Global Challenges and Ideas for Improvement

“We involved government workers also so that tomorrow if the project is closed when we go, we can create a sustainable system.” – Program Official, India

“Grant funding allows a CHW to really build those relationships…when they focus on exclusively what they can get paid for, that limits the role.” – Policymaker, US

“The program has increased our awareness about diabetes and hypertension…now we need to keep it going” –Frontline health worker, Brazil

Global Challenges and Ideas for Improvement

As HealthRise was implemented, there were several challenges shared across sites. Many sites reported difficulties with participant retention and follow-up care. Retention was a problem not only for participants but also with staff, with many sites reporting particularly high turnover for CHWs. A universal frustration was the pressure to demonstrate impact through improved clinical outcomes in a relatively short implementation period, particularly among grantees that needed more time to get the program started. Staff expressed the difficulties posed by communicating among the large number of organizations involved in HealthRise globally. People also expressed the need to build recognition of and appreciation for the value of frontline workers among communities and clinical providers, who were not always initially very receptive to them.

In all four countries, differences were observed at baseline in the cascade of care by sex and age group, and at endline, many impacts were more positive for females than males. This suggests that alternative strategies may be required to most effectively encourage screening and care-seeking among different subpopulations, particularly for males as compared to females. One possible interpretation of the observed effects is that the HealthRise model, focused largely on home visits, was more effective for females, who in many communities are more likely to be at home during the day. Females are also more likely to attend a consultation or an event at a health facility, which may be driven in part by males facing greater constraints from being unable to miss work, as well as other cultural factors. Vitória da Conquista, Brazil, was the only site that designed an intervention focused on industry working men, but even with a clinic functioning during night time, it was still difficult to enroll and monitor these patients (for example, no patient from this group had more than one blood sugar/blood pressure reading recorded). In South Africa, one screening event was held at select workplaces to try to screen more males, but even this resulted in 650 females and 312 males participating. These examples highlight that the challenge is not only facility operating hours, but more broadly to develop strategies to better incorporate males into the health system.

HealthRise participants representing each country and grantee organization expressed unique ideas to improve upon the initial design and implementation of the program, but within these site-specific ideas, a few common themes emerged. First, there was a broad recommendation to incorporate mental health conditions. Providers expressed the belief that these conditions were well-suited to a similar care model and that the high prevalence of these conditions among the patient population made these important targets for additional health services. Second, HealthRise staff requested additional and ongoing trainings to improve their ability to deliver high-quality care to patients. These included requests for refresher trainings from CHWs learning how to care for their first NCD patients; suggestions to incorporate more hands-on practice with testing equipment from providers not previously familiar with conducting blood pressure and glucose tests; and the idea to more widely utilize training on motivational interviewing, which some CHWs had the opportunity to