Counting Community Health Workers “Counts”

By Cindil Redick, One Million Community Health Workers Campaign

CONARKY, Guinea – How many community health workers (CHWs) are there? What are community health workers’ tasks? How can we more efficiently integrate CHWs into national health systems?

Global public health leaders widely acknowledge that there are not enough health workers in the world. Tragically, this fact has been further highlighted by current state of the Ebola epidemic in West Africa. With over 9,000 Ebola cases (confirmed, suspected and probable) spread throughout Liberia, Sierra Leone, and Guinea, we are seeing a devastatingly high need for frontline health workers.

The health workers that are on the frontlines where I am currently in Guinea and throughout in West Africa are doing admirably hard work to end this Ebola epidemic. But how many frontline health workers are fighting Ebola and addressing myriad health issues around the world? Unfortunately, due to a lack of data we do not have a clear picture of the number of frontline health workers, particularly CHWs, who are assisting in the efforts.

These were just some of the questions the One Million Community Health Workers (1mCHW) Campaign with the Frontline Health Workers Coalition, Johnson & Johnson and others explored in their side session at the Third Global Forum on Health Systems Research in Cape Town, South Africa a few weeks ago.

The basis for this panel discussion was a newly published policy report released by the Frontline Health Workers Coalition endorsed by 17 organizations including the 1MCHW  Campaign about the difficulty in assessing the state of CHWs within the global community. Panel speakers from Jhpiego, IntraHealth International, the University of Washington’s Institue for Health Metrics and Evaluation and the 1mCHW Campaign provided the context necessary for a dynamic discussion.

Sept. 29, 2014: Panelists from at the Frontline Health Workers Coalition satellite session during the Third Global Symposium on Health Systems Research in Cape Town discuss the need for improving community health worker data for decision making. Credit: Frontline Health Workers Coalition.

Sept. 29, 2014: Panelists from at the Frontline Health Workers Coalition satellite session during the Third Global Symposium on Health Systems Research in Cape Town discuss the need for improving community health worker data for decision making. Credit: Frontline Health Workers Coalition.

During the session, it was widely recognized that despite being invaluable to improving health outcomes in many countries, CHWs are still an “invisible cadre” due to a lack of uniform and organized data. More importantly, the fact that there are many different types of CHWs adds to the difficulty in tracking them—sometimes, the variation in types of CHWs confuses members of the communities they serve.

Defining CHWs is only the first part of the solution. After CHWs are defined and professionalized, how do we count them? This question led to an interesting conversation about the need for CHW registries. There was support for the creation of CHW registries. However, it was suggested during the discussion that data should be collected at the local, district and central levels, and it must feed up to the national level. It was also made clear that CHW registries need to be cohesive so that the proper cadre of health workers is counted and tracked. To do this, the development process must involve CHW supervisors and implementers to help plan for data collection; otherwise, the data flow will fall apart at local levels. It was also recommended that data be collected via mHealth systems, which offer promising options to make it easier for governments to collect data and support CHW level supervision.

Our panelists and audience largely recognized the value in establishing a universal definition for CHWs and widely supported the creation of national registries of CHWs. A solid definition of a CHW leads to better data, and better data not only enables governments to integrate and support CHWs as key components in their community health systems but also track CHWs’ efficacy over time. In turn, CHWs will be able to serve their communities at their maximum potential.

The clearest take-aways from this session and others in Cape Town is that harnessing the power of data is key to both strengthening the CHW workforce, professionalizing the CHW workforce and better understanding CHWs’ impact on health outcomes to inform policy decisions. Knowing this, it is imperative for us in the advocacy community to continue all efforts for CHWs and CHW data collection to finally make these frontline health workers count.

How One Pharmacist Can Make a Difference: Transforming Ethiopia’s Pharmaceutical Sector

By Annette C. Sheckler, Management Sciences for Health

Ayelew Adinew was working as a pharmacist in a large public hospital in Addis Ababa, Ethiopia. He looked around and saw that the 100-year old pharmaceutical system was broken.

There was no transparent and accountable system for providing the information needed for effective monitoring and auditing of pharmaceuticals and other commodities. There was not sufficient documentation to track consumption, inventory discrepancies, wastage, product over-stock or under-stock. There were no procedures to ensure the availability of essential medicines. The regulations were outdated and there was no enforcement of the relevant regulations in place to protect the safety of clients, ensure proper utilization of resources, and deter professional malpractice.

Physically, the pharmacy space was too small with no separate area for patient counseling. Essential equipment was missing and there was no transport for procurement. Managing medicines transactions had not been systematized; therefore the dysfunctional work flow was a deterrent to timely service delivery, convenience for clients, and the efficiency of the service provider. The pharmacy system clearly needed reform.

A SIAPS supported pharmacist hands medicine to a woman in Ethiopia.

A SIAPS supported pharmacist hands medicine to a woman in Ethiopia. Courtesy Management Sciences for Health.

Ayelew Adinew stood on the frontlines of the pharmacy. He could see the fundamental transformation that was needed to fix Ethiopia’s broken pharmaceutical system. Ayelew decided that he could be a more effective agent of change in the public health sector and was hired as a technical specialist for USAID-funded Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program. SIAPS, implemented by Management Sciences for Health, is a global health project that uses a systems-strengthening methodology to assure the availability of quality pharmaceutical products and effective pharmaceutical services. The end result is better health outcomes.

At SIAPS, Ayelew believed he would have the support to develop the tools needed to transform Ethiopia’s pharmacies into modern, well-functioning facilities that are auditable and accountable. SIAPS senior management, along with the technical staff, immediately recognized the value of Ayelew’s vision and gave him the support he needed to go forward with this transformative undertaking. According to Ayelew, “I was igniting the fire, SIAPS was adding the fuel.”

Working with spreadsheets, Ayelew began to break down each of the steps in all of the processes of a working pharmacy. Ayelew mapped out the flow of medicines and supplies through a health facility system. He created new tools and forms such as vouchers, sales tickets, and dispensing registers to organize and record the information. The next phase was testing the new system.

Debre Markos Hospital is a large referral hospital located in one of the regional states. There, this new system was piloted and given the name, Auditable Pharmaceutical Transactions and Services (APTS). The pharmacy and accounting staff, including cashiers and auditors, were training on the APTS system.

Today, there is legislation in four regions requiring APTS implementation in all pharmacies. Also, the Federal Ministry of Health has just signed the directive that covers the entire country requiring implementation of APTS.

One pharmacist, Ayelew Adinew, had a vision for fixing a broken pharmaceutical system that fell far short of serving the people of Ethiopia. With the help of his colleagues at USAID-funded SIAPS, the generosity of the American people, and the support of Ethiopia’s Ministry of Health and other partners in the government, Ayelew was able to rise to the level of a public health champion. Everyone wins.

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Why Many Developing Countries Could Not Achieve MDGs 4 & 5: A Health Worker’s Perspective

By: Tunde Ajidagba, Women Deliver Young Leader, Nigeria

In the past 15 years, there has been substantial achievement toward reaching Millennium Development Goals (MDGs) 4 and 5, which seek to reduce child mortality and improve maternal health. Since 1990, the baseline year for the MDGs, child and maternal deaths both have decreased globally by around 50%, and contraception prevalence has increased from 55% to 63%.

While progress has been sustained globally, it has been inequitable across and within countries and has been hampered by limited access to quality services. Despite some success stories, many developing countries, especially in sub-Saharan Africa, still did not achieve MDGs 4 & 5. Progress varies widely across countries even when levels of income are the same. As a doctor in Nigeria, I want to share from the health worker perspective why many developing countries did not meet the MDGs 4 and 5 goals. It is very important to understand why progress was delayed in these countries in order to inform post-2015 strategies.

The Facts

In 2013, 2.8 million newborn babies died in their first month of life and 2.6 million babies were stillborn. More than 75% of newborn deaths occur in South Asia and sub- Saharan Africa. More than 80% of neonatal deaths in sub-Saharan Africa and South Asia occur in babies and could be prevented with simple newborn care. At present rate of progress, it will be more than a century before a baby born in Africa has the same chance of survival as one born in a high income country.

Globally, there were an estimated 289,000 maternal deaths in 2013, a decline of 45% from 1990. The sub-Saharan African region alone accounted for 62% (179,000) of global deaths, followed by Southern Asia at 24%. At the country level, the two countries that accounted for one-third of global maternal deaths are India at 17% (50,000) and Nigeria at 14% (40,000).

My Perspective

Tunde Ajidagba is a Women Deliver Young Leader and a medical doctor at Obafemi Awolowo University in Nigeria.  Currently, he is the Coordinator of the Campus Health and Rights Initiative (CHRI) which works to improve the health and wellbeing of young adults at Obafemi Awolowo University.

Tunde Ajidagba is a Women Deliver Young Leader and a medical doctor at Obafemi Awolowo University in Nigeria. Currently, he is the Coordinator of the Campus Health and Rights Initiative (CHRI) which works to improve the health and wellbeing of young adults at Obafemi Awolowo University.

As a health worker working in a public hospital in Nigeria, I believe many developing countries did not achieve MDGs 4 & 5 due to the lack of a continuum of care, or sufficient skilled health workers during pregnancy, at the time of delivery, and shortly after the baby is born. Skilled providers include doctors, nurses, midwives or auxiliary nurses.

The majority of women in developing countries live in rural areas. Women in these areas face greater obstacles in accessing care as those living in urban areas at every point on the continuum. In Nigeria, 74% of women living in the urban areas received at least four antenatal care visit from a frontline health worker, while 38.2% of the women living in rural areas received at least four antenatal care visits. Also, 67% of women in urban areas had their birth assisted by a skilled provider, while 22.7% of women in rural areas had their births assisted by a skilled provider.

Having a skilled attendant at delivery is very important because most maternal deaths arise from complications during or shortly after delivery. Even if antenatal care is received, any delivery can become a complicated one and the presence of a skilled provider makes a huge difference.

Countries who did not achieve MDG 4 and 5 face serious health system challenges, particularly in financing their health workforce when there is low health workforce density of doctors and midwives. Efforts should be made to strengthen existing health systems to improve access and quality of care. There should be opportunities for doctors, nurses, midwives and auxiliary nurses to upgrade specific skills, such as management of preterm births, in-patient care of ill and small newborn babies, and management of severe infections. There should be incentives for quality health workers, especially those in rural areas.

As we set goals in the post-2015 development framework, countries who could not achieve MDGs 4 & 5 should focus on improving care at birth for women and their babies, targeting small and ill newborn babies. Health care bottlenecks, especially the shortage of midwives and neonatal nurses on the frontlines, should be addressed. This way, the post -2015 agenda will not be another empty rhetoric for developing countries.              

6 Critical #HealthWorkersCount Discussions at UNGA 2014

By Aanjalie Collure and Zoe Matza, IntraHealth International 

Originally from the Health Workforce Advocacy Initiative Blog 

Last week, global leaders convened in New York City to attend the United Nations General Assembly (UNGA) and several side-events dedicated to facilitating discussion on major global issues. With the spread of Ebola in West Africa, the high incidence of preventable maternal and child mortality, and the prevalence of HIV/AIDS and other infectious diseases in many areas, it is clear why side-events devoted to accelerating progress on global health goals consistently maintained high attendance rates throughout the week.

Interestingly, the urgent need to strengthen and support the global health workforce was re-iterated at several of these global health side-events as a critical priority if we are to achieve global health goals. Efforts to reduce child mortality, improve maternal health, combat infectious diseases,and achieve universal health coverage will be hindered if countries lack a well-staffed, well-trained and well-distributed health workforce underpinning a strong public health system. Below are a list of six memorable moments during UNGA Week when the need to prioritize health workforce strengthening powerfully resonated with all:

1. Bill & Melinda Gates Foundation Co-Founder Melinda Gates at the Social Good Summit: #HealthWorkersCount for Family Planning

This year’s Social Good Summit held by the UN Foundation, Mashable, the Bill & Melinda Gates Foundation and the 92Y featured several discussions about the inaccessibility of critical health technologies and resources to many people around the world. One such discussion was led by Melinda Gates, Co-Founder of the Bill & Melinda Gates Foundation, who pointed out that women’s desire for family planning resources around the world largely outstrips their accessibility to these resources. Indeed, 222 million women who want access to modern contraceptives lack access to them.

Melinda Gates emphasized the role of health workers as critical providers of these resources for hard-to-reach communities. She also asserted that health clinics not only provide family planning tools and counseling for women, but administer “holistic care” for women before, during, and after their pregnancies as well.

2. Model Liya Kebede and Malawian Midwife Victoria Shaba at the Social Good Summit: #MidwivesMatter for Maternal Health

Another powerful moment at the Social Good Summit was when Victoria Shaba, a Malawian midwife, took the stage to describe how many women in Africa lack access to skilled birth attendants like herself. Her description of one of the most stressful days of work- delivering close to 50 babies and handling numerous labor complications, all in a single night- illustrated the chronic shortage of skilled midwives in rural health clinics.

Model Liya Kebede, who has been a strong advocate for maternal health in Africa, further emphasized the integral role of midwives when she stated, “Most maternal deaths are completely preventable and treatable by a well-trained health worker.”

3. Kenyan President Uhuru Kenyatta, the African Union, UN Foundation and the Global Fund to Fight AIDS, TB and Malaria: #HealthWorkersCount for Strong & Resilient Health Systems 

In this high-level meeting convened by the Mission of Kenya, in partnership with the African Union, UN Foundation, and PEPFAR, speakers envisioned the possibility of global health convergence between lower and higher-income countries, which would avert nearly 10 million deaths per year.

Dr. Agnes Binagwaho, Rwanda’s Minister of Health, emphasized the need for an aggressive scale-up of African health systems, ensuring that there are adequate roads and transportation routes for ambulances, education for health workers, and appropriate sanitation and hygiene facilities for clinics. Dr. Mark Dybul of the Global Fund asserted the need to prioritize investments for improving public health systems by pointing to countries like Uganda, whose relatively strong health system and well-equipped health workforce was integral to controlling and mitigating the spread of Ebola in that country.

Echoing this statement, Kenyan President Uhuru Kenyatta described strong health systems as “what best protect Africans”, and urged for increased domestic financing for health not only to achieve health targets, but also to ensure the long-term prosperity and growth of African economies.

4. Johnson & Johnson and Partners: #HealthWorkersCount for Global Health Innovation


On a September 23 event astutely titled “Health Workers Count”, J&J and its partners brought together NGOs and private sector leaders together in an ideation session dedicated to working together to develop innovative solutions of major HRH issues in regards to health worker training, retention and deployment.

The session encouraged stakeholders to think of the broader health system when developing innovative solutions for common challenges faced by frontline health workers. Despite the explosion of mHealth and other high-tech gadgets for health workers, the session also emphasized the need for innovative ways to improve transportation to-and-from health clinics, improve management, and collect data on the state of a country’s health workforce. At the end of the session, attendees were energized and inspired to build cross-sector partnerships dedicated to supporting health workers in new and innovative ways.

5. Global health leaders from the United States, Pakistan, Japan and Zambia: #HealthWorkersCount for Universal Health Coverage


At a panel discussion hosted by the One Million Community Health Workers Campaign, key advocates for the global health workforce from diverse backgrounds came together to emphasize the need to strengthen human resources for health to achieve universal health coverage.

USAID Assistant Administrator Ariel Pablos-Mendez emphasized the role of health workers by describing them as the “brains, arms, heart and soul of health systems”. Echoing these statement, professor and economist Jeffrey Sachs argued that improving access to frontline health workers was a “no-brainer” with UHC prioritized in the post-2015 global health agenda.

Dr. Sania Nishtat, the first female Minister of Health in Pakistan; Dr. Toda, the Director of HRH at JICA, and Zambian Minister of Health Emerine Kabanshi all discussed how investments in their national health workforce have been critical to accelerating universal health coverage. Nonetheless, they also pointed to persistent challenges in ensuring the safety, retention and geographic distribution of health workers in Pakistan, Japan and Zambia, respectively. In his closing remarks, Pape Gaye, President and CEO of IntraHealth International, powerfully articulated the need for better data, strong advocacy, and targeted investments for health workers if we are to overcome these challenges.

6. Global Leaders Emphasize Why #HealthWorkersCount un #Post2015 Global Health Policy Discussions


During the two panels hosted by the Nigeria-based Centre for Health Sciences, Training, Research, and Development (CHESTRAD), panelists from the U.S., Latin America, Asia, and Africa discussed why greater involvement and cohesion among civil society organizations is needed to ensure bold action is taken to strengthen the health workforce in the post-2015 Sustainable Development Goals and the post-2015 World Health Organization Global Strategy on Human Resources for Health, both of which are currently being formulated by global bodies.

Panelist Pape Gaye, President and CEO of IntraHealth International, highlighted how the tragic events of the Ebola outbreak have made it very difficult for policy makers to ignore what can happen when there are not enough health workers, and not proper health infrastructure, to meet the needs of a population. Gaye called for greater attention and synergy of efforts to strengthen the health workforce to help achieve the vision of the many strategies world leaders have agreed to across global health.

Heather Teixeira of IntraHealth and the Health Workforce Advocacy Initiative (HWAI) spoke about the opportunity that local community service organizations participate in HWAI and other outlets to ensure their voice is heard in these discussions over the strategies and frameworks that will guide the global health policy agenda for the next 15-20 years. Teixeira also highlighted that a soon-to-be released advocacy toolkit from HWAI will provide information on organizations can use their expertise to advocate for better policies and increased investment in health workers at the country, regional and national levels

Broad participation of leaders from numerous national governments, NGOs, civil society and the private sector at several of these events demonstrates the growing support for prioritizing health workforce issues as critical to global health progress. As the world moves into the post-2015 agenda, it is essential that these leaders advocate on behalf of HRH issues as a strong and united front, to ensure that frontline health workers receive the necessary support they need to maximize their life-saving impact around the world.

Q&A with Dr. Melvin Korkor: Physician, Lecturer, and Ebola Survivor from Bong County, Liberia

By Aanjalie Collure, IntraHealth International and Frontline Health Workers Coalition


At the Global Health Security Agenda meeting hosted by the CSIS Global Health Policy Center and its partners on Sept. 26, I had the opportunity to meet Dr. Melvin Korkor, a physician, lecturer and Ebola survivor from rural Liberia. As a local health worker in Liberia, Dr. Korkor was able to provide insights on the challenges faced by Liberian health workers prior to the Ebola outbreak in his country. His heroic first-hand story demonstrates how the rapid spread of the virus has exacerbated these conditions and decimated already-strapped public health systems.

FHWC: Could you introduce yourself, and tell us a little about the hospital and region your work in?

Dr. Korkor: I’m Dr. Melvin Korkor, a lieutenant physician at Phebe hospital, which is found in rural Liberia. I’m also a teacher and a lecturer: I teach at the College of Health Sciences, Nurses and Physician Assistants.

FHWC: Do you mind reiterating your story you shared at today’s conference on the Global Health Security Agenda, from your first point-of-contact with Ebola at your hospital, to where you are today?

Dr. Korkor: It all started when there was an outbreak of Ebola in Lofa country, which is close to the border between Liberia and Sierra Leone. Guinea is quite far from my hospital, so Liberian health workers did not know much about Ebola because we have never had a major outbreak. We got to know about it when a lady came to the ER in the hospital with [displaying the following symptoms:] headaches, back pains and sleepless nights. Because we did not know much about Ebola, we decided to diagnose her with a case of malaria and typhoid. The patient subsequently died, and we got to know that she died of Ebola.

A few weeks later, 10 of us were confirmed positive: five nurses, one physician assistant, one laboratory technician, and two ambulance drivers. I am the only survivor. I was infected because of humanistic compassion: I touched one of the nurses who came down with Ebola without using gloves, I think that was my mistake.

A few days later I felt sick, and isolated myself from my family. My blood sample was taken to Monrovia, it was tested and came out positive. I was transferred to Monrovia, where we have the Ebola treatment unit (ETU). I discovered that three of my nurses had died, and two were in critical condition. Whilst I was there, I re-hydrated myself, and though I did not want to eat, I had to eat a lot so the transfer worked. I had contact with one of the nurses, who was on her dying bed. I told her to brave, confident and courageous, but she told me she was going to die. While we were talking, she asked me to take care of her two kids, and subsequently she died.

Days later, I was discharged from the hospital and went back to Bong County. The hospital was closed. With the construction of the Ebola treatment unit in my County, I hope that my hospital will be re-opened. We usually give care to pregnant women, to [children] under [age] 5, and we receive patients from Monrovia, Guinea, and Ivory Coast. We hope our hospital will be re-opened. We have an ETU where we will stop and prevent transmission.

We need help. We need our health workers to be trained in infection control practices, we need more infectious control supplies, and more ETUs in all parts of Liberia.

FHWC: What are the barriers health workers face to detecting and preventing the rapid spread of Ebola in Liberia particularly?

Dr.Korkor: We have many problems we are faced with. We have limited equipment and supplies to work with. We have low incentives – we cannot push people’s lives on the frontlines if we do not give them enough money. We have low training. These are a few of the problems health workers face.

FHWC: A lot of the coverage we have seen has been focused on the shortage of health workers and weak health systems in Liberia that made it unprepared when Ebola hit. Can you explain some of the challenges you faced before Ebola, and how the challenges have been exacerbated since the outbreak?

Dr. Korkor: One of the conditions the health workers [face] is that if the ETU is not constructed in the county, the hospital will not be re-opened. This is because all confirmed, probable and suspected cases must still go to the hospital if there is no ETU. Now that we have we have constructed a ETU, we should definitely be able to re-open the hospital.

Although our hospital was officially closed, we were still responding to labor and delivery complications. When the hospital was closed, we did close to 50 Cesarean sections, and did many blood transfusions to treat children with malaria and anaemia. Still, with the closure of the hospital, we have had a lot of cases where people haven’t been treated. No health worker wanted to put their life on stake [in a hospital], so our hospital was closed. That has a huge impact on the lives of Liberians.

FHWC: If you could advise the U.S. Government, how would you suggest they fund health systems, and support and strengthen the health workforce in Liberia?

Dr. Korkor: The public health system we have in Liberia is very poor. Curative measures are very expensive. We have very poor public health structures in Liberia, and have poor training for health workers. Health workers need to be well trained. We need more supplies. We need to encourage our health workers. We need to step up their salaries, so that they are happy to work. They need to have benefits and insurances, so that if anything happens to them, they can cover for their families. We need more hospitals, and trained and qualified health personnel. If all that was done, we would have a very vibrant health care system in Liberia.

I thank Dr. Korkor for taking the time to sit down with me and share his valuable insights on the state of Liberia’s health workforce amidst the Ebola epidemic. Like Dr. Korkor, health workers throughout West Africa are on the frontlines of providing life-saving care despite immeasurable costs to themselves and their families. Dr. Korkor is sharing his story and meeting U.S. Government officials in Washington to advocate for the strategic and sustainable long-term investments needed to build a resilient Liberian health system. 

Improved Data on Community Health Workers Critical to Achieving Global Health Goals

Report by alliance of top US-based organizations urges nations to maximize impact of CHWs by defining core competencies

Contact: Vince Blaser, Frontline Health Workers Coalition, or +1 301 787 4131

Cape Town, South Africa, September 29, 2014A new report finds that developing nations’ ability to deal with pressing health challenges like HIV/AIDS and ensuring maternal and newborn survival will be strengthened by creating a common definition for community health workers, as well as a core set of skills and competencies that would help ensure they are optimally trained, supported and deployed to provide care and treatment when and where it is needed most.

The report by the U.S.-based Frontline Health Workers Coalition urges nations to adopt improved, systematic data collection efforts for community health workers to more effectively assess the current state of the entire health workforce, enhancing nations’ ability to rationally integrate CHWs into their health system to better extend services into communities and deal with pressing health challenges.

According to the World Health Organization, at least 7.2 million additional doctors, nurses and midwives are currently needed to deliver essential services. However, without knowing the number of community health workers deployed, or their geographic location, global leaders are unable to determine on a global scale how they are helping to fill this shortage.  Without a common definition and understanding of expected tasks, countries cannot determine the right mix of skills for their health workforce and how best to integrate CHWs into the health system. With this information, CHWs can be rationally integrated into the formal health system, properly supported, and extend the health system to rural and other hard-to-reach populations.

Evidence suggests that in places where community health workers have been effectively and systematically integrated into national health systems, it has resulted in significant gains toward the health-related U.N. Millennium Development Goals (MDGs), including improvements in maternal health, reductions in newborn mortality and efforts to roll-back diseases such as HIV/AIDS, TB and malaria. The report recommends health workforce stakeholders look to the International Labour Organization “community health worker” definition and the ILO recommended set of core tasks in order to establish global consensus on a common definition, set of core tasks and competencies.

“We know how to prevent mothers and children from dying and how to drive down infectious disease pandemics like HIV/AIDS and malaria.  But we cannot do any of these things without a well-trained, supported and effectively deployed health workforce,” said Julia Bluestone of Jhpiego, Chair of the Frontline Health Workers Coalition. “Good data and rational integration of community health workers is key to unlocking this potential.  Better data and integration of these workers will allow countries to more effectively deploy their entire health workforce for maximum impact on saving lives.”

“We can create better managed health facilities and systems with well-trained and supported health workers,” said Michael Bzdak, Coalition member and Executive Director of Corporate Contributions at Johnson & Johnson. “Responsible use of data and technology will help the Coalition achieve this by accelerating the adoption of proven practices.  As we approach the establishment of goals in the post 2015-era, let’s take stock of the data we have and how we are using it to make decisions.  We have a great opportunity to harness the power of data to support the global health workforce.”

Other key report recommendations include:

  • Implementation of the 2013 Harmonization Framework, which calls for collaboration among various stakeholders to advance effective and rational integration of CHWs into national health systems and to optimize the role that CHWs play in achieving national health goals.
  • Creation of guidelines for a minimum data set of information on CHWs and the creation of national registries integrated into national human resources information systems to house this minimum data set.

About the Frontline Health Workers Coalition

The Frontline Health Workers Coalition is an alliance of 38 United States-based organizations working together to urge greater and more strategic U.S. investment in frontline health workers in developing countries as a cost-effective way to save lives and foster a healthier, safer and more prosperous world.

About the report

The report, titled A Commitment for Community Health Workers: Improving Data for Decision Making, is supported by Johnson & Johnson and endorsed by 17 FHWC members and partners. Contributing members to the report include IntraHealth International, Jhpiego, Johnson & Johnson, and the One Million Community Health Workers Campaign.

The Matrones of Diema

By Anne Pfitzer, Jhpiego

“If I were to speak to a matrone like me before she goes for training, I would tell her to really pay attention, not to be afraid to ask all the questions she might have and when it comes to practicing [on models first, then clients], to really master the steps. The objective for which she is going, she must attain it. For this, she must have confidence in herself, be sure of what she says, that it is correct information, and speak to people with conviction.” -Karle Magassa, Malian Matrone

Proud. Dedicated. Courageous. Matrones—a cadre of auxiliary midwives with 6 to 12 months of pre-service education—staff the majority of community health centers in rural Mali. Because their salary is lower than that of health professionals with higher qualifications, they are sought after by the ASACOs, the health management committees that manage and finance these centers. Another advantage matrones offer is the smaller social distance between them and the women they principally serve. As a result, they are vitally important in Mali, both in terms of the services they provide and the number of lives they impact. There is much for them to be proud of in the work they do to combat Mali’s high maternal mortality ratio of 368 per 100,000 live births, according to the 2012-2013 Demographic and Health Survey.

Last year, I visited nine matrones in Diema District, a remote area close to the Mauritania border; it was a chance to have long chats about them and their work. We often found amused and surprised looks on the faces of the young physicians deployed in these facilities that we wanted to speak to their matrones rather than the physicians. I was there to learn more about their ability to apply skills they had learned in the active management of third-stage labor, essential newborn care, postpartum family planning and insertion of contraceptive implants. What struck me most as I talked with them was their determination and diligence in acquiring new skills. I came away with newfound respect for this under-appreciated cadre of health workers, and was transfixed by the stories they told to illustrate the challenges they face in their daily work.

Matrone Saran Keita

Matrone Saran Keita

Saran Keita, a matrone in Diema, told me about a woman she encountered recently who was the victim of an obstetric fistula. Following a successful treatment, her care providers gave her Jadelle®, an implant that provides effective, long-lasting, reversible contraception for women.

“After some time, she told her husband that she was carrying a heavy bucket of water and she felt the rod break. Unfortunately … [at a nearby health facility] they removed her Jadelle, and now, two months later, she is again pregnant,” Saran said. She knows that childbirth after surgery to repair a fistula puts the mother at much greater risk for fatal complications.

When the mother consulted with Saran for antenatal care, the matrone took one of the Jadelle implants and used it as an example. “We all really manipulated it and bent it. So I asked, ‘do you think it can break?’” Saran, thanks to her diligent training, was confident that the implant had not broken and should not have been removed.

She has martialed all the care providers in her area to follow the pregnant mother’s progress very closely, making sure they are prepared for the cesarean section she will need at the time of birth. She also has not failed to educate her and her husband about the healthy family planning options they might choose following childbirth. Given that the contraceptive prevalence rate is only 10% across Mali according to the DHS, healthy birth spacing and family planning are important interventions to ensure the health of mothers and their families.

The USAID-supported Maternal and Child Health Integrated Program worked in Mali to build the capacity of matrones in just that sort of situation. These efforts will continue under the new Maternal and Child Survival Program to strengthen additional skills of frontline workers in health centers and in communities.

Not only are the matrones grateful for the new skills, they’re also innovative in how they’re using them. I asked Saran how she reached women who gave birth at home—a sizeable issue in many rural communities across the country.

“Well, parents need to obtain a birth certificate, which they get from the [community health center],” Saran said, adding, “At that time, we insist to see the mother and take the opportunity to pass messages about birth spacing. Also, during newborn immunizations, we pass these messages.”

Matrone Oura Soucko

Matrone Oura

Oura Soucko, a matrone in another Diema health center, said, “We really have to sensitize women about spacing births two to three years. And this helps me too! I [supervise] a lot fewer births than before; about 50 per month now, whereas before it could be between 60 to sometimes 75 a month.”

All of us in the Maternal and Child Survival Program team are well aware of the impact such family planning education can have on a mother, her children and entire families. As we approach World Contraception Day on Sept. 26, the impact of family planning cannot be understated as an intervention that can drastically change lives.

In the same way, we are proud of, and grateful to, health workers like the matrones of Diema, who provide education and health services to improve the lives of so many women, children and families across the world.

New Report: Why We Need Better Data on Community Health Workers

By Julia Bluestone, Jhpiego and Frontline Health Workers Coalition

CHWreportCommunity health workers are highly visible to the families they serve, walking to houses, delivering basic but essential health information and care to mothers and children.  But within established health systems, these health workers are largely an “invisible cadre.” They are often not counted, and when not on an official payroll, not tracked in any national human resource information system. That’s a lost opportunity to impact a health system countrywide.  When community health workers have been rationally integrated in national health systems – like in Ethiopia, Malawi and Nepal – the evidence shows they have helped lead to significant progress in achieving their health Millennium Development Goals.

In a new report released on the sidelines of the United Nations General Assembly in New York, the Frontline Health Workers Coalition calls for a systematic approach to assessing the extent of this workforce and its impact on health. The report recommends health workforce stakeholders look to the International Labour Organization “community health worker” definition and the ILO recommended set of core tasks in order to establish global consensus on a common definition, set of core tasks and competencies. The report, titled A Commitment for Community Health Workers: Improving Data for Decision Making, is supported by Johnson & Johnson and endorsed by 17 FHWC members and partners.

To enhance the quality and availability of data for decision-making, the report also calls for the creation of guidelines for a minimum data set of information on CHWs and exploring the use of national registries to capture and integrate data into national human resources information systems.  The 2014 State of the World’s Midwifery report found that, in 79% of countries surveyed, midwives supervised CHWs concerning sexual, reproductive, maternal, and newborn health, suggesting that countries often informally integrate CHWs into the health system. A commonly accepted definition, agreed-upon  understanding of core tasks and competencies, and minimum data set will help national ministries make data-driven decisions on how best to integrate these CHWs into health systems and collect and document best practices and impact-driven results.

The goals of ending preventable maternal and child deaths, achieving an AIDS-free generation, achieving global health security, filling unmet needs for family planning, and a whole host of other global health goals cannot, and will not, be achieved without the commensurate and rational workforce, with appropriate skill mix and rational sharing of tasks.

Read the full report online at and to join us tomorrow, Tuesday Sept. 23 from 9-11:30 am for an ideation session on improving health workforce data collection and use. The session will be livestreamed at and includes a virtual breakout session where we will be discussing the role of CHWs online. Please join us!

Health worker heroes at the frontline of the Ebola crisis

By Philip Carroll, Save the Children

The Ebola outbreak which started in south eastern Guinea in early 2014, has now spread to Liberia, Sierra Leone, Nigeria and Senegal. Ebola has highlighted the devastating impact that a crisis can have on an already fragile health system and has also highlighted the life-saving and heroic work of frontline health workers, who are risking their own lives to protect and save the lives of vulnerable children in remote communities.

Francis Vandy Rogers. Courtesy Save the Children.

CHW Francis Vandy Rogers. Photo courtesy Save the Children.

Francis Vandy Rogers is a trained community health worker and a carpenter. Francis, his wife and four children are temporarily displaced as a result of a fire outbreak that burnt down their thatch roofed house and 14 other houses in the town in April 2013. They are currently residing at the community training center – temporarily given to him as a result of his active role in the community – while reconstructing their house. Their main sources of water for drinking and other domestic uses are boreholes with hand pump and streams.

Every morning Francis carries his tools box and First Aid box to his workshop where the community people meet him for primary health service while doing his carpentry work. “Usually when they come for treatment I’d leave the wood work, get my hands washed and attend to them then I get back to work,” says Francis.

Francis explains the importance of the training and how he is helping the community. He says, “This training is useful because our people say ‘Korglor yia laygor eh kpokowa’ (translation: Information about an impending war can save the aged from being killed). If God has made it possible to get information about this killer disease they call Ebola, we should do everything within our power to put a bearer before it, especially when they have told us that it is not far from us. I learnt a lot about the prevention of this disease, which I’m going to sensitize my community members seriously about it.”

Francis continued, “First, we are going to ask the town chief to call all the people through the town crier to a meeting so that we can have the opportunity to sensitize everybody. Then we will continue with one on one sensitization and in the event of suspected case, we will immediately report to the health center. From what I learnt in the training, Ebola is a very serious disease that can kill very fast so even the sensitization method and message will be serious so that the people themselves should know that this a serious and must take it seriously.”

CHW Lansana Fofanah. Photo courtesy Save the Children.

CHW Lansana Fofanah. Photo courtesy Save the Children.

Another inspiring example of a heroic health worker is Lansana Fofanah, who is a farmer and a trained community health worker. Lansana and his wife have five children, two of which are living in kinship care. On a typical farming day, Lansana leaves his house very early in the morning and spends rest of the day and returns late in the evening to catch up with the Muslim congregational prayer. Lansana usually reserves a day or two in a week to do his community health services.

Talking about the training and how he plans to sensitize the community, Lansana says, “This training is very good and I consider it as an empowerment to save lives in our communities. Because prevention is the best solution to this Ebola disease. I have also learnt about the causes its signs and symptoms when someone is infected. We should always refer the Ebola patient immediately to the [primary health unit] to avoid its transfer to another person in the community.”

He adds, “I am going to call my community people to a meeting and I will explain to them the dangers of this disease. Because this Ebola does not have medicine and the only solution is prevention so we must abide by all the preventive rules such as stop eating dead animals, monkeys, baboons and bats and even fruits that have been eaten by these animals. Through this we can prevent the Ebola in our communities.”

This is the first time Francis and Lansana have been trained to carryout sensitization on Ebola virus prevention awareness and emergency preparedness.


What Lizzie Longshaw – and Her Daughters – Teach us about Health Promotion

By Julia Nakad, Hesperian Health Guides

A horrific car accident when she was only 2 caused Lizzie Longshaw of Zimbabwe to have her left arm amputated. As she grew up she realized that she and other women with disabilities in her community were further disadvantaged – they didn’t receive health exams since disability-friendly and accessible clinics were too far away and too expensive for them to visit, and the stigma against women with disabilities was too great at “normal” clinics. Lizzie and a group of women with disabilities began meeting regularly to discuss their health challenges, using a copy of Where Women Have No Doctor to learn more about the issues that most concerned them, including family planning and cancer. After months of working together, they persuaded a Ministry of Health official to open a government-funded mobile clinic to provide free cancer screening and family planning services for women with disabilities.

Lizzie’s group began organizing 20 years ago, before mobile phones, tablets and Internet cafes were available. For Lizzie and her colleagues, access to accurate health information led to dramatic improvements in health outcomes for women with disabilities. The incredible work carried out by Lizzie and the National Council of Disabled Persons of Zimbabwe inspire us to ask how we can increase well-being for all by increasing access to accurate, easy-to-use health information through today’s technology.

In some ways, books and print materials are the still the best: They have no batteries to run out, the only bandwidth they depend on is the reader’s concentration, and they’re easy to pick up and put down as life interrupts. But new technologies offer advantages, too.

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On Hesperian’s HealthWiki, a searchable online platform that functions well on slow internet connections, we make freely available the accurate, easy-to-understand health information found in our books. With Hesperian titles available in the HealthWiki in English, Spanish, and an increasing number of other languages such as Arabic, Chinese, Filipino, French, Haitian Kreyol, Khmer, Lao, Portuguese, Vietnamese, and Urdu (and more coming!),this resource helps equip health workers as they build health training and education programs in their communities. And as Lizzie’s experience shows, it also helps them to organize around unmet health needs and advocate for change.

In the past year, the HealthWiki received 2.5 million page views. While information about sanitation and hygiene, healthy food, and “pain in the belly and gut” are popular topics, a striking trend in HealthWiki engagement relates to women’s health information, especially in Spanish. Five of the 10 most viewed pages address pregnancy and reproductive health. Top sending countries to the HealthWiki include Mexico, Colombia, Argentina, Peru, Venezuela and Chile.

Latin America activist-researchers know that adolescents as young as 12 are increasingly engaging in sexual activity, that very high numbers of young women in Latin America report their first sexual experiences as forced or unwanted, and that it is often difficult to access contraceptives and dangerous or impossible to access safe and legal abortions. It stands to reason that the critical need for information about sexual and reproductive health in this region is reflected in HealthWiki use. Among the most-accessed pages in the HealthWiki are “Métodos seguros para realizer un aborto” (Safe abortion methods), “Riesgos y señas de peligro durante un embarazo” (Risks and danger signs during pregnancy), “Violación sexual” (Rape), and “Complicaciones del aborto” (Complications of abortion). Being able to find safe, trustworthy and comprehensive information in an online form responds to the needs of a new generation of tech-savvy yet still marginalized young women. The sheer number of visitors to the HealthWiki’s sexual and reproductive health materials demonstrates that this resource is meeting an urgent need by providing access to information that is otherwise difficult, or dangerous, to obtain.

The HealthWiki also supports the work of frontline health workers. Amelia Brandt, Associate Program Director at Medicines for Humanity, has experience taking the information in the HealthWiki from the computer to the field. In her role overseeing projects in Latin America, she covers 10 projects in 4 countries: Guatemala, Guyana, Haiti and the Dominican Republic. She works with local, faith-based organizations and non-governmental organizations to build the capacity of community and frontline health workers, with the goal of reducing child mortality.

The “LaLoma” project serves the communities of Consuelo and Quisqueya in the Dominican Republic, with the support of Medicines for Humanity. Photo courtesy of Medicines for Humanity.

The “LaLoma” project serves the communities of Consuelo and Quisqueya in the Dominican Republic, with the support of Medicines for Humanity. Photo courtesy of Medicines for Humanity.

Consulting with her partners on clinical evidence they collect in their communities, Amelia leads a process to determine which areas need training. She then searches for useful materials: “The first place that I go is the HealthWiki,” Amelia said, adding, “I pull out everything relevant that I find (for example, materials about women’s health- adolescent pregnancy is major concern, especially in the Dominican Republic) and send it to our partners in the field for us to discuss and determine what will be most appropriate for use in trainings with our [community health workers]. The material is accessible – it includes health information, different ways to present that information, and activities to accompany it. It’s easy for people with different levels of training experience to use.”

Where Lizzie Longshaw had to labor over a book, a photocopier, and paper, scissors, and tape, new technologies like the HealthWiki make Amelia’s job easier and more conducive to localization.

From promoting contraception options to preventing the spread of Ebola, frontline health workers are the lifeblood of health systems, especially in remote and resource-poor areas. Providing health information to support their programs and facilitate the long-term improvements only they are capable of carrying out is crucial. Health information in all formats – books, flip charts and posters, radio and video, online and via cell phone  – in as many languages as possible will make all the difference in the world.