positive changes snowball to larger ones? How do we address power and conflict as we take scale into consideration? Etc.

If we believe in this accountability business, we will need to advance on our macro (scale and time) questions, while continuing to build on experience and evidence about community capacity and social capital. We may also have to dig a bit more into the black box of how health workers’ disposition to act is supported and strengthened by more than cognitive processes. Donor investments for research, and implementation will be needed to help us move frontline health workers into the sort of functional and learning system, which transparency, participation, and accountability can help advance.


Nurses and Stories Are a Powerful Combination

By Cecilia Amaral, IntraHealth International and Frontline Health Workers Coalition

This blog was originally posted on Vital, the IntraHealth International blog.

Samalie with a small group of clients. Photo courtesy of Samalie Kitooleko.

Samalie Kitooleko wants you to know that nurses are independent professionals who undergo years of education and do not simply take orders given by doctors. She should know. She’s one of them.

In fact, Samalie is “changing the face of nursing leadership in Uganda to one of a confident, critical thinker who takes initiative and leads by example.” Those are the words of her supervisor, Dr. Chris Longernecker.

Samalie is also one of twelve women who will be honored tomorrow ahead of the World Health Assembly in Geneva at the Heroines of Health Gala Dinner. Samalie will add storyteller to her resume as she shares the story at the gala of her endless support for her clients.

She is one of several health workers trained by IntraHealth International and Medtronic Foundation in effective storytelling.  Policymakers need to understand what is actually needed to support health workers’ roles in health service delivery, and powerful storytelling can help convey just that.

Samalie’s nursing journey started over two decades ago. For the last 15 years she has worked at the Uganda Heart Institute, rising through the ranks from a smart and conscientious nurse taking care of clients with chronic cardiovascular illnesses to a leader and trainer of health workers—and a strong advocate for patient-centered care.

She understands that care is not just about the treatment, but also about building relationships with her clients, being there for them, listening to their stories, explaining their conditions and treatment, welcoming calls at 3:00 in the morning, or making follow-up calls when they miss an appointment.

“The best thing about being a nurse is seeing someone coming to the hospital very sick and seeing that person going home with a smile on their face,” Samalie says.

Resolutely seeking these smiles, she championed the formation of a national patient support group for young women living with rheumatic heart disease and also holds leadership positions on other projects at the Uganda Heart Institute.

Being a nurse, particularly in a resource-limited setting, comes with challenges. Cardiovascular diseases require a lot of medication, which poorer clients often can’t afford. Though Samalie can’t help them financially—and doubtless she would if she could—she does provide the social support her clients need, even if that requires showing up at their houses. Somewhere, somehow Samalie finds a way to care for them.

“There’s always something that you can do for a patient,” she says.

At the World Health Assembly, Samalie aspires to convey the crucial role that nurses can play in bridging communication gaps between health workers and clients. Often, clients have difficulty understanding their illnesses or treatments, which can hinder the condition. By sharing her story she hopes to inspire stronger policies that facilitate access to the medical treatment women from poorer social backgrounds deserve.

Working with Jeff Polish, a storytelling coach, taught her to translate her experiences into carefully crafted narratives that will touch and stay with her audiences. “Samalie is pretty incredible, if you ask me,” he says. We completely agree, Jeff.  

Hear Samalie Kitooleko speak at the Heroines of Health gala and reception hosted by Women in Global Health and GE Healthcare on May 21 ahead of the World Health Assembly. Co-sponsors of the event include IntraHealth International, the Frontline Health Workers Coalition, Global Health Council, the United Nations Foundation, Women Deliver, and the Global Health Centre at the Graduate Institute, Sweden. 

Through the Pharmacy Window

by Margarite Nathe, IntraHealth International

Elina Nantinda, an assistant pharmacist dispenses ARVs for a patient at the antiretroviral (ART) clinic at Omuthiya District Hospital, Namibia. Photo by Morgana Wingard, courtesy of IntraHealth International.

“When I was in grade 8, I was into two things: fashion and medicine,” says Elina Nantinda, a 25-year-old pharmacy assistant in rural Namibia. “So I decided to study hard. I thought, ‘It would be so nice to work with medicine and to know more about yourself and how medicine works in your body.’”

Today she runs the pharmacy at Omuthiya District Hospital’s HIV clinic in northern Namibia, dispensing antiretroviral medicines to a hundred clients per day, on average. People come from miles around—most on foot—for HIV services at Omuthiya. And most come to see Elina at some point.

When she started this job at Omuthiya last year, Elina spent two days working with a senior pharmacist. But then that person was moved to the main clinic, and she’s been on her own ever since.

“Being alone, you learn more and faster,” Elina says. “But we need another person in our pharmacy, so that when one is dispensing the medications, the other is entering data into the computer.”

Like all the other health workers at Omuthiya, Elina is constantly busy. Yet she’s always on the watch for clients who look lost or in need of help, and her watchfulness helps the whole clinic run more smoothly.

“I watch their facial expressions,” Elina says, particularly those of clients who come to pick up their medications—and especially when they don’t ask questions. “If they look confused or uncertain, I know I have to find a way for them to understand. I know any error on their part is going to be my fault. And sometimes patients don’t want to hear instructions about their medications because they think they’ve been taking them so long, they already know everything.”

In fact, HIV has become a way of life for many in Namibia. Today, according to the Ministry of Health and Social Services, overall HIV prevalence in the country is 17.2%, and slightly higher in Omuthiya.

So Elina asks them, quietly and kindly, to describe to her how they take their meds. This is how she sometimes finds out a client may be taking too many pills at once.

“This is really bad,” she says. “They have heart pains and they don’t sleep, so they usually come back to us within days.”

Or she sometimes finds that clients are taking the pills at the wrong time.

“Today a patient came from Onyaanya,” Elina says, which is 39 kilometers away from Omuthiya. “I could see the patient didn’t look normal. I asked, ‘How do you feel?’ The patient told me, ‘Sometimes after I take my medication, I feel like I’m drunk after two hours, and I want to sleep. I just feel like I’m not normal. It’s not me.’ So I asked, ‘How are you taking this medication?’ I found the patient was taking a tablet in the morning”—which is contrary to current guidance.

So Elina explained that the client should start taking the medication at night before going to bed.

Hard-working lady

Elina at the clinic at Omuthiya District Hospital. Photo by Morgana Wingard, courtesy of IntraHealth International.

I ask Elina why she chose medicine over fashion.

“I’ve always been a hard-working lady,” she tells me. “I used to visit the orphans in Windhoek, and I wanted to help them. I worried that God would feel bad about me if I’m not doing something to help.”

She hopes to become a full-fledged pharmacist someday, but will have to raise money for school.

Then I ask Elina if there are any other health workers in her family. She tells me no, she is the only one. So when any of her relatives is feeling bad, they always come to her.

“I feel so proud about that,” she says.

Elina Nantinda is employed through IntraHealth International’s USAID HIV Clinical Services Technical Assistance Project in Namibia, which is funded by the US Agency for International Development through the President’s Emergency Plan for AIDS Relief (PEPFAR). IntraHealth is working with the government of Namibia to increase the number of health workers providing HIV services and provide the support and training they need to reach the country’s goal of an AIDS-free generation. Read more about IntraHealth’s work in Namibia.

Valery Mwashekele and Cherizaan Willemse contributed reporting to this story.