At a recent conference, health delegates from 42 countries agreed to implement a new strategy that trains NPCs in emergency obstetric surgery to address the lack of health care workers. Along with other developing areas, most African countries are suffering from a significant lack of medical professionals. This shortage is particularly implicated in the high rates of maternal and infant deaths during childbirth. The WHO has estimated that in sub-Saharan Africa alone, there is a shortage of nearly 1.5 million health care workers; women there face a 1-in-13 risk of dying in childbirth. Most women are unable or unwilling to access medical facilities or workers, even during emergencies; for example, in Ethiopia, only 6% of all births occurred in a health facility.

By expanding the number of NPCs and training them in surgical childbirth procedures, it is hoped that more births will be attended by trained health care workers who can assist women during emergencies. A program in Mozambique that trains midwives in surgical techniques has already achieved significant results. The country is on the way toward meeting several of the UN’s Millennium Development Goals, particularly those surrounding maternal and newborn health.

In a similar low-tech program, USAID’s maternal health group ACCESS (Access to Clinical and Community Maternal, Neonatal, and Women’s Health Services) focuses on developing and extending home and community based interventions. A new report from ACCESS is a guide for carrying out “community mobilizations” to improve maternal and newborn health. The program focuses on identifying the specific obstacles of the community, and working with the population to implement realistic changes. For example, essential interventions like the use of misoprostol (which induces labor) can generally be provided safely by trained health care workers at the household and community level, and prevent almost 70% of infant deaths. Additionally, simple preparations, such as providing folic acid to the mother during pregnancy and preparing a clean space for the birth, can be done by community health workers trained in pregnancy and childbirth.

More information:

Video: Birth of a Surgeon (documentary of Mozambique’s midwife training program)

In War and Isolation, a Fighter for Afghan Women

Bold Solutions to Africa’s Health Worker Shortage

Malawi: Role of traditional birth attendants to change

Global Low-cost Health Initiatives

A June article in the New Yorker by Atul Gawande, which is reportedly required reading at the White House, examines the costs of health care by looking at the most and least expensive health-care markets in the US. In particular he studies McAllen, Texas, which has one of the highest costs of medical care per person in the country, and Rochester, Minnesota (home of the Mayo Clinic), which has among the lowest. Rochester also provides some of the best quality health care in the nation. Gawande’s findings led him to conclude that the Mayo Clinic system, which pays doctors an annual salary to keep them from treating their practices like “profit centers”, and emphasizes a peer-review process to improve quality of care, are the best hope for improving American health care. This requires breaking the “untenably fragmented, quantity-driven” systems that are becoming the norm in US medical care.

Gawande notes at the end of his piece that the decisions that need to be made about America’s health care system are greater than the public versus private insurance debate; rather, they involve a total reorganization of the health system. Enacting the principles already in place in the lowest-cost, highest-quality medical institutions in the country – removing any financial incentive for doctors to order unnecessary procedures and taking collective responsibility for patients – require a significant reordering of our priorities.

Others are also looking outside of the political discussions that focus on either “raising taxes or cutting care,” instead seeing a better way: “redesign.” Medical professionals from ten communities across the country with below average health spending and above average health outcomes recently traveled to Washington DC to discuss how changes they have implemented have lowered cost without reducing quality. Gawande, one of the meeting’s organizers, explained that change in these communities occurred quickly, as “[h]alf of these communities used to be high cost and transitioned to low cost over the last decade,” suggesting that national reform is also possible.

The meeting, organized by the Institute for Healthcare Improvement, allowed professionals from low-cost, high-quality hospital groups to exchange ideas about cutting costs and preventing unnecessary care. For example, physician groups in Everett, Washington were combined and two hospitals were merged while health coaches counseled healthcare workers to smooth admission and discharge practices. A health group in La Crosse, Wisconsin, has focused on working with elderly patients to create advanced directives, a crucial component of end-of-life care that can also help lower healthcare costs significantly. These methods, along with a shift to electronic medical records, improvement in health care data collection and better coordination among providers, were among the most common steps cited by medical groups seeking to restrain expenses.

Similarly, health care practitioners in Birmingham, Alabama studied a health program in Zambia to create their own AIDS clinic based on the Zambian model. At this clinic, called “Project Connect,” patients receive appointments in five days or less after calling, and social workers interview all patients to address issues that might make it difficult for a patient to return for follow up appointments. Another example is the Prevention and Access to Care and Treatment Program, a community-based project that uses community health workers to assist HIV/AIDS patients in staying adherent to treatment. The program, modeled on work begun in Haiti under Partners in Health, has been adopted for use in inner-city Boston and is expanding to include New York City and Miami.

Mark Dybul, the former US Global AIDS Coordinator, explains why methods of care in poorer nations are now receiving greater attention: “We learned from Africa that in a very resource-limited setting, you can do very effective chronic care delivery that doesn’t have to be overmedicalized.” With much of the debate on health care reform focusing on lowering expense, it appears that these cost-effective programs from the developing world will become more popular to US health care providers.

More information on health in America:

Getting good value in health care

Whistleblower tells of America’s hidden nightmare for its sick poor

Concerns on plan show clashing goals

Forget who pays medical bills, it’s who sets the costs

Community health worker administering medicine in Rwinkwavu. Photo courtesy of Partners in Health.

[Editor's note: In addition to Dr. Binagwaho, Dr. Fidele Ngabo, Cathy Mugeni, and Niloo Ratnayake also contributed writing to this post.]

Access to care in resource-constrained countries has three major barriers to overcome: finances, infrastructure, and geography. Community health workers (CHWs) are an unavoidable solution for both infrastructure and geography. The Government of Rwanda has recognized that CHWs are necessary in order to improve access to health in rural communities. By using CHWs, with their approach to health at the community level, Rwanda hopes to solve 80% of health problems in the country.

Rwanda has set up a system where each village (100 to 150 households) elects two volunteers to act as CHWs for the general population. Because each community votes on one woman and one man to serve the village in this capacity, becoming a CHW is now a position of respect, raising gender equity throughout Rwanda.

These two CHWs are then trained to monitor growth and development in children, to care for people living with HIV, and to refer sick patients to the nearest health facility. Their training is designed by the Ministry of Health, which enables them to provide services in a harmonized manner throughout the country. By sensitizing the local village and making themselves available, they improve access to care; because of CHWs, a greater number of previously unreachable Rwandan citizens now have access to care. The CHWs trained this year to provide services to their villages are trained to treat certain diseases using amoxicillin and to distribute family planning tools (condoms, contraceptive pills, and injectable contraception).

Taking lessons from the work done by the associations of persons living with HIV/AIDS at the community level, Rwanda dedicated two other village-elected CHWs, one woman and one man, to dealing solely with end-of-life issues. These CHWs are responsible for caring for people in the late stages of any disease, which helps ease the burden on family members. Their care also decreases the number of dying patients brought to the hospital.

CHW explaining how to feed children and the meaning of the growth chart outside a house. Photo by Cathy Mugeni.

As there continues to be a high maternal morality rate in Rwanda, the Government is also training traditional birth attendants as CHWs to promote birth delivery at health facilities. CHWs are paid for every delivery they transfer to the local health center.

All activities are included in the health reporting system through reports that CHWs give to the Executives Secretary of each Sector, who in turn report activities to the Director of Health at the District level. At present, CHWs are all volunteers, but the Government of Rwanda is working on compensating these workers with performance-based financing and helping them to create cooperatives.

In conclusion, the five CHWs per village create community ownership, since it is the community who elected them. They also improve access to care and decrease hospitalization through what they manage at the community level. The harmonized training of all CHWs throughout the country is key. Community health workers are a smart and unavoidable solution that enables effective health care to bypass a lack of infrastructure in a resource-constrained country.

When Dr. Jennifer Furin started treating patients in Lesotho at the Nohana Health Center in July 2006, many of her patients had never had access to a doctor. In fact, after walking hours up and down mountains to reach a clinic, patients would often find it locked and unstaffed. If the clinic was open, basic medicines and supplies were scarce, and the nurses could offer little comfort to their patients who were suffering from highly infectious diseases such as HIV/AIDS and tuberculosis. Almost none of the patients – in spite of HIV rates in Lesotho approaching 30% – had ever been tested for HIV, let alone had access to lifesaving anti-retroviral therapy (ART). A mere handful of patients were being treated for TB.

Nohana is one of approximately fifty health clinics scattered across the mountains in rural Lesotho – each more logistically challenged than the next. About a dozen of these remote clinics (including Nohana) have access to a nearby airstrip – enabling staff and supplies to arrive from the capital, Maseru, in approximately 30 minutes. Via land, the treacherous trip from Maseru to Nohana would take 6 hours or more by car, traveling the edges of steep mountains on barely visible dirt paths. Now, with assistance from the pilots and planes of Mission Aviation Fellowship (MAF), the Partners In Health Lesotho (PIHL) team can adequately supply and staff these clinics, ensuring that they are open and that care is available whenever our patients make the long journey to seek medical treatment.

In February 2008, a small team from the Harvard News Office visited two of the PIHL mountain clinics – Nohana and Bobete. They were able to capture the essence of our programs in Lesotho via stunning text, photos, and video – accessible here. I’d like to direct you to a two part photo/video story filmed in Nohana, featured below. It is the story of Kazabelo – a tiny, malnourished 15-month-old baby on the edge of death.

For Kazabelo, the story ends well – at least in the short term. She has survived this round of her life’s battle, and is a plump and healthy toddler (see picture) less than six months later.

Whether our patients come to Nohana, Bobete, or one of the four other remote clinics operated by PIHL in four of Lesotho’s most rural and mountainous districts, the care they receive is essentially the same. We staff each of our six clinics with a full-time physician, who is trained in management of HIV/AIDS and TB as well as primary care and trauma. In addition to treating patients, the PIHL physicians work closely with clinic nurses who are paid by the Lesotho Ministry of Health and Social Welfare – training them in infectious disease management and other critical skills. The doctors and nurses are supported by a cadre of lay health workers, who handle various administrative tasks – including HIV testing and counseling, and food distribution.

The physicians also hire and train Community Health Workers (CHWs) – the key to finding and treating so many patients in the remote villages served by our clinics. Our CHWs visit HIV patients daily to ensure that they are taking their medications properly and consistently, and to check for side effects and other problems of poverty (such as lack of food or water) which might interfere with treatment. CHWs are the vital link between clinic and community, encouraging neighbors and friends to visit the clinic for testing and treatment, notifying the doctors when patients are too ill to make the long journey themselves, and supporting chronically ill patients through months and even years of treatment for HIV/AIDS and TB.

Unfortunately, Kazabelo’s painful story is not unique. There are far too many underweight, malnourished infants and children in Lesotho – and worse, many of them do not arrive to our clinics in time. In a country where an entire generation of adults is being wiped out by the dual epidemics of HIV & TB, too frequently very young children are left in the care of their aging grandmothers. Current estimates peg the orphan rate in Lesotho between 16 and 30% – very likely the highest per capita orphan rate in the world. How old will Kazabelo be when her grandmother can no longer care for her? Will she survive long enough to witness the right to health care become a right realized by everyone in Lesotho?