5 Ways to End AIDS by 2030

This article originally appeared in Devex.

By Margarite Nathe, IntraHealth International

When it started in the early 1980s, everyone was scared. No one knew how to help the people who were filling U.S. hospitals and then swiftly dying, or what to do for others suffering the same fate around the world. It was 1984 when one U.S. health official expressed hope for a vaccine within two years.

Now, over three decades and 39 million deaths later, we finally know how to treat, prevent and control HIV, although a vaccine remains elusive. But knowing is different from doing. The real challenge is scaling up what we’ve learned to stop new infections for good.

Last month, UNAIDS announced its new fast-track strategy to end the AIDS epidemic by 2030. “If the world does not rapidly scale up in the next five years, the epidemic is likely to spring back with a higher rate of new HIV infections than today,” officials from the U.N. agency said. That’s partly because half of the 35 million people who live with HIV today don’t know they’re HIV-positive, so they don’t know they’re in danger of passing the virus on to others.

By 2020, if the fast-track approach goes to plan, 90 percent of people who live with HIV will know their status, 90 percent of people who know they are HIV-positive will be on treatment, and 90 percent of people on treatment will have suppressed viral loads, making them less likely to transmit the virus. And by 2030, AIDS will no longer be a threat to our public health.

The goal is ambitious. There are still a lot of global problems and prejudices to overcome. But today experts can see what once seemed impossible — ending the epidemic — is finally within reach, and these five focus areas are going to help make it happen.

1. More health workers, ready for anything.

Lab technicians, doctors, nurses, even the truck drivers who deliver antiretroviral therapies and other meds to clinics around the world are all health workers, and they’re at the heart of health and well-being in any community.

HIV demands all different types of health workers and skill sets, including palliative care, counseling, research, pharmacology and obstetrics, to name just a few. Pediatrics is another big one, as one of our greatest challenges ahead will be making sure all HIV-positive infants and children are on treatment.

According to the World Health Organization, we need some 7.2 million additional doctors, nurses and midwives worldwide. And unless we invest in the global health workforce, that number will grow to 12.9 million by 2035.

To end the AIDS epidemic, the world needs more health workers who are trained and ready to do the job, stationed in the right places, connected to the right technology, and safe from infection and violence. Countries also need to make better use of the health workers they have. Without health workers, we can’t test or treat even a single person — much less end an epidemic.

But it’s not just health workers’ skills the world needs. It’s also a commitment to equitable, unbiased health care for all.

2. Focus on key populations.

Members of key populations — something of a euphemism for sex workers, men who have sex with men, transgender people and injectable drug users — are marginalized and stigmatized. Their isolation and high-risk behaviors mean these groups have much higher HIV prevalence rates than others and they suffer the bulk of new infections.

Not so long ago, U.S. policy tried to prevent global health organizations from working with certain key populations. And when we did, we were often required to first document our moral indignation by proclaiming our opposition to, for example, prostitution.

Today this policy has changed. But that doesn’t mean that these key populations are getting the HIV services they need. Take Uganda’s infamous anti-homosexuality law — enacted and then repealed this year — which made it difficult for many to seek or even provide care without risking life in prison. Similar laws are still on the books in some countries.

Many members of key populations have been turned away by health workers. And many more have been socially outcast for so long that health care doesn’t even seem like an option anymore. So they fall through the cracks of health care systems around the world.

One example is in South Sudan. The HIV rate among the general population is relatively low, only 2.2 percent among adults. But among female sex workers — and there are many, particularly wherever there’s a strong military presence — the rates are much higher. The ongoing war and all its effects on the health system have turned the country into a tinderbox for potential HIV infections.

That’s why IntraHealth International, in partnership with the South Sudanese government, reaches out to sex workers at brothels and lodges, trains peer educators (that is, other active female sex workers), promotes and distributes condoms, provides testing and counseling for HIV and syphilis, and links women to other critical health services. Of the 546 sex workers we tested between July and September of this year, almost 32 percent were HIV-positive. Fortunately, most are now enrolled in treatment and getting the care they need.

3. Rock-solid health systems.

Over the past 35 years, we’ve seen what a strong health system can do to help countries respond to HIV. And in the past year, we’ve seen another virus, Ebola, spread out of control in West Africa. It’s clearer than ever that vulnerable health systems around the world have a long way to go.

Strong health systems are the bedrock of any healthy population. They lay a foundation built on governance, financing, technology, research, service delivery, and the health workforce (also known as human resources for health). To successfully address an epidemic such as HIV requires focus on each of these things, not just a few.

One way to make these systems stronger — and to lower rates of HIV — is to ensure systematic HIV testing and counseling. Integrating different types of services (HIV and tuberculosis, for example, or HIV and family planning) is a way to reach those at greatest risk.

Starting this year, a new USAID-funded global project called Linkages will play a big role in strengthening health systems around HIV. The project will build capacity within governments and civil society to offer high-quality HIV services that are sustainable, evidence-based, and comprehensive, specifically to key populations.

4. Strange bedfellows, unexpected results.

What do you get when you gather motorcycle taxi drivers, local traffic police, and a regional health management team in rural Tanzania? Hundreds of men and boys eager to lower their chances of contracting HIV and want to learn road safety tips all in one place.

It happened this year as part of a drive to offer voluntary medical male circumcision to men and boys in hard-to-reach areas. IntraHealth worked with the union of Kahama’s motorcycle taxi drivers to gather hundreds of community members together to offer the service, which lowers a man’s risk of contracting HIV through heterosexual intercourse by 60 percent.

Everyone had a great time, especially when a popular Tanzanian comedian showed up and talked about his own circumcision. And hundreds of men and boys opted for the procedure during the event.

Global health needs more strange bedfellows — that is, innovative partnerships — like these if we’re going to end the HIV epidemic.

5. ARVs to treat and prevent.

It was 2011 when U.S. scientist Myron Cohen and his team at the University of North Carolina at Chapel Hill discovered that treating HIV-positive patients with antiretroviral therapy while their immune systems are still strong significantly lowers their risk of transmitting the virus. His study proved the concept of treatment as prevention.

Today, some 13.6 million people (of the total 35 million who live with HIV) have access to antiretroviral therapy. We’ve come a long way. But the final push will mean making sure as many people who live with HIV as possible are taking these medications to reduce their viral loads — and their chances of transmitting the virus.

It will also mean honing our overall approach. Think community-based testing campaigns, provider-initiated testing and counseling, and even self-testing. But countries need health workers and strong health systems to support these approaches.

The endgame

PEPFAR, the Global Fund and UNAIDS are all changing their programming priorities,” says Karen Blyth, director of East Africa programs at IntraHealth.

The new focus: key interventions that save lives.

“That’s because we know now that a generalized approach often doesn’t work,” Blyth explained. “In Uganda, for instance, new HIV infections are now rising, after dropping for 15 years. So from this point on, it’ll be about targeting the hotspots of the epidemic — reaching exactly the right people in the right places with the right treatment and services.”

The next 15 years are going to make global health history. They may mark the end of the most damaging epidemic in our lifetimes, during which countries around the world rallied together to face a unifying threat. Of course, these five approaches alone won’t be enough to bring this chapter to a close. But each one is vital to reaching our goal.

We’ve got just 15 years to make it happen. Let’s get to work.

[IntraHealth’s work in Tanzania is funded by the US Centers for Disease Control and Prevention (CDC) and in South Sudan by the CDC and the US Agency for International Development.]

Health Workers in Many Kenyan Clinics Brave Community Health Care Alone

By Melissa Wanda, Family Care International, Kenya

In a village in rural Kenya, a woman in labor travels miles along rutted dirt roads to get to the nearest health center. She wants to give herself and her baby the greatest possible chance of surviving childbirth and returning home to begin new and healthy lives. When she arrives however, the gates are locked; the nurse has gone home.

Kenya, with only 11.8 health workers per 10,000 people (more than 40% below WHO’s recommendation of 22.8 per 10,000), is one of 57 countries — including 36 in Sub-Saharan Africa — with a critical shortage of health workers.

Many local health facilities have only one health worker, often a nurse, to provide all patient care. This puts a heavy strain on the health worker, and means that many intended 24-hour health facilities are often closed for extended periods of time. Kenya’s news media has also reported recent health worker strikes in reaction to late or non-payment of wages.

Kenyan health workers share frustrations and challenges of working at understaffed health centers. Photo courtesy Family Care International.

Kenyan health workers share frustrations and challenges of working at understaffed health centers. Photo courtesy Family Care International.

The Government of Kenya has committed to strengthening human resources for health in the public health system. Several civil society organizations (CSOs) working to improve reproductive, maternal, newborn, and child health (RMNCH) have come together to advocate for the fulfillment of this urgently important promise. This alliance, co-led by Family Care International (FCI) and the African Women’s Development and Communication Network (FEMNET) under FCI’s Mobilizing Advocates from Civil Society (MACS) project, is conducting advocacy at the county level in Kenya, since counties are responsible for making many health spending decisions in Kenya’s recently decentralized administrative structure and health system.

With support from the MACS project, Deutsche Stiftung Weltbevoelkerung (DSW), a member of the advocacy alliance in Kenya, has surveyed community perceptions of the need for more health workers, and explored how effectively county governments have invested in addressing those needs. Working in two urban and two rural counties, DSW conducted research at various levels of the health system, including outpatient dispensaries, health centers, and hospitals. DSW found that counties are not budgeting or investing spending adequately enough to ensure that facilities have enough health workers to provide high-quality services. Although special funding has been set aside nationally to hire new health workers, counties have mainly been spending this money to pay current staff. DSW is sharing these findings with MACS and county health authorities, leading to one county already committing to hire an additional 72 nurses.

DSW also brought together community members and health facility staff to discuss the state of care at local health facilities. Community members complained that lack of staff meant an absence of essential services, especially at night and on weekends. Health workers expressed the frustrations of working alone, often lacking the drugs and supplies they need to treat their patients, and the low morale that comes from working under those conditions. For example, one nurse described a recent evening when she was the lone nurse caring for six women in labor!

These community meetings opened new channels of communication, fostering greater understanding and accountability between health workers and the communities they serve. This enabled health system users and health workers to join together in search of practical solutions.

Peter Ngure, DSW’s project lead, shared with me a story about one community in which participants said they prefer to come to the hospital — a long distance from their homes —in the afternoon, so they have time in the morning to travel there. In response, the hospital rearranged staff work schedules, deploying more nurses in the afternoon than morning hours. Similarly, community members learned that the hospital holds Monday afternoon staff meetings, helping to explain why appointments are often unavailable at that time, which had been a repeated source of frustration and confusion.

“This dialogue between community members and health workers helped to build much-needed goodwill during these very challenging times,” said Mr. Ngure.

FCI, DSW and the members of the civil society advocacy alliance will use these findings and experiences to hold county governments accountable for addressing the health worker shortage. When the Kenyan Ministry of Health releases its upcoming human resources for health strategy, which will provide specific guidance on exactly how many health workers should be assigned to each health facility, alliance members will work to make sure that counties follow that national policy, so that every Kenyan mother, seeking care for herself and her baby, will be greeted by open gates and a health worker with the skills and resources to ensure their survival and good health.

Chiapas Health Workers Improve Maternal Health with mHealth

By Julia Nakad, Hesperian Health Guides

Rural Chiapas might appear to be an unlikely place for mHealth initiatives to gain traction – with one person in four unable to read, and little cell phone reception or internet connectivity in the mountains, it would seem that accessing understandable information through mobile technology would be a challenge for health workers and patients alike. Yet the community health workers of Compañeros en Salud (CES) have found unexpected ways to make innovations in mobile health technologies work for them and strengthen their programs.

CES, a sister branch of Partners in Health, started training frontline health workers in 2012, who in turn began outreach initiatives to treat patients who previously had to travel long distances and pay exorbitant prices to receive care. In the two years since the project’s start, CES has managed to provide affordable care to tens of thousands of patients. This reach is in some part due to their incorporation of mHealth apps (which function offline once downloaded) to better manage their patient information, minimizing the “time consuming and error prone process” of using and maintaining paper health records. Within just one year, the team was able to use this technology to collect health information from over 5,000 patients.

A CES health worker field tests the app with a patient. Courtesy Hesparian Health Guides.

A CES health worker field tests the app with a patient. Courtesy Hesparian Health Guides.

More recently, CES staff realized they could use these tablets for more than just data collection and efficient record keeping; they could also use them as tools to educate health workers and their patients. Mobile apps could also be used to train health workers and help them to build new skills such as identifying symptoms and responding to emergencies. Frontline health workers could also use educational images and messages with patients to help explain a condition or help a patient to describe their symptoms.

To explore this idea, CES performed a field-test using the Safe Pregnancy and Birth App, a mobile application developed by Hesperian Health Guides in 2011 to provide life-saving information about pre- and post-natal care. The field test was conducted by community health workers, midwives, and clinic staff, who used the app during checkups with patients. Health workers then provided feedback and recommendations about the app.

The field-test in Chiapas provided a great deal of useful and constructive feedback for Hesperian for future updates and development of additional apps. CES partners commented that they “plan on continuing to use the app in pre-natal monitoring, especially with health workers and prospective parents. In particular, field testers most appreciated the helpful sections about “Staying Healthy During Pregnancy,” a “How-To” section for health workers, and information about “Signs of Shock,” as well as the clear illustrations.

A screenshot from the “How-To” section of the app. Courtesy Hesparian Health Guides.

A screenshot from the “How-To” section of the app. Courtesy Hesparian Health Guides.

They also included helpful suggestions for making the content even more accessible to those with fewer literacy skills, and advice on how to improve the app so that it helps health workers and patients to develop an emergency plan. This feedback will help us refine the design and content of this and future apps. In general, CES field testers found that “it is anexcellent teaching and learning tool that will undoubtedly be a benefit to many people around the world by empowering them with useful and practical information for caring for a pregnant woman and her baby before, during, and after delivery.”

The app may serve an especially important role in Chiapas, where women die in childbirth 70% more often than the national average, with survival rates that are three times lower for indigenous women. According to CES, the leading causes of maternal death include postpartum hemorrhage, preeclampsia, and puerperal infections.

The app is downloadable from iTunes or Google Play, and functions offline once downloaded. Courtesy Hesparian Health Guides.

The app is downloadable from iTunes or Google Play, and functions offline once downloaded. Courtesy Hesparian Health Guides.

The app, which has been downloaded more than 193,000 times since its launch in September 2011, was recently selected by the mHIFA working group as one of the top seven mHealth pregnancy apps from a pool of nearly 1,600 apps reviewed. The mHIFA Working Group is part of Healthcare Information for All by 2015 (HIFA2015) , an online community committed to a world “where people are no longer dying for lack of healthcare knowledge.” They sought to identify the mHealth projects that empowered people with actionable lifesaving information on the topics of child health, maternal health, and first aid. Additionally, they were looking for projects that easily could be used in resource-poor areas, and found that the Safe Pregnancy and Birth app fit this criteria as most capable of providing “actionable health information directly to parents, families, and children.”

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.

For more information, please visit www.siapsprogram.org.

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

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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

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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

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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

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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, vblaser@intrahealth.org 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
Soucko

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.