By Inka Weissbecker, Global Mental Health and Psychosocial Advisor, International Medical Corps

Two years ago, Majeed*, a Somali refugee living in the Ethiopian refugee camp in which International Medical Corps works, began acting inexplicably different. Majeed would become startled for no apparent reason, act suspicious of his parents, and shout and talk incoherently. He also ran away from the refugee camp and, when his family and neighbors found him, became violent. Majeed’s father ended up putting chains on him to keep him from running away or harming himself. But then International Medical Corps reached Majeed with mental health services.

Majeed suffers from chronic psychosis. Most people like Majeed do not have access to mental health care to manage their symptoms, which prevents them from living and fully functioning in their communities. There is a vast shortage of mental health professionals and services in low- and middle-income countries. According to the World Health Organization (WHO), low-income countries have 0.05 psychiatrists and 0.16 psychiatric nurses per 100,000 people— 200 times less than in the rates in high-income countries (WHO, 2005). An estimated 76%–85% of people with mental health problems in less-developed countries received no treatment in the last year (WHO, 2012).

In humanitarian emergencies, the percentage of people with a severe mental disorder, such as psychotic disorders, increases by 1%, while mild or moderate mental disorders such as post-traumatic stress disorder or depression might increase by 5%–10% (WHO, 2005). People with mental disorders are especially vulnerable to stigma, discrimination, violence and abuse. They and their families often seek traditional healers and religious leaders for help first and are not often aware that other effective treatments exist.

With funding from the U.S. Bureau of Population, Refugees and Migration (BPRM), International Medical Corps is implementing a project to integrate treatment for WHO and national priority mental health and neurological conditions in Ethiopian Administration for Refugee and Returnee Affairs health clinics in the Dolo Ado refugee complex in Ethiopia. Photo courtesy International Medical Corps

Mental disorders account for more of the world’s disease burden in terms of disability-adjusted life years than HIV/AIDS, tuberculosis and malaria combined (WHO, 2008). Mental health problems cause significant suffering, decrease people’s ability to complete daily tasks, engage in livelihood activities and employment, take part in educational opportunities and build supportive relationships with others.

In order to close the gap between the number of people who need mental health care and those who receive it, we cannot rely only on mental health specialist. Therefore, WHO recommends the integration of mental health into general health care. The WHO published the Mental Health Gap Intervention Guide in 2010 to support the training of general health care providers in identifying and managing priority mental health and neurological conditions that are most prevalent or cause a high degree of impairment—such as depression, psychotic disorders, substance use, epilepsy, unexplained somatic complaints and developmental disorders in children. Several low- and middle-income countries have already made mental health and primary health care integration part of their national policies and plans, often with WHO support and/or international NGOs as implementing partners. Those countries include Brazil, Nepal, Ethiopia, Afghanistan, South Sudan, Somalia, Libya, the occupied Palestinian territories and Jordan, among others.

Frontline health workers play a critical role in scaling up access to mental health care. Community health workers can identify people in need and facilitate access to health facilities, as well as help with follow-up care. Research demonstrates that community health workers can be trained to treat some common mental disorders, such as depression (Rahman et al, 2008). An increased number of trained doctors and mid-level staff are needed to address mental health conditions at the health facility level, including pharmacological treatment and management of unexplained somatic complaints, which are common in primary health care settings and can be stress-related.

Today, Majeed is recovering because mental health services are being integrated into general clinic health facilities in the Somali camp where he lives. A few months ago, Majeed’s father proudly held up the chains he had previously used, telling other community members that mental health problems can be treated. Scaling up access to appropriate care for people with severe or chronic mental illness and common mental disorders like depression is possible. Frontline Health Workers play the most critical role in making those efforts succeed.

*Names and identifying information changed to protect privacy

References

Rahman A, Mali A, Roberts C, et al (2008): Cognitive behavior therapy–based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomized controlled trial. Lancet 372:902– 909, 2008.
World Health Organization (2004). The global burden of disease: 2004 update. Available at: http://www.who.int/healthinfo/global_burden_disease/en/index.html
World Health Organization. (2008). Scaling up care for mental, neurological and substance use disorders. Mental Health Gap Action Program. Geneva, Switzerland.
World Health Organization & United Nations High Commissioner for Refugees (2012). Assessing Mental Health and Psychosocial Needs and Resources: Toolkit for Major Humanitarian Settings. Geneva: WHO, 2012.

By Sonia Lowman, International Medical Corps

In a country where one in three children is malnourished, Aminta Shamit Koroma helps lead the fight against hunger as Sierra Leone’s national nutrition program manager. To do this, she depends on frontline health workers at the community level to make sure that nutrition services reach those who need them most.

Lead mothers in International Medical Corps’ nutrition care groups demonstrate proper handwashing, a health intervention critical to the success of USAID’s Sustainable Nutrition and Agriculture Program. Photo courtesy International Medical Corps

Growing up in Freetown, Aminata saw hungry kids around her neighborhood every day and then, like now, she would take them home to feed them. She always wanted to go into medicine, but says her hands were too unsteady for dissection. It was while attending university that she realized being a nutritionist would allow her to take care of sick people without having to pick up a scalpel. So she went to graduate school in London to study nutrition before returning to Sierra Leone to take a position with the Ministry of Health.

Then a war of extreme brutality broke out. The lucky ones fled, albeit with nothing. Aminata was among them. She ended up in Maryland, where she worked for nearly a decade while waiting (and waiting) for the fighting to stop and peace to hold. All the while, she thought of home and how she would make it back one day.

In 2007, Aminata was finally able to return to Sierra Leone and in 2009, she started working for the government again as its national nutrition program manager. That same year, Sierra Leone was ranked among the five countries with the highest global hunger index score by the International Food Policy Research Institute. Roughly 70 percent of Sierra Leone’s population lives in poverty and one-third of the country’s children under age 5 suffer from chronic malnutrition (ACDI/ VOCA).

When Aminata was hired, only four districts had nutritionists. Today, thanks to her aggressive recruitment efforts and persistent advocacy, all 13 of Sierra Leone’s districts have at least one nutritionist. There are four national Officers for the Community Management of Acute Malnutrition (CMAM), Infant and Young Child Feeding (IYCF), and nutrition surveillance, as well as four clinical nutritionists at the hospital level. To implement national policies at the community level, non-governmental organizations like International Medical Corps help manage Sierra Leone’s IYCF and CMAM programs with the help of dedicated frontline health workers hired directly from the communities in which they work.

For example, International Medical Corps helps implement USAID’s Sustainable Nutrition and Agriculture Program, which integrates five cross-cutting themes into nutrition interventions: resiliency to shocks, productive youth, gender equity, environmental stewardship and good governance.

Aminata and the frontline health workers implementing nutrition programs in Sierra Leone have dramatically increased nutritional coverage across the country and are reaching far more people than ever before. Says Aminata, “It is so rewarding to see malnourished children come in and get better,” and it will be “that much more rewarding when the malnutrition rates go down.”
Although malnutrition is a complex ailment easily exacerbated by medical complications, to Aminata, the appeal of being a nutritionist is that “you can see people get well right before your eyes.” She has watched countless children and women recover quickly with “just nutritious food and proper care.” And while it remains critical to address the myriad complexities of nutrition, it does not intrinsically make sense why some people get enough food and others do not. It should be simple; we should be able to get this right.

With people like Aminata and the frontline health workers of Sierra Leone at the helm, and the continued support of partners like USAID, we just might one day.

By Maryjane Lacoste, Country Director, Jhpiego-Tanzania

Wampembe, Tanzania—In this remote corner of western Tanzania, where the nearest hospital is four hours away on a rutted, rock-strewn dirt road, pregnant women are relying on midwives Adelina Kizzila and Flora Mwananjela to help them give birth safely and deliver healthy newborns. I visited the Wampembe Health Center, where these midwives work, and quickly discovered the precariousness of giving birth here.

Nurse Flora Mwananjela at Wampembe Health Center is providing emergency lifesaving care to pregnant women and newborns. Photo credit: Jhpiego

Not a single phone company provides service to this health center, and the truck that travels twice a week from the village to town takes much longer than the four-hour trip by jeep that I took. If a woman in labor has complications before 3:30 p.m,, the health center can radio for an ambulance. But it will take four hours for the ambulance to arrive, and another four hours for it to return to the district hospital on that same rutted road. In short, any woman with a complication during labor is basically out of luck.

A properly trained frontline health worker such as a midwife is the only hedge against death for an expectant mother. Ashura Baraka, a 25-year-old mother who gave birth to her fourth child at the Wampembe Health Center during the middle of the night, knows this well.

After delivering her daughter at the center, the new mother received a shot of oxytocin. Soon after, however, nurse-midwife Kizzila discovered that Baraka had a retained placenta and began to bleed. Kizzila shouted for help. Mwananjela, the facility nurse midwife in-charge, came to Kizzila’s aid, guiding her step-by-step to manually remove the placenta and give the mother an additional oxytocin injection, thus stopping the postpartum hemorrhage.

Thankfully, both of the midwives on call that night had been trained in basic emergency obstetric and newborn care (BEmONC) under the Mothers and Infants, Safe, Healthy and Alive (MAISHA) Program, funded by USAID and implemented by Jhpiego and partners. As a result, Ashura went home healthy with her new baby girl, Upendo, in her arms.

My visit to Wampembe underscored for me the vital role frontline health workers play in keeping women in remote areas alive and healthy. In the days leading up to Mother’s Day, a day where families around the world celebrate and give thanks for the love and guidance only a mother can provide, we must also remember the hundreds of thousands of pregnant women in underserved communities who do not have access to lifesaving care. Unfortunately, because of the shortage of frontline health workers like Adelina and Flora, not every child will be able to celebrate this Mother’s Day. By increasing the number of frontline health workers we can help to save the lives of countless mothers and newborns.

Ashura Baraka, 25, with her new baby girl, Upendo. Photo credit: Jhpiego

By Kiran Ramchandani, White Ribbon Alliance for Safe Motherhood

Midwives save lives. Yet, two-thirds of women in the poorest, least developed countries give birth without a skilled birth attendant. Only when we have enough skilled midwives will we stop the needless deaths in childbirth of girls and women across Africa and Asia.

The midwife has an important role to play, not just in ensuring a safe birth but also after the birth to support the mother in looking after her new baby, and advising on birth spacing and family planning.

But in order for midwives to offer that much needed support to women and to deliver high quality care, they themselves need the right support and training. Tales of the poor treatment and neglect of women in health facilities are all too common. They are often linked to low staff morale, inadequate staffing levels and lack of training. This means that even when care is available, the quality can be so poor that women receive little benefit. It also prevents women from seeking help when they really need it.

To raise awareness of the issue, White Ribbon Alliance Tanzania convened a group of midwives to make a film to highlight their working conditions; ‘What I Want is Simple’.

This short film features midwives such as Christine James Mwandalima, who asks, “Is it too much to ask to have a clean toilet that actually works, or a salary that allows me to feed my family?”

White Ribbon Alliance is pushing for respectful maternity care to be recognised as a human right worldwide. And it is midwives themselves who are at the forefront of this rapidly growing campaign, as the most powerful agents of the change they seek.

By Mandy Folse, Director, Frontline Health Workers Coalition

Note: This post originally appeared in the ONE Campaign Blog

Almost every week on this blog, someone from our 30 member organizations tells another story illustrating the inspiring and tremendous impact frontline health workers are making in saving and improving lives around the world. What might not be as well known is that, according to USAID, 0.0000087% of the U.S. budget in 2011 went to global health programs, including programs that help thousands of frontline health workers save millions of lives.

Several surveys of the American public have shown that many people think these investments in global health and development comprise at least 10% of the budget. When it’s pointed out that global health funding comprises far less than a penny per taxpayer dollar, the already strong support for these programs grows substantially. The power of this support from the American people has resulted in leadership from Democratic and Republican presidents and bipartisan support in Congress of robust global health investments.

Courtesy IntraHealth International

This tradition of strong bipartisan support for improving global health continued this past month with President Barack Obama’s release of his fiscal year 2014 budget request.

According the Kaiser Family Foundation, President Obama requested $8.3 billion in FY 2014 for global health programs under USAID and the State Department. This amount would be more than $260 million (or 3.2%) more than was enacted for FY 2012, or $142.3 million (or 1.7%) more than the estimated allocation for FY 2013.

Investments specific to the training and support of frontline health workers are made within  programs to improve maternal and child health, improve nutrition, increase access to family planning, and prevent and treat diseases such as HIV/AIDS, tuberculosis, malaria and pandemic influenza. Because these investments are so widespread between different government agencies and within different programs of government, it is imperative that in order to get the most bang for our buck, the U.S. government have a strategy on how its programs will address the frontline health workforce crisis.

Members of the U.S. Congress and those within U.S. government agencies are taking notice of a need for such a strategy. U.S. Reps. Nita Lowey (D-NY) and Ander Crenshaw (R-FL) recently introduced a resolution calling for government agencies “to develop a coordinated and comprehensive health workforce strengthening strategy with concrete targets for increasing equitable access to qualified health workers in developing countries, particularly in underserved areas, with a strategic focus on frontline health workers.” The U.S. Agency for International Development (USAID), meanwhile, has created the new Office of Health Systems. Staff members in the office are working with their counterparts across the U.S. government on a results framework focused on strategies to strengthen health systems, including improving support for frontline health workers.

The Frontline Health Workers Coalition will continue to work with the U.S. government to get the maximum benefit of America’s global health investments by ensuring that the frontline workers needed to deliver health care in the developing world are well trained and supported.

Lisa Meadowcroft, Executive Director, AMREF USA

Midwife Esther Madudu receives the REAL Award from Ugandan Minister for Health, Hon Dr Christine Ondoa (left) and AMREF Uganda Country Director, Dr Abenet Berhanu (right). Photo Credit: AMREF

At AMREF, we were thrilled and so proud to learn last year that one of the thousands of health workers we train or whose skills we upgrade through our eLearning, mHealth or onsite programs, was selected to receive one of the first, global REAL Awards for the work they do as a REAL person on the frontlines of health care.

We were over the moon last week though when we witnessed the great joy and celebration of the REAL Awards presentation to Esther Madudu, an AMREF-trained midwife in Katine, rural Uganda, to celebrate and honor the lifesaving work she performs every day. We were especially moved to see the recognition and importance accorded to all frontline health workers through the participation of the Ugandan Minister for Health herself at this joyous event.

Esther works in a remote, poorly equipped health center, often under harsh conditions. Without electricity, Esther has been known at times to hold her cell phone in her mouth to light up night time deliveries. Esther and her one midwife colleague are among the few skilled and trained professionals able to deliver babies and look after moms who come not only from the immediate area, but often walk for miles from surrounding villages.

This past week though, Esther’s health center was a place of joyous celebration and support for frontline health workers. The event was a full-blown celebration not only of Esther and her lifesaving work, but also of her colleagues at the health center, family members and the many levels of government (national, regional and district) with which AMREF partners to ensure health services reach those in need in remote communities throughout Uganda.

The Ugandan Minister of Health herself, the Hon. Dr. Christine Ondoa, presented Esther with her REAL Award which was presided over by Uganda’s Deputy Minister for Health and AMREF’s country director in Uganda, Dr. Abenet Berhanu, along with the deputy country director, Dr. Susan Wandera.

“(Esther’s award) is a signal that health workers in Uganda should know that we do recognize their excellent work,” Dr. Ondoa said during the ceremony. Esther herself was just thrilled and can be seen in the television coverage dancing with her colleagues while holding her REAL Award high in the air. “The REAL Award has finally been delivered to me at my work place so I’m really glad,” she said with a big smile. Esther also expressed gratitude to her colleagues and more so to her mother for the support she has given Esther enabling her to carry out her work efficiently.

Overall it was a terrific day with entertainment provided by the local Village Health Team members who are beneficiaries of AMREF’s Katine Community Project. The event was comprehensively covered by NTV Uganda, a popular national TV station, along with other local media.

The REAL Awards celebration in Uganda last week was just that – a lot of dancing, refreshments and overall jubilation to pause and take a moment to honor and celebrate frontline health workers everywhere whose dedication and commitment to their work is literally lifesaving.

Photo Credit: AMREF

By Pape Gaye, IntraHealth International and Louise Holly, Save the Children UK

Note: This blog was originally posted on the Impatient Optimists blog

Last week with the Capitol Dome in Washington, DC, looming in the background, seven health workers from across the United States—from a hospice worker in Flippin, Arkansas, to a chronic disease care doctor in Bucks County, Pennsylvania—became forever linked to a midwife in Uganda, a community health worker in India and eight other inspiring health workers from around the world. We hope that they will look back at this connection, forged as the first recipients of the REAL Awards, and say it helped launch a movement to solve one of the largest hurdles to progress in global health: the huge shortage of trained and supported frontline health workers.

The REAL Awards were given to frontline health workers in the US and around the world providing care under extraordinary circumstances. These women and men are saving lives and building stronger, healthier communities every day. The REAL Awards celebration was the culmination of the first-ever World Health Worker Week—a worldwide effort to support, appreciate, and raise awareness of the vital role of health workers everywhere. Communities, partners, and policymakers around the world mobilized to support the frontline health workers in their communities, as well as called attention to the challenges they face every day.

We also called attention to the sobering facts documented by the World Health Organization: more than 1 billion people have little or no access to essential services, and more than 4 million new health workers, including at least 1 million additional frontline health workers in developing countries, are currently needed to address health care needs. Not addressing this crisis would perpetuate a reality none of us want to see – 48 million women a year giving birth without a skilled health worker present, and millions dying or becoming disabled because of lack of access to basic services.

So while World Health Worker Week and the REAL Awards were nice ways for us to show our gratitude for the health workers that currently save millions of lives, we hope that events like these become a catalyst for the advocacy needed to get the support and co-workers they need to reach everyone. Our organizations—IntraHealth International and Save the Children—are proud to be helping to lead several partnerships that aim to enact this change, including the Frontline Health Workers Coalition in the US and the global Health Workforce Advocacy Initiative.

We’re starting to see effect of this advocacy, from members of the US Congress hearing from the REAL Award winners last week about the need for a US government strategy that focuses on frontline health workers in developing countries, to Ugandan civil society successfully advocating to its Parliament last year for about $20 million to fill critical health posts.

But, as global leaders prepare to gather in Brazil this November for the Third Global Forum on Human Resources for Health, we realize that much more needs to be done, especially on the frontlines of care. During the forum, advocates around the world will be pressing for leaders to take concrete steps to address the frontline health workforce crisis as a key part of efforts to achieve universal health coverage.

Without more workers like those we honored last week, there will be no one to deliver the essential health care needed to keep families alive and thriving.

By Mary Beth Powers, Save the Children

Note: This blog was originally posted on the Impatient Optimists blog

Yetagesu Alema, a frontline health worker, is standing in front of the Germana Gale Health Post in Ethiopia. Photo courtesy: Save the Children

As we drove down a dusty road in Northern Ethiopia en route to our celebration for Tirhas, the REAL Award winner from Ethiopia, I was expecting a decent turnout for this dedicated health extension worker, perhaps her family members and a few close friends. I was floored by the reality: throngs of people lining both sides of the street as we approached the hotel, holding up signs with Tirhas’ photo on them, cheering as though we were part of the President’s inaugural parade.

This type of fanfare is what I had hoped to see for every health worker as we conceptualized the REAL Awards, but admittedly, I was doubtful that it would actually come to pass. Health workers, after all, are often unsung heroes, performing their lifesaving work with dedication, but also humility.

The REAL Awards was our way to help shift that paradigm. We wanted to create an awards platform that celebrated the work of these countless men and women, in the same vein as the myriad award shows we have for athletes, actors and musicians. Of course, I shouldn’t have been surprised that, upon selecting our first-year winners, a common response I heard was: “While I’m incredibly honored, I don’t really know why I was chosen; for me, I was just doing my job.”

The spotlight is not in most health workers’ comfort zone. But we wanted to give them a chance, if only for one day, to feel like celebrities. That’s why we flew our US winners to Washington, DC to recognize them for the incredible work they do day in and out. Well, most of them anyway. Dr. Joseph Tate, an Atlanta-based obstetrician and our winner in the newborn and mother care category, respectfully declined our offer to come because he didn’t want to be away from his patients for that long. Did I mention health workers were dedicated?

So in the end, eight out of our nine US winners came. Besides attending a reception in their honor, they also got the chance to meet their Member of Congress, get their picture taken on the steps of the Capitol Building, and, most importantly, advocate on behalf of their health worker peers. But it will take more than a few congressional meetings to get health workers around the world the support they need to continue saving lives. One way you can help is by signing this resolution, introduced by Reps. Nita Lowey (D-NY) and Ander Crenshaw (R-FL), which calls for American leadership to continue to build a capable health workforce.

And while we weren’t able to give all 60 million health workers in the world a REAL Award, I do hope you take the time to thank the health workers in your life. They may not be among our honorees this year, but they still deserve our appreciation.

By Joan Holloway and Imane Sidibe, International Association of Providers of AIDS Care

In this first ever World Health Worker Week, it is important to recognize the critical role frontline health worker are playing in responding to the HIV/AIDS epidemic globally.

According to UNAIDS, an estimated 34.2 million people worldwide were living with HIV at the end of 2011. More people than ever are receiving antiretroviral therapy (ART) as treatment coverage continues to expand. More than 8 million people in low- and middle-income countries were receiving treatment in 2011—1.4 million more than in 2010. At the same time, it is estimated that more than 7 million people in these countries who are clinically eligible for ART are not receiving it.[1]

Expanding access to ART is more than simply delivering drugs. It requires an innovative approach to service delivery, an approach that emphasizes the importance of prevention, retention in care, and adherence to medications. This in turn requires a departure from traditional health care models that depend on specialized professionals in highly concentrated settings. There is a need for HRH solutions that can provide high-quality services at low cost.

These solutions should improve the efficiency and effectiveness of the existing workforce while providing a sustainable approach to improving the quality of and achieving efficiencies in the care delivery. An emerging response that has the potential to meet these criteria is a multidisciplinary care team approach.

Multidisciplinary care teams are partnerships between health care professionals and other cadres of the health workforce, including community health workers, toward a common purpose—improving the quality of and achieving efficiencies in the delivery of health care.

In 2012, the International Association of Providers of AIDS Care (IAPAC), with funding from the OPEC Fund for International Development, began the implementation of a multidisciplinary care team approach to providing HIV care. A multidisciplinary care team approach, in this context, is defined as involving the rational redistribution of task among all members of the health care team. It is a comprehensive approach of which task shifting is a component.

In partnership with Jimma University and the HIV/AIDS Prevention and Control Office of Ethiopia, we began data collection in five clinical sites in Jimma, Ethiopia. The Agaro Health Centre in Jimma was identified as the health centre most in need of an HRH intervention. The information from the date gathered at the site is being used to guide the development and implementation of the multidisciplinary care team approach. Agaro serves about 25,000 people annually and is linked to a health post staffed by a health extension worker. The number of health workers at Agaro is nowhere the number needed to meet the service needs of the population served. A physician is not on site and is available only by referral to one of two specialty hospitals.

Photo courtesy of IAPAC

Implementation of the multidisciplinary care team approach also will involve the introduction of an electronic health information system to link the three components of the delivery system – the health center, the hospital, and the health post. A health literacy and quality of life assessment of the population living with HIV served by the center is due to begin in the next few months, just prior to the introduction of the team approach. One year following implementation, data will again be collected to assess the efficiencies in the provision of HIV/AIDS services including:
• HIV testing and linkage to care opportunities;
• Expanded access to ART for clinically eligible adults and children;
• Expanded prevention of mother-to-child transmission (PMTCT) services; and
• Access to treatment as prevention for serodiscordant couples.

The multidisciplinary care team approach also aims to achieve:
• Improved individual, community, and population treatment outcomes;
• More rational use of existing health workers including health extension and community health workers; and
• Increased job satisfaction and opportunities for clinical leadership for all members of the health care team.

An essential feature of the team approach to HIV/AIDS care is that all members of the care team are involved in making HIV an important entry point to other priority health services, such as maternal and child health, treatment adherence and retention in care and treatment for related co-morbid conditions such as tuberculosis and malaria.

[1] Together we will end AIDS. Joint United Nations Programme on HIV/AIDS;2012

Note: This was originally posted on Management Sciences for Health’s (MSH) blog.

World Health Worker Week is April 8-12, 2013. Let’s show the world just how much #HealthWorkersCount. Watch and share the video, thank a health worker, and donate $10 in honor of a health worker.

“We realized that educating the community was something we had to focus on,” says Madina, a trained Afghan midwife, as she describes involving elders and religious leaders in helping to improve access to family planning and perinatal care for women in Khost province, including one woman who came to the health facility suffering complications from a home birth.

Watch video.

Health workers save lives. What will you do to thank a health worker?