Placing their lives on the line to quell an Ebola outbreak

By Kelly Willis, Accordia Global Health Foundation

Outbreaks of the dreaded Ebola virus in the Africa’s Great Lakes region have claimed hundreds of lives in the last 20 years, but thanks to the courageous efforts of United States government-supported frontline health workers like Brenda Picho, an outbreak in Uganda’s Kibaale District in July was quickly contained.

Ebola hemorrhagic fever is a highly contagious disease that causes severe fever, muscle pain, vomiting, diarrhea and bleeding; the disease kills more than half of those infected. There is no vaccine and no known treatment. A rapid and coordinated response is essential in containing these outbreaks – and the outcome is largely determined by actions of the “first responders.”

Among the first responders in Uganda were the frontline health workers of Accordia’s flagship institution based in Kampala—the Infectious Diseases Institute (IDI), Makerere University. IDI staff has been working hand in hand with rural health professionals in Kibaale for years, building their confidence through training and mentorship opportunities, as well as strengthening existing clinical and laboratory systems.

Field staff at the Infectious Diseases Institute (IDI), Makerere University, hand out protective clothing to frontline health workers in Uganda’s Kibaale District during an Ebola outbreak in the area in July 2012. Courtesy: IDI

Upon discovering the outbreak, IDI staff immediately began working with local health leaders to organize efforts to contain the disease and protect those most vulnerable to exposure. In no time, emergency supplies had been procured, including protective clothing for frontline health workers most at risk. Prevention measures were demonstrated and isolation facilities were established. IDI staff led efforts to maintain safety standards, provided meals to the hospitalized and quarantined, maintained morale among other health workers, and minimized panic in the community.

At the center of IDI’s efforts was Brenda Picho. A pharmacist by training, Brenda works in Kibaale as part of the U.S. Centers for Disease Control and Prevention (CDC)-supported Saving Mothers, Giving Life project. Her efforts in the community had been focused on reducing maternal mortality by helping mothers during labor, delivery and responding to postpartum complications.

Brenda had heard of a pregnant woman in the community who had died in one of the health facilities and whose family kept getting sick and not responding to treatment. When the clinical officer who provided the family’s care fell ill, Brenda said she became “very alert and concerned.” When the cases were confirmed as Ebola, Brenda said she was “speechless,” adding, “I did not want to believe what I was hearing.”

Her natural fear of this dangerous disease did not stop her and other health workers from putting their own lives on the line to protect the health and wellbeing of others. Brenda’s actions and those of her colleagues are a telling example of how frontline health workers benefit the communities in which they live and work, and ultimately play one of the most essential roles in emergency response.

The U.S. government has a tremendous opportunity to highlight its support of inspiring health workers like Brenda, as well as strategically invest in supporting frontline health workers in the countries with the greatest need.

To read more about Brenda’s personal account of the Ebola outbreak Kibaale and to learn more about how IDI combines expertise in training, clinical care, prevention services, and research to provide fast, effective and comprehensive responses to health emergencies like this, please visit Accordia Global Health Foundation’s website http://www.accordiafoundation.org.

Uganda Increases Number of Health Workers

By: Meredith L. Ritchie, White Ribbon Alliance

Photo courtesy of the White Ribbon Alliance Uganda

Uganda deserves praise! The government recently committed to recruiting more than 1,014 midwives; 1,436 nurses; 758 nursing officers; 223 medical doctors; 283 anesthetists; 1,101 clinical officers; and 1,360 laboratory technicians for the fiscal year of 2012-13, according to the White Ribbon Alliance of Uganda.

The lifetime risk of death for a pregnant woman in Uganda is 1 in 35, according to the 2011 UDHS report. Additionally, Uganda’s 2012 Human Resources for Health Bi-Annual Report found that the proportion of approved positions filled by health workers at all levels nationally was only 58%, with some district hospitals having as low as only 16% filled posts. The report also found that health workers were poorly motivated and faced unsatisfactory working conditions. The Ugandan government also committed to raising health workers’ salaries from approximately $480 a month to $1,000 month in January 2013, in order to attract more workers to the rural, hard-to-serve areas of the country. This will hopefully relieve the alarming statistic found by a 2008 World Bank study: 80% of public sector medical workers in Uganda work in urban areas, where only 20% of the population lives.

Frontline health workers are often the first point of maternal services for Ugandan women, and they are essential for the management of safe pregnancies. Midwives, nurses and doctors are vital for progress on maternal and child survival. Ensuring that a health worker is within reach, and is trained, equipped and supported, is crucial to the achievement of Millennium Development Goals 4 and 5. During labor, complications cannot always be predicted and may rapidly become life-threatening. Countries where most births are attended by a health professional with the skills to spot and manage complications generally have lower death rates for mothers.

If this commitment from Uganda is fully met, the country’s health sector budget will increase from 7% to about 8% of the national budget. This map and graphic illustrates the critical need for skilled birth attendants across the world, and emphasizes the importance of frontline health workers in saving lives.  

Moving forward, the White Ribbon Alliance of Uganda and Coalition to End Maternal Mortality members will convene a reflection meeting to focus on monitoring and accountability mechanisms for these new health funds.

Sustaining the Impact of Community Health Workers: Evidence from Health System Assessments

By: By Avril Ogrodnick, Abt Associates

Photo Credit: John Palen

Countries seeking to expand health services to the community-level to ensure equity of access to care frequently turn to community health workers (CHW) as an essential expansion of the health team.  A variety of approaches to training, hiring and supporting community health workers have been implemented by countries, and there are many important lessons learned to be shared across countries.

Through the Health Systems 20/20 project, Abt Associates examined the approaches that countries are taking to expand services through training and deploying CHWs. Health Systems 20/20 completed 25 Health System Assessments, a rapid indicator-based methodology that determines the key strengths and weaknesses of a health system using a set of internationally recognized qualitative and quantitative indicators.  The assessments found that a variety of approaches to utilizing CHWs are implemented by countries, from fully public and salaried employees to volunteers, and to autonomous, private providers who sell health and other products to generate income.

For example, in Angola, the government has recently reintroduced the CHW cadre, which existed until the civil war disrupted the health system. An estimated 6,000 CHWs have been trained in several separate initiatives by different organizations. CHW are responsible for home visits and community education and have strengthened the link between communities and health facilities.

In Uganda, the Living Goods model, launched in 2007, combines microfinance with the CHW concept. Village women are selected and trained to educate their communities on health promotion, sell health protection products door-to-door for a profit, and refer people to health facilities. Their first basket of products is obtained on credit, and the NGO provides close monitoring and supervision.

CHWs have been providing health services at the household/community level in Lesotho since 1975. The CHW program was adopted as a national strategy for PHC in 1979 following Lesotho’s participation at the 1978 Alma Ata Conference. Until 2008, CHWs received no remuneration, and their only benefit was free medical care for themselves and their immediate family. In 2008, the government took a step towards institutionalizing the community-based health service by paying CHWs a small monthly salary.

Perhaps the strongest example of CHWs is in Ethiopia, with the introduction of Community Health Extension Workers (CHEWs) at the local level in Kebeles under the Health Extension Program. CHEWs operate at the community level and are fully paid by the government. There are now four CHEWs per 10,000 people and their impact is witnessed throughout the health system.  According to Mr. Bizayene, CEO of the referral Mekelle Hospital, maternal mortality is decreasing because of the CHEWs’ efforts; he has personally only seen one maternal mortality case the year the HSA was done.

Findings from the HSAs also informed the steps countries can take to ensure that CHW models are sustainable in the long term.  Countries should first develop clear policies that define the specific roles and responsibilities of CHWs within the health system.  CHWs also require sufficient funding, appropriate training to address the community’s burden of diseases, supervision from health professionals, and appropriate incentives.

The contribution CHWs make to the health system can be substantial.  Further analysis of the lessons learned by countries implementing a CHW model is important to increasing the impact of these vital frontline health workers.

Elements of a Successful Partnership

By: Susan O’Halloran MPH, Frontline Health Workers Coalition

Forming a successful partnership takes commitment, work and significant thought.  Partnerships can help provide more visibility to an issue using the various partner networks, bring the creative thinking of more people to the table on an issue, and share managerial, technical, communication, implementation  and financial tasks, to name a few examples.  Partnerships can also be frustrating and a time burden if certain critical pieces are missing.  Some of these critical elements are:

  • Commitment to a shared goal
  • Leadership so that all partners know what is expected of them and how they can contribute to the shared goal and feel their contributions are valued
  • Communication so partners have a way to be heard and can also hear from other partners
  • Progress toward the shared goal

A new public-private-partnership has formed in Uganda that has tremendous potential to strengthen human resources for health (HRH) in the country.  On June 28, 2012, representatives from the US government, Government of Uganda, global corporations, local Uganda companies, Ugandan private health associations and NGOs from the Frontline Health Workers Coalition gathered for the “Partnering to Strengthen Human Resources for Health in Uganda” meeting.  The purpose was to engage the private and public sectors, identify priority HRH issues and agree on collaborative actions aligned with the Government of Uganda’s Human Resources for Health (HRH) plan.

This might have been just another meeting with some good thought given to the HRH situation in Uganda.  What sets this meeting apart is the leadership exhibited at the last session of the day when participants volunteered to form a steering committee and identified a chair to carry the work forward.  The group is called Health Works Uganda and the partners all share a commitment to strengthen health capacity in Uganda at all levels.  They have two priorities over the next year.  The first is to set forth the Health Works Uganda partnership framework and begin to establish systems to keep the partnership functioning.  The second is a focus on one of the six priority HRH issues identified – Retention and Motivation of Health Workers, especially frontline health workers.  A workplan will be developed within the next two months with specific action steps outlined for the various partners.  This exercise will also allow partners to seek out areas for collaboration in order to cut down on duplication of effort.

This is a new partnership, but it already has members with shared commitment to the HRH issue in Uganda and leadership.  No doubt as the leadership takes the members through the workplan exercise, communication channels and progress benchmarks will be determined.  We wish Health Works Uganda much success in their efforts to strengthen human resources for health in Uganda with a public-private-partnership model.

Written by: Susan O’Halloran, MPH.  Susan is the Director of the Frontline Health Workers Coalition. The Frontline Health Workers Coalition is a dynamic and influential coalition of 25+ NGOs working together to urge greater and more strategic U.S. investment in frontline health workers in the developing world as the most cost-effective way to save lives and foster a healthier, safer and more prosperous world.

Frontline Health Workers Are Key to Meeting Family Planning Needs Worldwide

By: Oying Rimon, Bill & Melinda Gates Foundation

Credit: The Bill & Melinda Gates Foundation

Around the world, frontline health workers are often the first link to lifesaving care and supplies, and in some cases they are the only link for families and communities in rural and impoverished areas. This is also where most of the world’s unmet need for family planning resides. More than 200 million women in developing countries want to delay or avoid pregnancy but lack access to modern methods of contraception.

Family planning and frontline health workers: worth the investment

In just a few short weeks, the foundation, together with the UK government and other partners, will host the London Summit on Family Planning. It will be a groundbreaking global convening of developed and developing country government and civil society leaders, who will pledge to address the contraceptive needs of an additional 120 million women in the world’s poorest countries by 2020. The summit will also focus on tackling cultural barriers to contraception and encourage countries to adopt a rights-based approach, which enables women to decide whether, when, and how many children to have. At the foundation, we often talk about how frontline health workers and family planning are extremely cost-effective strategies to save lives, and improve health and development broadly. For instance, every three seconds a child’s life is saved thanks to the care provided by a frontline worker (PDF), who can be provided basic training for as little as $300 (U.S.). Likewise, investing in family planning services has a proven cost-benefit return for both developing and developed country governments, and addressing current unmet contraceptive need could prevent one in three maternal deaths and one in four infant deaths.

A personal connection

For me, frontline health workers are not just a smart investment, but also a community I feel personally committed to. Back in the 1970s, one of my first jobs was as manager of a national family planning program in my native country of the Philippines, which included more than 4,500 outreach workers and 50,000 community-based volunteers providing information and services to couples in their neighborhoods. I met with many of these highly committed community-based workers and saw first-hand how crucial a role they played for the country’s population, nearly half of which resides in urban slums.

In the Philippines, this first-string of health providers, mostly midwives and barangay (village) health workers, fills the gaps of an overwhelmed healthcare system and provides critical health. As of 2012, contraception use in the country, which is 80 percent Catholic, is just 34 percent. Yet current political leadership is committed to bringing family planning services closer to the people. Recently, I was on a personal visit there and was pleasantly surprised to see many of the same individuals I used to know, still working for their communities–although many now qualify for senior citizen discounts!

Progress is possible

In other parts of the world, frontline workers are already doing more to provide family planning services to the poor and marginalized. For example, in Uganda, recent policy changes allow community health workers to provide injectable contraceptives to women, and have resulted in significant improvements in contraceptive access countrywide (PDF).

Frontline workers have the ability to reach those most in-need. We know that progress is possible. Yet in order to see results, frontline workers need to be adequately trained, supported, and integrated into the broader health system, and they need consistent access to cost-effective family planning supplies. Imagine the impact if we worked to prioritize policies like task shifting and training that enable frontline workers to deliver family planning services to meet the needs of millions?

The London Summit on Family Planning will aim to galvanize new financial and political commitments to ensure this progress, and convene leaders to affirm that every woman in the world deserves the opportunity to determine her own future. With the right resources and policy support, I believe there are few limits to what frontline workers can do. Empowering them with family planning knowledge and supplies, which they can deliver to women worldwide, will have an immediate and far-reaching impact. Doing so will benefit not just women themselves, but families, communities, and entire nations.

Frontline Health Workers Are Key to Meeting Family Planning Needs Worldwide’ is also featured on the Bill and Melinda Gates Foundation blog “Impatient Optimists.” You can view the post here.

Written by: Oying Rimon, Bill & Melinda Gates Foundation. The Bill & Melinda Gates Foundation is a member of the Frontline Health Workers Coalition, a dynamic and influential coalition of 25+ NGOs working together to urge greater and more strategic U.S. investment in frontline health workers in the developing world as the most cost-effective way to save lives and foster a healthier, safer and more prosperous world.