Impact Magazine No. 18 by Impact Magazine

THE MAGAZINE OF PSI

No. 18

O N H E A LT H W O R K E R S

TECHY SOLUTIONS FOR HEALTH SYSTEMS

MANDY MOORE A S K S 7 QUESTIONS

IN PARTNERSHIP WITH

The world should never be short of care. Johnson & Johnson and its partners are committed to developing and training healthcare workers around the world, as they fulfill the promise of helping people live healthier lives.

ÂŠ Johnson & Johnson Services, Inc. 2014

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EDITOR’S NOTE

THIRTY YEARS LATER, WE ARE (STILL) THE WORLD THE MAGAZINE OF PSI

EDITOR-IN-CHIEF Marshall Stowell Director, External Relations and Communications mstowell@psi.org

MANAGING EDITOR Mandy McAnally Manager, External Relations and Communications amcanally@psi.org GUEST EDITOR Laura Hoemeke Director, Communications and Advocacy IntraHealth International CONTRIBUTORS PSI Samrawit Gougsa Sophie Greenbaum Jyoti Kulangara Regina Moore IntraHealth International Carol Bales Lindsey Freeze Corinne Mahoney Margarite Nathe

PSI is a global nonprofit organization dedicated to improving the health of people in the developing world by focusing on serious challenges like a lack of family planning, HIV and AIDS, barriers to maternal health and the greatest threats to children under five, including malaria, diarrhea, pneumonia and malnutrition. psi.org

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s we go to press, the rampant spread of the Ebola virus in West Africa is in the news. People worldwide are talking about it, and calling for action to control the outbreak. It reminds us of 1985, when international reporting on the Ethiopian famine spawned a new awareness of health challenges in low-income countries – and a new desire for action. In response, the music community came together to produce We Are the World, a song that inspired the world. Around the same time, global awareness of the HIV pandemic rose – and led to a call to action and funding for HIV prevention, care and treatment. A new era of citizen activism, engagement and advocacy for global health began. Today, nearly 30 years later, the way we invest in global health has evolved, and so has citizen activism. In most wealthy countries – and a growing number of middle-income countries – aid is commonly accepted as a valuable humanitarian, political and security investment. Our approach, however, lags behind. We have unwittingly built a system in which global health advocates compete for funding allocated to specific diseases: HIV, malaria, tuberculosis…the list goes on. There are countless powerful coalitions that advocate to lawmakers, at conferences and in the media. Too often, though, this successful advocacy does not carve out investments to address the conditions that make long-term improvements untenable – inadequate health workforces and weak health systems. Until we address the need for stronger systems and a stronger global health workforce, vertical efforts may lead to results – but those results may be short-lived and inefficiently achieved. The attraction to funding diseases is clear – results are more easily measured and communicated than long-term investments in capacity building, health markets and the health workforce. And measurable impact is essential to persuading lawmakers, who need positive stories and numbers to share with constituents. At PSI and IntraHealth, we are constantly fine-tuning our efforts to deliver measurable shortterm results and long-term impact. We address multiple diseases and health challenges while supporting systems that deliver high-quality care. To end extreme poverty and ensure universal health coverage, we must build stronger health systems and a robust health workforce. We need long-term, coordinated and efficient investments. We need an evolution – maybe a revolution. A revolution would require a converging of various organizations, coalitions and initiatives, stronger leadership from health ministries and other national stakeholders, and streamlined coordination among all global health actors. We need to change the public and political discourse. We need to ensure that when we devote our attention to singular causes and crises, we also have in-depth conversations about our increasingly interconnected global health system. The Ebola outbreak exposed the need to better invest in health systems. It also demonstrates that health systems can’t function without welltrained, supported health workers. After all, we still are the world. So MARSHALL STOWELL let’s begin another new era in global LAURA HOEMEKE Editor-in-Chief, health. And let’s start by focusing on Director, Communications Impact health workers. n and Advocacy, IntraHealth International psi.org | impact

PSI NETWORK

CONTENTS

FEATURE: FOCUS ON HEALTH WORKERS

PSI Ambassador Mandy Moore Asks 7 Questions

Shortages and Solutions Impact Interviews Ministers of Health in Senegal and Mali

Expert Insight Impact interviews the World Bank's Dr. Tim Evans Senior Director, Health, Nutrition, Population and Global Practice

10 Feature: Focus on Health Workers

16 5 US Committed to Championing Health Workers Dr. Rajiv Shah Administrator, USAID

COVER PHOTO: © CAROL BALES COURTESY OF INTRAHEALTH INTERNATIONAL

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5 Techy Solutions for Health Systems Margarite Nathe Senior Writer/Editor, IntraHealth International

ÂŠ REGINA MOORE / PSI

TH E MAGAZ I N E OF PSI | NO. 18 | 2014

AT THE CORE OF HEALTH SOLUTIONS: THE CLINIC OWNER, PHARMACIST AND SHOPKEEPER

Where Health Workers Stand James Campbell Director of Health Workforce, World Health Organization and Executive Director, Global Health Workforce Alliance

Good information = Good decisions Michael Bzdak Executive Director, Corporate Contributions, Johnson & Johnson

The Power of Education Dr. Vanessa Kerry, CEO and Co-founder, SEED Global Health

Health Workforce Must Become the It Issue Vince Blaser Deputy Director, Frontline Health Workers Coalition

22 The Clinic Owner, Pharmacist and Shopkeeper Regina Moore Manager, External Relations and Communications, PSI

26 A Smart Workforce Needs Smart Analysis Oscar Abello Online Editor, Impact magazine

30 Policy Matters: Health Workers Are Critical to Reaching An AIDS-Free Generation Rep. Barbara Lee (D-CA) Rep. Ileana Ros-Lehtinen (R-FL) Rep. Jim McDermott (D-WA)

32 Final Word To Strengthen Health Systems, Invest in People Karl Hofmann President & CEO, PSI and Pape Gaye, President & CEO, IntraHealth International

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PSI AMBASSADOR

MANDY MOORE ASKS 7 QUESTIONS…

➊ | The Ebola outbreak in West Africa

has caught the world’s attention and puts health workers’ safety at risk. What can we do now to prepare and protect health workers as the outbreak continues to spread? And how can we help countries be better prepared for future crises?

➋ | How do we make health workers a

priority in the post-2015 Sustainable Development Goals?

➌ | A country’s government is ultimately

n October, Mandy Moore joins PSI and IntraHealth International in Tanzania to experience a week in the life of a health worker. In advance of her trip, we began a conversation about health workforce challenges and solutions. Together we’re asking some big

questions about the future of health workers. And we ask you – our Impact readers and important members of the global health community – to weigh in on the conversation. Post your responses to our questions at psiimpact.com/7Q and follow

responsible for delivering the best care to its citizens. But many people in low-income countries get their health care from private-sector providers. How can we make sure the lifesaving contributions of health workers in these facilities are valued?

➍ | There is a shortage of 7.2 million

health workers globally. How can we reduce the shortage and save lives in low-income countries?

Mandy’s journey on Twitter at #healthworkerscount.

➎ | A large portion of global health

funding goes to specific diseases, like malaria, HIV and TB. How can we make sure that the need to recruit and retain highly performing health workers are prioritized within that funding?

➏ | Many countries have developed vol

unteer community health workforces. What can we do to ensure that these volunteers have job security and are fairly compensated?

➐ | How will technology play a role in the

lives of health workers in the next 10 years? What technologies (biomedical, mobile, etc.) could have the most impact?

▲ Mandy Moore meets a young boy in Cameroon during her visit with PSI in 2011.

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Administrator Shah visits a small clinic that belongs to PSI's Sun Quality Health franchise in Yangon, Myanmar.

US COMMITTED TO CHAMPIONING HEALTH WORKERS

his past June, we marked the second anniversary of the Child Survival Call to Action, when the world came together to craft a global goal to end preventable child deaths by 2035. In the past two years, we pioneered an approach that has empowered partner countries to lead with robust business plans and evidence-based report cards. With a strong foundation in place, now is the time for the global community to mobilize around focused and results-oriented country action plans to realize a world where all children live to celebrate their 5th birthday. Since the beginning of the Obama administration, the U.S. has invested $13 billion in child and maternal survival. Emblematic of the strong bipartisan legacy of American leadership in global health, this commitment represents a 56 percent increase in annual funding since 2008. Most importantly, we have aligned our resources in priority countries and toward the life-saving interventions that have the greatest impacts on mortality. We have focused on the 24 countries, primarily in sub-Saharan Africa and South Asia, that account for 70 percent of child and maternal deaths and half of the unmet need for family planning.

B Y D R. R A J I V S H A H, A D M I N I S T R ATO R, USAID

Throughout the past 18 months, USAID has undertaken an ambitious review of every dollar we spend to prevent child and maternal mortality in these 24 countries in order to identify inefficiencies and accelerate reductions in child and maternal mortality. Our recently published report, Acting on the Call, demonstrates with unprecedented transparency how we are advancing President Obama’s commitment to bend the curve of progress. Ending preventable child and maternal deaths requires a new model of development that harnesses the power of science and business to push the boundaries of possibility. In Southeast Asia, for example, we supported randomized control trials and feasibility studies demonstrating that chlorhexidine could cut infant mortality by 23 percent. We partnered with a local Nepali pharmaceutical company and community health workers to deliver the lifesaving antiseptic to expectant mothers. Today, efforts to introduce it are underway in 15 other countries. The results from this approach have been extraordinary. In two years alone, we’ve helped achieve an 8 percent reduction in under-five mortality in the 24 focus countries, saving 500,000 lives. Maternal mortality has fallen by half in

these same countries over two decades. In 2013 alone, the U.S. provided 12.8 million pregnant women with HIV testing and counseling, as well as helped to protect 240,000 babies who would otherwise have started life with the virus. We are proud of this progress, but even more must be done to ensure that every child survives and thrives, and that no mother dies from preventable causes as a consequence of pregnancy and childbirth. More than ever, we need our partners to join with us and align their investments with country-owned plans that focus on delivering results for the most vulnerable families in the most vulnerable communities. By accelerating our rate of progress together, we can save the lives of 15 million children and almost 600,000 mothers by 2020. Ending preventable child death and realizing an AIDS-free generation will only be possible if we continue our investments in health workers. The 24 priority countries face severe challenges not only in terms of employing quality health workers, but also in sending them where they are needed most. To tackle these challenges, we have evolved from simply focusing on building and educating cadres of health workers to developing innovative approaches that address their deployment, retention and management. In Uganda, for instance, we helped to improve human resources information systems and explored new incentive schemes to retain staff. As a result, the Ministry of Health was able to hire 6,000 additional health workers and double physician salaries. Two years in a row, President Obama has called upon us in his State of the Union address to join the world in ending extreme poverty and its most devastating consequences – child hunger and child death – in the next two decades. It is an ambitious but achievable vision. With a clear path for action going forward, we can deliver on this fundamental human aspiration and usher in one of the greatest contributions to progress in history. n Adapted from USAID’s new report, Acting on the Call: Ending Preventable Child and Maternal Death. Read the report at usaid.gov/ActingOnTheCall.

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SHORTAGES SOLUTIONS Impact talks with Senegalese Health Minister Dr. Awa Coll-Seck and Minister of Health and Public Hygiene of Mali Ousmane Koné about their health workforce challenges, successful programs and partnership. SENEGAL: DR. AWA COLL-SECK I M PA C T: How have health

workers had an impact in Senegal? ➜ AWA C O L L - S E C K : It is often the doctors, midwives and nurses – those who hold diplomas – who are recognized as true health workers. But there are many others, including community health workers and volunteers, who are just as important to our health system. For example, in Senegal, we rely heavily on Badien Gokh, or community godmothers. Their main objective is to address and resolve reproductive health issues within their communities. They provide counseling to pregnant women and encourage them to give birth in facilities with qualified personnel. Sixty to 65 percent of women in the country give birth in facilities under the supervision of qualified personnel. This means there are still many women who give birth elsewhere, which contributes to our high maternal mortality ratio. Badien Gokh talk with women about breastfeeding, encourage mothers to take their children to get vaccinated, and provide advice on family planning. They play a very important role in our health system. But they are not paid – they are volunteers. IMPACT: What are the main challenges that Senegal’s health

workers face? ➜ ACS: Senegal has health worker shortages in nearly every professional cadre. For example, we have one midwife for every 2,500 women of reproductive age. Compare this to the World 6

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Health Organization’s recommendation of one midwife per 300 women. We have three main challenges in addressing these shortages. The first is recruiting and hiring adequate numbers of health workers. We have recently recruited 1,000 qualified individuals, 500 of whom are midwives. Nearly all of these recruits will be sent to remote areas. This leads to our second challenge: geographic disparities. Approximately 75 percent of our health workers are in urban areas, while 60 percent of our population lives in rural areas. We need to create more incentives for health workers to move to those rural regions, including making sure there are good schools for their children. We need to decentralize resources and ensure that rural areas can develop the infrastructures they need. The third obstacle is the retention of personnel in these remote areas. We are striving to retain health workers by ensuring that they have what they need, they are not overworked, and tasks are appropriately shared and shifted to lessen the burden on all health workers. I M PA C T: How do international NGOs and other partners help

strengthen your health workforce? What are some examples of successful partnerships? ➜ A C S : A perfect example of our successful partnership with NGOs is around family planning. A year and a half ago, the contraceptive prevalence rate in Senegal was about 12 percent. Through the joint efforts of the Ministry of Health, NGOs and our other partners, we have already increased that rate to 16 percent. Our goal is to reach 27 percent by the end of 2015. It is truly a team effort – we work like one big family. While we could, of course, use more funding – both international and national – to truly achieve our goals, we are fortunate

“ By drawing on the strengths of all partners and sectors and ensuring that the work is well coordinated, we can truly benefit the entire population of Senegal.” —Dr. Awa Coll-Seck

▲ Céline Nataye Sow manages the Sampathe Health Post in Thiès, Senegal, which serves almost 20,000 people. Under her leadership, the post has been renovated and has reduced waiting times.

to have partners who are in touch with our realities and who work to support our programs with us, and not against us. Many of our successful initiatives are based on multisectoral partnerships with a variety of international and local partners. International NGOs such as IntraHealth International have helped us to recruit personnel, especially in under-served areas; to build the skills of our health workers; and to create online training courses so that health workers can maintain their credentials. Another great example is the informed push model. This strategy, which is funded by the Bill & Melinda Gates Foundation and Merck, and implemented by IntraHealth, uses the distribution channels of the private sector to ensure that contraceptive methods are always in stock and available in even the most remote health posts and health huts. This is how we want to continue working. By drawing on the strengths of all partners and sectors and ensuring that the work is well coordinated, we can truly benefit the entire population of Senegal. The interview with Minister Coll-Seck was conducted by Awa Cheikh Seye Ndiaye, IntraHealth International, Senegal.

ADEMAS: PSI’S PARTNER IN SENEGAL ADEMAS, PSI’s newest network member, has been operating in Senegal since 1998. ADEMAS is implementing programs, in partnership with the Government of Senegal, in reproductive health, family planning, HIV and AIDS, nutrition, malaria, and water, sanitation and hygiene. With the support of USAID, ADEMAS has turned its focus toward marketing products and services, using its expertise in consumer and provider marketing to expand the market for contraceptives in Senegal. Through communication campaigns (TV, radio spots and road shows), community mobilization, door-to-door visits and more, ADEMAS is overcoming barriers to family planning use, access and advocacy.

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MALI: OUSMANE KONÉ I M PA C T: How have health

workers had an impact in Mali?

➜

DR. OUSMANE KONÉ:

If I must choose just one example, I would share our experience with active management of the third stage of labor (AMTSL), an innovation that prevents post-partum hemorrhage. Severe bleeding or hemorrhage is the leading cause of maternal death in Mali. This is why we strongly adhered to the introduction and scale-up of AMTSL. Health care providers have been instrumental in its implementation. This task has been delegated to matrones (auxiliary midwives). Our goal is that all women who deliver have access to a matrone. AMTSL, combined with universal access to caesarean section procedures and a stronger referral and evacuation system, has helped to reduce maternal mortality by nearly 20 percent. The maternal mortality rate has dropped to about 460 deaths per 100,000 live births in 2006 from 582 deaths for 100,000 between 1995 and 2001. In 2009, the urban maternal mortality rate was at 115 per 100,000 live births – a rate below the MDG target. In rural areas, however, the rate remained high at 550 per 100,000 live births. IMPACT: What are the biggest challenges Mali’s health

workers face? ➜ OK: The ongoing challenge is raising the quality and quantity of human resources to achieve a ratio of 23 health professionals (doctors, midwives and nurses) per 10,000 people. To achieve this goal, Mali will need more than 14,307 new health professionals by 2018. The lack of human resources for health as well as health worker motivation and retention remain key issues we must overcome in order to meet the Millennium Development Goals. A program should be implemented at the country level to address the lack and inadequate distribution of health workers and to ensure universal access to high-quality health services. IMPACT: How do international NGOs help strengthen your

health workforce and in which areas could partners improve? ➜ OK: We greatly appreciate the support from international NGOs. The humanitarian NGOs help us by providing emergency assistance, especially in managing people who are displaced or in precarious situations, by supplementing our staff in order to provide appropriate care. Development NGOs involved in long-term programs assist in our situational analyses and in the development and implementation of the Health and Social Development Plan (PRODESS). For example, IntraHealth International, through the USAID-funded CapacityPlus project, assists us in implementing health workforce information software (called iHRIS). This software will help us 8

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“ Mali will need more than 14,307 new health professionals by 2018.” make decisions based on reliable data and help us decentralize human resource management to the regional level. Other NGOs support the recruitment of community health workers or training for doctors and midwives in schools. International NGOs should support Mali’s government in implementing its health policy. They can strengthen our staff by working in all components of the PRODESS. In no case should they replace the Ministry of Health; their activities should supplement ours. For example, we expect our partners to: adhere to national policies and programs; strengthen pre- and in-service training for health professionals; connect with universities and training centers on an international level to strengthen our capacities in biomedical research; award scholarships in technical areas where training is not locally available; introduce proven approaches and resultsbased financing to enable us to manage our resources efficiently and ensure equity, both in funding and in access to health care; and mobilize technical and financial resources to implement PRODESS. I M PA C T: Mali is a pioneer in using task-shifting strategies to

increase access to maternal and child health services. How have those strategies changed the situation in rural communities? ➜ O K : The program for Essential Care in the Community (ECC), led by community health workers, stands out. The program targets children under age 5. From June 2011 to November 2012, the ECC recruited, trained, provided supplies to and assigned nearly 2,000 community health workers to the Sikasso, Kayes, Koulikoro, Ségou and Mopti regions. The rollout was thanks to an exemplary partnership between the state and local governments, and the technical and financial partners of Mali, and the workforce in the field. Many of these community health workers are former matrones or assistant nurses, who were recruited and assigned to their sites after completing the appropriate training and assessments. Community health workers are responsible for basic newborn care; family planning; management of moderate malnutrition, uncomplicated malaria, diarrhea, pneumonia; and referral of complicated cases to community health centers. Each health worker cares for 1,500 people on average across several satellite villages and their assigned sites.

▲ PROFESSOR KALILOU OUATTARA has been head of Urology at Point G University Hospital Center in Segou for more than 30 years. He has performed thousands of fistula repair operations. Now, he is training a new generation of surgeons. Under the USAID-funded Fistula Care Project, in collaboration with IntraHealth and the Government of Mali, he trained 18 surgeons to perform basic repairs.

The program has shown positive results. From April 2011 to March 2012, community health workers treated approximately 17,000 cases of malaria, 9,500 cases of diarrhea and 12,600 cases of acute respiratory infection in children under 5 – nearly 20 percent of all cases in this age group. These health conditions would not have been channeled to the local community health centers or would have been sent late, incurring high costs and resulting in a critical prognosis for some children. This strategy has led to expanding health coverage so that health care is more accessible to rural populations, especially the poorest. n

PSI’S NETWORK MEMBER IN MALI PSI/Mali was founded in 2001 to use commercial marketing strategies to improve reproductive health and child survival, working through both the public and private sectors, and to reduce new HIV infections. Since then, we have added programs in malaria treatment and prevention, clean water, improved sanitation, treatment of cervical cancer and introduced programs to reduce the incidence of female genital cutting. PSI/Mali also created and supports the ProFam franchise, which is a national network of branded private health clinics that offer women high quality family planning services. PSI/Mali implements programs in partnership with the Ministry of Health and Public Hygiene, and is supported by a variety of donors including USAID; the Global Fund to Fight AIDS, TB and Malaria; and the Dutch and German governments.

The interview with Minister Koné was conducted by Dr. Cheick Touré, IntraHealth International, Mali, and Zouboye Mariam Diaw.

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FOCUS

ON HEALTH

WORKERS

They are the front line, first responders and last mile.

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VIDYA (right) is an accredÂited social health activist in the Uttar Pradesh village of Alipura. She is one of more than 820,000 in India who offer key preventive services and health education to women. Too often Indian women in low-income communities lack the educational opportunities and community support to become health workers. But her work has increased her community's respect for her, she says. In this edition of Impact, PSI and IntraHealth feature stories of more champions ÂŠTREVOR SNAPP/COURTESY OF INTRAHEALTH INTERNATIONAL

like Vidya - doctors, midwives,

community outreach workers in Haiti, Ghana, Myanmar and beyond. We call on the global health community to mobilize support for health workforce challenges and bring solutions into focus. n

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FLAVIE JOSEPH is a community outreach worker with PSI in Haiti. Her son Mike was often sick with diarrhea as a child, so she wants to help other mothers avoid the same struggles. Flavie organizes sessions in homes, health centers, schools, churches and women’s group meetings to show mothers in her community how to protect their children from malnutrition and waterborne diseases. She teaches them about family planning and tells them where to go for quality antenatal care and clinic-based delivery services. “I want my son Mike to become useful, too – for himself, our family, and this society.” Flavie knows that teenage pregnancy and HIV can keep her son from achieving his dreams. So she also regularly talks to Mike and his friends about protecting themselves. “Everybody benefits when everyone is healthy – especially the children.” n

PSI’s work with Flavie and other community outreach workers is made possible by USAID.

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DR. ENO BINEY

©CAROL BALES/COURTESY OF INTRAHEALTH INTERNATIONAL

is an emergency medicine specialist at Komfo Anokye Teaching Hospital in Kumasi, Ghana. She chose her specialty because there was no form of organized emergency treatment available in the country. Medical emergencies were usually rushed to emergency care centers that didn’t have specially trained health workers or triage systems in place. During her training, Eno saw how this led to delays in medical diagnosis and treatment, and lost lives. Eno graduated in the first class of emergency medicine specialists from the Ghana College of Physicians and Surgeons. The college’s training program is funded through the PEPFAR Medical Education Partnership Initiative (MEPI). It’s the first of its kind in West Africa. “This integrated approach to patient management is saving people’s lives,” Eno says. n IntraHealth’s CapacityPlus project is a MEPI partner, collaborating with medical schools in 12 African countries.

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SARAH OWAR rides her motorbike to the Owam District Health Office in Uganda every day. She’s a biostatistician and also manages the district's Human Resources for Health Information System, which runs on IntraHealth’s iHRIS software. Sarah says the most important use of the system’s data is to monitor the quality and quantity of health workers: “Because here it’s about saving lives. So how many lives are we going to save with the kind of capacity that we have?” n

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ASTON BIREETWA IS A TAATA AMBASSADOR with PACE, PSI's network member in Uganda. He works with the St. Apollo Health Centre III in the Wakiso District and manages 11 zones/villages in Masajja parish. His job involves talking to expectant parents about the importance of antenatal care and delivering in a health facility. Aston was trained by PACE under the Merck Ugandan Mothers (MUM). He and his fellow ambassadors empower fathers and mothers-to-be to make good decisions about their health. They also refer women to nearby health providers in the ProFram network, which is a franchise of highly trained and privately owned health facilities, operated by PACE across Uganda. n Visit PACE at www.pace.org.ug and Merck for Mothers at merckformothers.com.

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TECHY

SOLUTIONS FOR HEALTH

SYSTEMS

B Y M A R G A R I T E N AT H E , S E N I O R W R I T E R/E D I TO R, I N T R A H E A LT H I N T E R N AT I O N A L

Today we know how to eradicate polio, tackle malaria and ward off maternal deaths. We can even see our way to an AIDS-free generation. These are things we couldn’t say 50 years ago – or in the case of AIDS, even 10 years ago. Still, we’ve got a long way to go. One billion of us live below the poverty line, with little or no access to basic health services. We need greater coordination, economic stability and stronger health systems before universal health coverage will come into view. And new challenges are looming. As our life expectancies rise and economies grow, so do rates of non-communicable diseases such as cancer, heart disease and stroke. The World Health Organization (WHO) estimates that in Africa, deaths due to diabetes will increase by 42 percent throughout the next 10 years. In fact, WHO says that deaths from chronic diseases will outstrip those from infectious diseases, maternal and perinatal conditions, and nutritional deficiencies more than four-fold, killing 28 million Africans in a decade.

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Our ability to finish the work we’ve started with polio, malaria and other communicable diseases – and to prepare for the work ahead – depends on the individuals who work at the front lines of health care, and those who work behind the scenes to support them. IntraHealth International, PSI and other organizations that focus their efforts on the health workforce are part of a growing field called human resources for health, or HRH for short. HRH is not a sexy term. The field’s name and acronym have an unfortunate tendency to obscure its significance for those who don’t spend their days thinking about it. It’s difficult to see where people fit in. But in fact, people are the very definition of human resources for health. HRH boils down to this: humans are the most valuable resource we have when it comes to fighting disease and improving health. They can be nimble, efficient and brilliant. But they can

also be overworked, undersupervised and lacking in up-to-date knowledge and skills. For health workers – the human resources in HRH – to be effective, the health sectors in which they work must be solid. WHO estimates a current global shortage of at least 7.2 million doctors, nurses and midwives. We need strong political leadership to train and support more of them. We also need to make the most of those we have. That means making sure that health workers are where they’re needed most, and that they have access to the necessary training, tools and resources.

New technology is making this easier than ever. Today, a midwife in rural Guatemala can reach out to faraway colleagues for advice. A clinic manager in Senegal can track the use of essential drugs and supplies. And a state official in Laos can see where all of the country’s pharmacists are situated with just a few keystrokes. Such technology means that investments in human resources have never been more cost-effective, nor extended farther into the hard-to-reach places of the world.

➊ HUMAN RESOURCES

INFORMATION SYSTEMS Say a government realizes that illness and preventable deaths are keeping its population from thriving economically. So it decides to really beef up the country’s health system by making sure clinics are stocked and staffed, and by recruiting new workers – the whole nine yards. Before the government can do any of that, it needs information. How many health workers are in the country? Where are they? Are they working where they’re most needed? Or are they clustered in the cities, turning rural areas into health-care deserts? What services are they qualified to provide? Are they licensed and registered? Is their training up to date? Does the country need more health workers? If so, where and what types? These are powerful data points that many countries simply don’t have. But digitized, streamlined human resources information systems are offering governments the tools to capture and analyze these data, and to use that information to plan and budget for their health sectors. iHRIS (pronounced “iris”) is one such tool. It’s a suite of free, open-source software applications that IntraHealth has been developing throughout the past 10 years, most recently through the USAID-supported CapacityPlus project. iHRIS helps countries around the world to gather, wrangle and control their own health-sector data. These information systems take the place of the scattershot, paper-based filing systems that fill entire rooms in many health facilities and government buildings. Using iHRIS, government officials and clinic workers alike can easily find, share, manage and update personnel files. The software is customizable, so users can tweak it to fit their own data needs. It interoperates with other information systems such as OpenMRS and DHIS 2. And technologists in-country are learning to use and maintain iHRIS, cultivating a thriving community of professionals who can collaborate internationally. So far, 19 countries are using iHRIS to track more than 950,000 healthworker records worldwide. It would have cost these countries $177 million in licensing fees alone to do that with proprietary software. These tools are allowing low- and middle-income countries to take control of their health sectors sustainably and make sure care is available where it’s needed most.

➋ eLEARNING Health workers are lifelong learners. They have to be, given how quickly their field changes. But for those stationed in remote areas, midcareer classroom learning is often impossible. There are logistical challenges – who will staff the clinic while they’re gone? – as well as insurmountable travel expenses. As a result, both health workers and their clients often miss out on any benefits that come with new techniques and best practices. Fortunately, eLearning is changing that. The Global Health eLearning Center, for example, and CapacityPlus’s HRH Global Resource Center – both funded by USAID – offer free, high-quality eLearning courses on global health, HRH, health informatics, health service delivery, and more. And the Ministry of Health in Kenya is now using eLearning to conduct orientations for new health-sector employees, cutting down on the expense and time it takes to orient such workers. The eLearning industry is expanding. Selfpaced eLearning is growing annually at a rate of 15.4 percent in Africa and 17.3 percent in Asia. Computer-based training allows health workers to update their skills on their own time and at their own pace. And their communities reap the benefits.

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➌ MOBILE PHONES AND APPS

“ Not only are mobile phones connecting health workers to faraway colleagues and new communities of practice, but the devices are also helping workers provide better health services during their visits with clients.”

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Imagine you’re the only nurse – or maybe even the only health worker – in a village in rural India. You’ve got no boss, no colleagues to support you, no one to offer you advice on tough cases. You can’t leave town to update your training because that would leave the clinic unstaffed and anyone who needed urgent care would have no one to turn to. Now imagine how a simple mobile phone could change that. Not only are mobile phones connecting health workers to faraway colleagues and new communities of practice, but the devices are also helping workers provide better health services during their interactions with clients. Mobile health, or mHealth, is the growing practice of using mobile devices to support health care. There are mobile apps that help clients to remember their clinic appointments or to take medication. There are apps for health workers that help them to update their training, make diagnoses, or get in-the-moment guidance about how to handle certain situations. mHealth can be essential during crises, too – including in the ongoing Ebola outbreak. There are plenty of guidelines out there for health workers around Ebola safety and care, but the challenge is getting information to the hard-to-reach areas where many work. Two new mHealth courses by IntraHealth offer a way to do that through SMS text messages or through interactive voice response on simple mobile phones. Many other organizations and networks, such as Medic Mobile, Dimagi, the mHealth Alliance, mPowering Frontline Health Workers and the mHealth Working Group, are working to get mobile technology into the hands of health workers who can use it. And so are national governments. For example, India – a country of 1.2 billion – has nearly 1 billion mobile phone subscribers, and growing smartphone sales will make it the secondlargest country for smartphone use in the world in 2014 (just ahead of the U.S. and just behind China). It also has the greatest number of maternal deaths in the world. So when the government began looking for ways to harness mobile technology to improve health care, IntraHealth responded with mSakhi, a mobile phone app that helps community health workers called ASHAs (Accredited Social Health Activists) to better care for women and newborns. The app helps ASHAs in the state of Uttar Pradesh counsel families on everything from birth preparedness to caring for sick newborns. Many ASHAs lack literacy skills, so mSakhi is designed to be highly visual and auditory. Since 2006, the government of India has invested in more than 820,000 ASHAs, training them to provide care in the country’s most impoverished, remote communities. And the country’s investments are paying off. The maternal mortality ratio has dropped from 280 maternal deaths per 100,000 live births in 2005 to 190 in 2013.

“ Technology is not, in and of itself, the solution to our global health challenges. It’s useless without humans, but incredibly useful as a tool.”

➍ MOBILE

PHONE VERIFICATION When you’re sick and need to see a doctor, chances are your mind is on recovery – not on whether the doctor who’s treating you has appropriate licensing. Those who work as health-care providers but don’t have the appropriate licensing are a problem in many countries, including Uganda. They’re known to con clients into paying for ineffective treatments and even to cause harm with their care. That’s why the Uganda Medical and Dental Practitioners Council decided to move away from the paper-based filing system it had been using to keep track of registration and licensing information for its members, and to implement iHRIS instead. The council now uses iHRIS Qualify to track data for more than 4,000 health workers. The council easily shares its data with the Ministry of Health, which then uses the information to plan and budget for Uganda’s health workforce. But even better for the Ugandan public, the information is available online and through a mobile directory. Clients in Uganda now have the power to check the credentials of more than 4,000 doctors and dentists. To use the system, a client simply sends the council a text message with the word “doctor” and a practitioner’s name. A message then comes back from the council to indicate whether the worker is registered and licensed. Thanks to the directory, thousands more health workers have complied with registration and licensing requirements. And when they don’t, clients can be sure to look elsewhere for care.

➎ INTERACTIVE

VOICE RESPONSE Relying on textbooks and written information isn’t always the best way to train. Not all health workers can read, for instance, and many speak languages that are not often written. That’s one reason the Ministry of Health in Senegal is taking a close look at its mHealth initiatives and exploring new ways to use the technology more widely – and more creatively. In Thiès, Senegal, IntraHealth worked with health officials to pilot an interactive voice response program that helps nurses and midwives update their training in family planning services. The USAID-supported initiative, which is the first of its kind, works with a simple mobile phone and uses a question-and-answer approach that’s scientifically proven to help students retain information better than more traditional learning methods. The program uses a technology that’s been around since the advent of touchtone phones. (If you’ve ever called a bank and heard a voice say, “Press one to hear bank hours,” you get the idea.) Training programs that use interactive voice response can be recorded in any language. And users like the flexibility – they can update their training any time that’s convenient for them, without leaving their clinics unstaffed.

WHAT COMES NEXT?

Technology is not, in and of itself, the solution to our global health challenges. It’s useless without humans, but incredibly useful as a tool. Solutions that are designed by and for the health workers who use them are the innovations that will help us to finish what we’ve started in global health, and will allow us to face the challenges ahead. We can reach new levels of health and well-being by investing in sustainable, country-owned systems that make health workers a priority. It’s time to invest in our human resources. After all, they’re the most valuable ones we’ve got. n

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A CONVERSATION WITH THE WORLD BANK’S DR. TIM EVANS S E N I O R D I R E C TO R, H E A LT H N U T R I T I O N, P O P U L AT I O N A N D G LO B A L P R AC T I C E

IMPACT: What are three critical

elements of the global health workforce that governments and donors must address to attain and sustain universal health coverage? ➜ TIM EVANS: The first element is to recognize the centrality of the health workforce in accelerating progress towards universal health coverage (UHC). Adequate numbers of appropriately trained and located health workers – be it for the provision of clinical services or the management of health insurance regimes – are mission critical to UHC. Too often, however, the health workforce is an after-thought or marginal consideration in policy and plans. Too many countries lack credible capacity to manage the workforce as an agent of change for UHC and it ends up being weighed down. Recognizing the value of the workforce and building capacity to manage more proactively are essential ingredients to UHC reforms. Ensuring equal access to health care for all defines the second critical element: the recruitment and retention of qualified health workers to serve in areas of greatest need. This is more easily said than done and requires a multi-pronged solution that includes investing in education and training of students recruited from these under-served communities; developing curricula and training materials that reflect local needs; creating a safe work environment; and managing monetary and nonmonetary incentives to attract and retain workers in the community. A third critical element relates to developing greater awareness of and competency in managing health workforce labor markets. Health workers are sensitive to differences in remuneration, working conditions and career prospects. Disparities in these factors both within and across countries create powerful market forces for migration, often negatively impacting the provision of health services. Avoiding 20

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such fallout requires a better understanding of these market forces and effective interventions to counter their adverse consequences. I M PA C T: What are the biggest chal-

lenges in the adequacy of data on health workforce for policy decisions? ➜ T E : The biggest data challenge relates to the absence of broadly accepted standards for counting and assessing the performance of the health workforce. The data that exists is usually incomplete, out-dated, skewed towards public sector medical professionals and away from private sector and public health workers. A new system that identifies the numbers, locations, productivity, inflows and outflows of health workers will help to provide the nature and magnitude of health worker challenges as essential inputs to policy.

care teams of health workers. Given the global shortage of health workers, the demand for high-skilled health professionals is likely to come under considerable competition from regional and global health labor market. National human resources for health strategies will need to take into account competing domestic and international interests. The challenge will not only be to increase the number of skilled health workers but to transform the way they are selected and educated. I M PA C T: PSI and IntraHealth will travel

with a delegation to Tanzania in October to see our programs and meet health professionals. Can you talk about the Bank’s focus on health worker performance analysis in the country? ➜ T E : In Tanzania, the World Bank and other partners support the health sector through a sector-wide approach and

I M PA C T: How do economic,

demographic and epidemiologic transitions in many low- and middleincome countries impact the demand for health workers? ➜ T E : Overall, these trends are likely to accelerate the demand for health workers across the globe, although the magnitude and rate of increase in demand will vary from country to country. With economic growth, population aging and the information society, the public’s expectations for health care are increasing demand for quality health services everywhere. Together with urbanization and unregulated commercialization of health care, this demand skews the supply of health workers towards costly procedures and high-tech interventions in tertiary care hospitals. Achieving UHC will require shifting these expectations toward a greater demand for primary prevention and community/home-based models of care, supported by multi-disciplinary primary

DR. TIM EVANS previously served as the Dean of the James P. Grant School of Public Health of BRAC University in Bangladesh and Assistant Director-General at WHO. He has been a leader in advancing global health equity and health systems performance at the Rockefeller Foundation and the Harvard School of Public Health, and in developing innovative partnerships at the GAVI Alliance; INDEPTH and Health Metrics networks; the Global Health Workforce Alliance; and the World Alliance for Patient Safety.

the Health Basket Fund, which helps with local government service delivery, health systems strengthening at the local level, and the procurement of medicines and other health commodities. The Bank also supports a capacity-building grant mechanism to improve the capacity of local governments to manage their health services, including human resource management. This is linked to activities through the Ministry of Health and Social Welfare and Prime Minister’s Regional Administration and Local Government, which support the performance management process and strengthen oversight structures. One way to look at the results of improving health worker performance is through the analysis of service delivery indicators (SDI). The Bank has supported Tanzania and other African countries in this endeavor. At the policy level, the government has decided to introduce performance- or results-based financing as an approach to improve health worker performance by moving away from input-based financing, and focusing on performance or results. Following a successful Pay-for-Performance (P4P) pilot, funded by the Norwegian government, the Bank is assisting the Tanzanian government in redesigning a results-based financing system that will be pre-tested in one region this year, and starting the next financial year the new systems will be rolled out nationwide in a phased approach. IMPACT: What is the role of the private

sector in human resources for health? ➜ TE: The private sector is growing rapidly in many health areas, including professional education and service delivery. This expansion is both a source of opportunity and concern for human resources for health (HRH). The growth of the private sector in health is creating new training and employment opportunities; however, without appropriate alignment with UHC objectives, it may create challenges to the access and quality of health professional education, and skew health workers towards facility-based, tertiary care. In many countries, public sector pay, support and supervision are such that health workers are often absent, low-performing and seeking work in the private sector. As such, it is necessary to manage the public-private mix with respect to education and employment to assure universal access to quality health services. n

WHERE HEALTH WORKERS STAND B Y J A M E S C A M P B E L L, D I R E C TO R, H E A LT H W O R K F O R C E, W O R L D H E A LT H O R G A N I Z AT I O N, A N D E X E C U T I V E D I R E C TO R, G LO B A L H E A LT H W O R K F O R C E ALLIANCE

he Recife Political Declaration, endorsed at the Third Global Forum on Human Resources for Health, and its adoption at the 67th World Health Assembly in May 2014, provides a timely opportunity to outline a contemporary vision for the contribution of health workers to universal health coverage (UHC). During the last 10 years, the international community has focused on addressing health workforce shortages in low-income countries. One example is the recent Ebola outbreak. It is compounded by weak health systems with shortages of trained health workers and is a threat to global health security. However, there are health workforce challenges in every country, and the resolution demands a global strategy. UHC necessitates addressing the critical dimensions of availability, accessibility, acceptability and quality of health workers and how they ensure that individuals obtain quality care. We also need to frame these discussions within the context of aging populations, demographic transitions, the rise of noncommunicable diseases, and how individuals obtain health and social care. We are already seeing countries re-imagining and re-engineering their workforce to provide health and social services through community-based models. A global, contemporary strategy on human resources for health (HRH) has the value of putting evidence and best practices out there for countries to consider. It will be an agenda, relevant to low-, middle- and high-income countries alike. The global strategy will bring together the best understanding of national needs and the thinking of the world’s experts. The Global Health Workforce Alliance is overseeing the development of eight evidence papers that will inform the JAMES CAMPBELL has worked strategy, and a call for papers on as a researcher/advisor on human the impact of national investment resources for health for the United in HRH is forthcoming. A first Nations Population Fund, World Bank, draft of the strategy will be Bill & Melinda Gates Foundation, U.K. available for consultation in and Norway governments, and others. early 2015. This draft will be His recent works include A Universal subject to review by the World Truth: No Health without a Workforce, Health Organization’s Regional released at the Third Global Forum on Committees and Executive Board HRH, and the 2014 State of the World’s before presentation at the 69th Midwifery report. He was previously World Health Assembly in with the Instituto de Cooperación May 2016. n Social Integrare in Barcelona.

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AT THE CORE OF HEALTH SOLUTIONS: The Clinic Owner, Pharmacist and Shopkeeper B Y R E G I N A M O O R E , M A N A G E R, E X T E R N A L R E L AT I O N S & C O M M U N I C AT I O N S, P S I

ook no further than a clinic, hospital, pharmacy or kiosk to see the complexity in achieving better global health. NGOs and governments spend a significant amount of time trying to better understand the people receiving health products and services, and much less time trying to understand those delivering it – especially private-sector health workers. Below are the stories of three people who contribute significantly to improved health because of the strong support they have received in their own businesses. 22

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DR. AYE AYE: FRANCHISING, STRENGTHENING HEALTH SYSTEMS Many years ago, Dr. Aye Aye Mu purchased a small clinic nestled next to her home in the capital city of Yangon, Myanmar. Dr. Aye Aye juggles her roles as a mother, a doctor and a small business owner as she runs her clinic to provide for her family. More than 10 years ago, PSI/Myanmar approached Dr. Aye Aye with a business ▲ Clinic owner proposition. PSI was creating a network of Dr. Aye Aye Mu franchised health centers, called Sun Qualreviews a client’s ity Health, and was looking for dedicated lung X-rays. Her clinic owners to join. The more Dr. Aye Aye clinic is a member learned about franchising, the more she of PSI/Myanmar’s felt it would help her and her clinic, and she Sun Quality Health became one of the first providers within network. the franchise network.

PHARMACISTS: FACILITATING MARKETS, STOPPING DRUG-RESISTANCE Boniface is a pharmacist in Ukundae, Kenya. He serves clients with a wide range of needs every day. One of his best selling products is antimalarial medication. Malaria is common in some parts of Kenya, so pharmacists are often quick to sell antimalarial medicines to customers with fevers. Malaria is not the only cause of fever, though, and unnecessarily treating someone wastes high-quality frontline malaria drugs and contributes to a growing resistance to those medicines. Today, there is a quick and easy test available to diagnose malaria. Rapid diagnostic tests return results in mere minutes and can be safely administered by lower-level health-care providers. Pharmacists and other health workers can use the tests to accurately diagnose their clients and provide appropriate care. Nevertheless, in many countries, the tests are not readily available at pharmacies and drug shops, or are more ▼ Boniface, a expensive than the recommended malaria pharmacist in treatment when they are available. Kenya, speaks For Boniface and other pharmacists, this can with his client present a real problem. If Boniface doesn’t have Aloise before the skills to administer the test or doesn’t know administering a how important it is, he might presumptively rapid diagtreat for malaria. And if the tests are not finannostic test for cially viable for him to stock or sell, his business malaria. may suffer.

Through the Sun Quality Health network, Dr. Aye Aye has seen a marked improvement in her business. As a franchisee, Dr. Aye Aye is connected to training that might be out of reach for a stand-alone clinic in a poor neighborhood. She can stay up to date on the latest research and medical best practices and make sure she always has the necessary instruments, medicines and other products at hand to provide the highest-quality care to her clients. Because she is part of a well-known network, Dr. Aye Aye has the added benefit of brand recognition. Clients know Sun Quality Health clinics and trust their quality. Community outreach workers within the network also educate people and communities about health issues and drive traffic back to these clinics, growing Dr. Aye Aye’s client base. The Sun Quality Health network allows PSI/Myanmar to invest in Dr. Aye Aye, not only in her clinical skills but also in the business skills to help her clinic meet the needs of her clients. Today the Sun Quality Health network is Myanmar’s largest private health-care system, with 2,000 outlets serving more than 1 million people. PSI/Myanmar works with its franchisees – which provide more than 10 percent of the nation's family planning services, and diagnose and treat 15 percent of the country’s tuberculosis patients – so they can offer a range of services at the highest quality of care.

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PSI and our partners are creating markets for these rapid tests in Kenya, Madagascar, Nigeria, Tanzania and Uganda. The project is supported by UNITAID, which uses innovative financing to increase funding for greater access to treatments and diagnostics for HIV/ AIDS, malaria and tuberculosis in low-income countries. Together, we analyzed the market to identify the barriers that pharmacists face in using the tests to properly diagnose and treat customers.

40-60

percent of people in malaria-endemic countries who seek care for malaria in the private sector PSI then addresses these barriers, enabling the market to grow on its own. We work closely with Boniface and other pharmacists to teach them how to administer tests and educate them on the benefits of testing before treating. We also work with local pharmaceutical importers and the Government of Kenya to ensure that the tests are of high quality, as well as affordable and realistic for them to stock and sell. Today, when clients come in asking for antimalarial medicine or complaining of fevers, Boniface first talks to them about why it is important to diagnose then treat. He’s then able to administer the simple test at an affordable price to his customers and, if the results are positive, he can provide the proper antimalarial treatment. Boniface’s business grows because clients trust his judgment and respond to the right treatment. Because the market is beginning to function properly, he doesn’t need to choose between doing what’s best or what’s most profitable. Boniface can feel confident that he is properly treating his clients and running a good business.

be reminded about the importance of breastfeeding. Six months later, that same woman will receive a message about fortifying her child’s solid food to make sure his or her nutritional needs are met. To help her practice this healthy behavior, she receives a voucher for free micro-nutrient powder at a local Troca Akibranded shop, such as Chefe’s. Chefe saw immediate benefits to joining the program. He gets great satisfaction from knowing he’s helping people, but he has also seen real and immediate improvements to his business. When a customer redeems a voucher for one of the Troca Aki health products, Chefe validates the code by SMS with Movercado and makes a profit on the product. Because of the community outreach and vouchers, the products move quickly off of his shelves, translating into cash. He also sees new faces. Many of the customers who come for their free products have never been to Chefe’s shop and often buy other goods while there. Chefe says he thinks of his shop as another ▼ Chefe, the child and puts incredible care and dedication owner of a into it. He takes the greatest pride seeing his small shop in own sons taking care of the business. He may PSI/Mozamnot fit the typical image of a health worker, bique’s “Troca but Troca Aki allows and encourages Chefe to Aki” network, be both an entrepreneur and a health provider validates a by continually improving his business while voucher code creating something that he is proud to share via SMS. with his family.

Chefe owns a tiny kiosk near a bus stop and school in Maputo, Mozambique. The small shop is his livelihood. With limited cash at his disposal to invest in stock and little room to store extra goods on his shelves, Chefe needs to use all of the space he has for items that will consistently be purchased and rotated. This makes stocking a bed net, water treatment, or other health product – versus a soda bottle or small quantity of rice – a difficult and rarely possible choice for most shop owners. This isn’t the case for Chefe. He sells several health products in his shop, including condoms, safe water treatment and micronutrient powder to fortify infants’ food with necessary vitamins and minerals. He’s able to do this because he joined the “Troca Aki” or “Exchange Here” network. Troca Aki is part of a PSI/Mozambique initiative called Movercado. Through this initiative, health educators reach members of the community with important messages tailored to their lifestyles. For instance, a woman who has just given birth will 24

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SOLUTIONS LIKE THESE WORK because they respond to individual health workers’ professional and financial needs. When we take a human-centered design approach to better understand the providers of health, we increase quality, job skills and job satisfaction. Bringing private-sector solutions to scale at community and country levels helps us to build stronger health systems, more effectively allocate scarce donor resources, and integrate a variety of products and services in convenient locations. n

COURTESY OF PSI

INCENTIZING PRODUCT SALES IN MOZAMBIQUE

GOOD GOOD INFORMATION DECISIONS B Y M I C H A E L B Z D A K, E X E C U T I V E D I R E C TO R, C O R P O R AT E C O N T R I B U T I O N S, J O H N S O N & J O H N S O N

ho can argue with the idea that good decisions should always flow from good information? This seemingly obvious logic raises questions about how we collect, access and sort information, and, ultimately, use it to make decisions. How can we be sure that we have the right data at the right time, and that it is organized and interpreted in the right way to support decision-making? Consider, for example, that the Institute for Health Metrics and Evaluation (IHME) at the University of Washington produces a tremendous volume of robust data on population health and health systems on a regular basis. What would happen if funders and other stakeholders effectively used these data regularly to inform decisions and take action? Consider also the work of Hans Rosling, a professor of global health at Sweden’s Karolinska Institute, and his ability to present datasets in seductive, compelling and understandable ways. What would happen if more data from all

MICHAEL BZDAK manages Johnson & Johnson’s strategy to strengthen the health care workforce as well as efforts around program evaluation and the volunteer support program. He is a visiting part-time lecturer in the in the School of Communications and Information Studies at Rutgers University and an adjunct faculty member at New York University.

sectors were presented in such dramatic and effective ways? The potential of taking the IHME data to Rosling-like conclusions is apparent, but the steps in between are mind-boggling. Since discovering the volume of data produced by a group like the IHME and the inspiring data visualizations of someone like Hans Rosling, I understand, in a new way, the potential power of data to change minds and inform decisions. I have also discovered that complex processes are

As we reach the end of the MDG commitments, I see a critical need for the effective use of data to help drive our goals around health for the next generation of global health targets. Health systems decision makers and advocates for the health workforce – human resources for health – have a long way to go in effectively and collectively using data to drive decisions around defining, hiring, developing and deploying health workers. We know, for example, that the availability

“ Funders should be taking a leadership role in advocating for the better use of real-time data to drive our decision-making.” involved with data work, from its collection to using it to explore choices and make decisions. David Mimno from Cornell University compares data collection and analysis to woodworking. According to Mimno, working with data involves joining information together as well as selecting and pruning. It is “like building a data chair,” Mimno says. “You turn a dataset on the data lathe, and then glue it to the appropriate slot in another dataset. Carpentry has all these aspects, from selecting and shaping to careful joinery.” This analogy reminds us not only to honor the power of data but also that we, as collectors and users, have a responsibility to make careful decisions – joining, selecting and pruning. Funders should take a leadership role in advocating for the better use of real-time data to drive our decision-making. We should be leaders in collecting, verifying, analyzing, sharing and reporting our data. We must also advocate for a more systematic and consistent collection of data.

of birth attendants is linked to reductions in maternal and infant mortality. We do not, however, adequately train and deploy enough attendants to reach those who need health services. We have also seen promising research linking management training to better health outcomes. Yet resources for management development are neither properly allocated nor universally included in project budgets. I believe in the promise of better managed health facilities and systems as a result of well-trained health workers. I also believe that the responsible use of data and technology will accelerate the adoption of proven practices to improve health systems. As we approach a new era of global goal-setting, let’s take stock of the data that we have and how we are using it to make decisions. Data have given us the power to be selective and have provided us with a great opportunity to collaborate in supporting the global health workforce. After all, don’t we all agree that good decisions should flow from good information? n

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A SMART WORKFORCE NEEDS SMART ANALYSIS B Y O S C A R A B E L LO

▲ A new mother at Gondar University Hospital.

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magine Sara. She’s a younger woman, newly married to a taxi driver in an emerging market, less defined by her age than she i s by her stage in life. She’s at a crucial moment, weighing whether or not it's worth it to finish her last year of university and start a career in health care, something she’s dreamed about since she was a young girl watching her mother give birth to her younger sister. She could drop out and choose a safer option, like a job in the garment industry, or perhaps return to working on her family farm. Maybe she has an aunt or uncle who offered to invest in setting her up in a small shop selling groceries and beauty products. Or maybe she has heard that a global health insurance company is hiring sales people in the capital, and if she completes her studies she may be qualified for a position there instead of on the frontlines of health care.

Sara’s decision represents a challenge for global health actors. How can they be better equipped to avoid losing her to other, less risky or more promising career opportunities for her and her future family? What can health systems do to better attract top-level talent like Sara? And even if she does follow through to start her professional life in the global health workforce, how equipped are global health actors to keep her there? “This is indeed a very important question,” says Dr. Vera Cordeira, founder and president of Associaçao Saúde Criança, which has faced similar workforce challenges as it has scaled up its multidimensional approach for improving family health to reach more than 40,000 people per month in Brazil. “For us and for most of the social organizations mainly based in the global south, this is one of our main challenges. “We are lucky to have great people working with us who are extremely dedi cated to our cause,” Cordeira continues. For a career as a global health actor to remain viable option for Sara, the field will have to counter with more than just the promise of fulfillment through a life of service to others. The private sector has demonstrated that employers can use employee-level data to improve employee retention, incentivization, training and skill development, and productivity. How can global health leaders apply similar data analyses to improve health systems? Will these analyses better position global health systems to attract and retain the best and the brightest? Multinational corporations have adopted the practice of analyzing employee data in order to determine how to improve the overall productivity and cost-effectiveness of their workforces. Companies can now make data-driven decisions about what stage in the workforce to focus their recruiting and hiring, and what practices they can internally invest in to improve employee retention. “People management has moved beyond viewing workforce spending as an expense to a more expansive view that it’s also an investment,” says Haig Nalbantian, senior partner at Mercer and co-lead of the company’s Workforce Sciences Institute. Nalbantian, a labor and organizational economist, has spent years with his team examining the data that workforces

generate, drawing inferences based on the available evidence on what investments prove to be key drivers in improving employee productivity while reducing overall long-term costs to the business. The past five years, he observes, have been transformational. “We don’t spend time any more talking about value of workforce investments to clients. Now we talk more about what kind of workforce analytics to measure. “Just as marketing functions apply heavy duty analytics to understand consumer behavior, corporations understand they need to do the same for their workforce,” says Nalbantian. “Cost-based or

ment, and did other complementary work.” Then, of course, there’s the issue of wages. Tulenko spoke of another study in Uganda that compared wages in public and private sectors for workers with equivalent years of experience. In general, she says, health workers were getting paid less than others across all sectors with equivalent experience. What does that mean for Sara’s long-term career prospects in health as compared with other sectors? Continual workforce development is important for career growth, as Sara and her peers will always take an interest in growing professionally. Coupled with data

“ A strong global health workforce means attracting, retaining, and developing talent continuously- something that may seem obvious yet remains woefully neglected.”

qualitative methods for deciding workforce investments are not good enough anymore. You need to understand the return on recruitment, training, compensation and supervision.” On recruitment and training, global health systems face key challenges. In Nigeria, for example, 60 percent of Sara’s peers on track for a career in health care drop out, according to a study by CapacityPlus, USAID’s flagship health workforce project. “Just an investment of $300 to $500 each would be enough to see them through that final year,” says Kate Tulenko, senior director at IntraHealth International and director of CapacityPlus, referring to investments mainly in the form of targeted scholarships for students at risk of financial dropout. Global health actors can also take a page from corporations and use data to determine the right benefits packages or other programs to attract and retain Sara and her peers. “One company noted in one of their growth markets workers were lacking education,” Nalbantian says. “So compensation packages included tuition reimbursement, they worked on building schools in partnership with local govern-

to inform what new skills and knowledge are needed in a given context, continuous workforce development is also vital for addressing the rise of new challenges, such as the rising burden of non-communicable diseases. “Facilities may be over-staffed for some services while lacking staff for other needs,” says Dr. Tom Achoki, global health professor at the University of Washington and director of African Initiatives at the Institute for Health Metrics and Evaluation. “You find a place where there is only one nurse trained to deal with diabetes, but there are a growing number of diabetes patients.” “The biggest problem that we have is there is not harmonization in how we collect information in these different areas. There’s not alignment between the workforce and the staffing norms and service they provide,” Achoki says. Achoki also believes that having data on continuous workforce development can help to identify opportunities for task-shifting – moving less complicated procedures like administering diagnostic tests or injecting common medications previously prescribed by more qualified staff – which psi.org | impact

can help employers Mwembeladu to save money over Maternity Hospital, time and implement Zanzibar. Johnson & solutions at greater Johnson, UNFPA. scale. “We have to be able to know that more can be shifted to lower cadres of health workers while being able to monitor and maintain quality and efficiency,” Achoki says. Employee incentives are crucial to evaluate in order to develop health systems. Much data exist on the incen tives that systems used in different workforces, which can assist health leaders in improving talent recruitment and retention where it is most needed. “Let’s think about very clear incentives about how to retain the highly trained skilled professionals we have,” Achoki adds. Full-time versus part-time status is one important incentive that’s often taken for granted in global health programs. Yet that combination can have dramatic effects on the bottom line – measured by finance as well as by quality of delivery. Nalbantian and his Workforce Sciences Institute looked at eight years of data from 25 facilities in a regional hospital system, covering everything from innercity communities to wealthy suburbs and remote rural locations. In a previous attempt to cut costs, the system had dramatically shifted toward hiring parttime instead of full- time workers, thinking that the savings in compensation and benefits would improve their bottom lines. The data contradicted that intuition. The system average was 44 percent full-time workers, but the optimum ratio that would provide the best value for money was 63 percent full-time workers. “That’s not quite an argument against part-time workers, which have their advantages in terms of flexibility to respond to volume or sudden shifts in disease burdens,” Nalbantian says. “It’s just an argument that you can’t just look at compensation as a way to determine value for money.” But is this type of analysis really applicable to NGOs? “We’ve done this work with NGOs,” Nalbantian says. “They’ve been some of the most fun and rewarding projects I’ve been involved in.” He mentioned work with the Organisation for Economic Co-operation and Development, studying its retention and performance of technical staff, as well as work with 28

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” Employee incentives are crucial to evaluate in order to develop health systems.“

the Boys & Girls Clubs of America on local chapter leadership factors as standout examples of using the analysis outside of the traditional corporate realm. There’s no telling exactly how high the stakes are for understanding what can recruit and retain Sara and her peers as health workers in emerging economies. But one can look to other service industries for a sense of what’s possible. Think about the potential implications on global health systems if we thought about workforce development in the same way that Nalbantian does across the private sector. Working with a regional retail bank, Nalbantian and his team gathered data at the branch level – market share, customer retention, growth of premium accounts, and other measures of customer acquisition and revenue growth. Their analysis found that the single biggest predictor

of business success was an employee's average length of service in a position as a frontline worker – in the bank’s case, tellers, customer service reps and assistant managers. They were able to predict that by increasing the average length of service across all frontline branch staff by one year on aggregate, it would be worth $40 million more to the bank’s bottom line annually. Meanwhile, the potential for the average tenure for a health worker in an internationally supported health program remains a mystery. If it were known which incentives could recruit and retain Sara and her peers for longer careers in key global health workforce positions, what might that do to the bottom-line social impact? n

THE POWER OF EDUCATION

B Y D R. VA N E S S A K E R R Y, C E O A N D C O-F O U N D E R, S E E D G LO B A L H E A LT H

elson Mandela once said, “Education is the most powerful weapon which you can use to change the world.” I believe wholeheartedly that education is a spark that can light the fires of many minds. For much of my career, I have worked in resource-limited settings where I have witnessed people’s lives dramatically and often unfairly affected by struggling health-care systems. Health-worker shortages limit the abilities of many countries to deliver even basic health care, let alone respond to more complex needs. Exacerbating the problem is the current global disease burden, which is highest where personnel shortages are worst. SubSaharan Africa, for example, has nearly a quarter of the global disease burden, but only 3 percent of the global health workforce. While many public health efforts have expanded the number of frontline providers, there has not been the same focus on highly skilled doctors, nurses and midwives. The solution, in concept, is simple: health professional training. Investing in a strong, qualified generation of doctors, nurses and midwives is essential to better health-care delivery and stronger health

DR. VANESSA KERRY, MD, MSC, is CEO and co-founder of Seed Global Health, which addresses the health profes sional shortages that contributes to health inequity. She is a physician and assistant professor at Massachusetts General Hospital and an associ ate director at the hospital’s Center for Global Health. She is faculty at Harvard Medical School.

systems. Despite the breadth of efforts to strengthen human resources for health, there are very few programs that invest in current and future generations of publicsector medical and nursing faculty. The Global Health Service Partnership (GHSP) – a public-private partnership between Seed Global Health, the United States Peace Corps, and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) – is implementing this education-based approach on a global scale. In collaboration with host country governments and training institutions, GHSP

supplement what she taught them in the classroom. One day, a student ran up to her and said, “Madam, I diagnosed a patient with pneumonia! He had a cough, chest pain and respiratory distress!” The bedside training pushed the students beyond their theoretical lessons to successfully treat patients in the clinical setting. Skilled health professionals like Maureen and Dorothy are providing essential training to local faculty, who in turn provide ongoing support to frontline health workers, improving health care now and for generations to come.

” Education has the power to transform global health. It is up to us to light the fire.“ sends U.S. physicians, nurses and midwives as volunteer educators for one year to medical and nursing schools in Malawi, Tanzania, and Uganda. There, they immediately increase teaching capacity and support clinical-care delivery. Alongside local faculty, these health professionals teach trainees in classrooms and on wards and help to develop innovative teaching tools and clinical guidelines. We are already seeing the ripple effects from this program’s model. Our inaugural class of 30 GHSP volunteers taught more than 2,500 trainees. Maureen, an OB/GYN volunteer working in rural Tanzania, trained 45 hospitalbased labor nurses on life-saving labor practices this past spring. Shortly after, her fellow physicians asked if she had also taught nurses in the rural villages. Maureen had not, but the 45 labor nurses had spread the word and even taught the community doctors. Maureen had trained the hospital staff, and the effects had spread throughout the community rapidly. When Dorothy, a GHSP nurse serving in northern Tanzania, realized that her trainees were lacking hands-on experience – a common issue in many of our sites – she worked alongside her students on the wards to

The GHSP model has been called the “missing link of health care delivery” by Dr. Joyce Banda, former president of Malawi. It is not only effective, but also efficient. The program leverages the Peace Corps’ 50-plus years of experience placing U.S. volunteers abroad and combines it with Seed Global Health’s technical expertise and experience in medical and nursing education. The GHSP places U.S. health professionals at a lower cost compared with many other programs, and builds deep, mutually beneficial relationships with in-country partners. Seed Global Health also offers debt repayment to offset education, mortgage or other financial burdens, reducing barriers for the highest-qualified candidates to engage in service. To help meet demand, GHSP is expanding. We are sending 42 volunteers to all of the same sites and several new ones. One of Maureen’s students sent her a thank-you note in which he said, “A candle loses nothing by lighting another candle.” And then he continued, “You were that candle to us, and I will light another new candle someday!” Education has the power to transform global health. It is up to us to light the fire. n psi.org | impact

policy matters HEALTH WORKERS ARE CRITICAL TO REACHING AN AIDS-FREE GENERATION B Y R E P R E S E N TAT I V E S B A R B A R A L E E (D-C A ), I L E A N A R O S-L E H T I N E N (R-F L) A N D J I M M C D E R M OT T (D-WA) C O-C H A I R S O F T H E C O N G R E S S I O N A L H I V/A I D S C A U C U S

hen we talk to people on the frontlines of the global fight against HIV/ AIDS, one thing becomes immediately clear: There is a great shortage of trained health workers. Dedicated health workers provide millions of people who are living with HIV in developing countries with life-saving antiretroviral treatment, care and support, and with testing and counseling services. Often, clinics are out of reach for many people, so frontline health workers go to their communities. They ensure that patients adhere to their medication, provide home-based care, and lead prevention and stigma-fighting efforts. But there is a significant lack of these critical frontline fighters. As a result, many of those who are most vulnerable to this pandemic have little to no access to health workers. This is an enormous barrier to the long-term goals of preventing new infections and ensuring

that all in need of antiretroviral treatment receive it. As we have seen from the recent Ebola outbreak in West Africa, a lack of welltrained and supported health workers makes the fight against a range of global health threats – and the daily business of saving the lives of mothers and children – much more difficult. Six years ago, great champions from both parties joined us in writing one of the greatest bipartisan pieces of legislation of this century – the Lantos-Hyde Global Leadership Act Against HIV/AIDS, Tuberculosis and Malaria. Lantos-Hyde reauthorized the President’s Emergency Plan for AIDS Relief (PEPFAR). Among the provisions of that legislation was a PEPFAR requirement to train and retain 140,000 new health workers. To meet this goal, more work must be done to ensure that partner countries have the adequate staffing levels to deliver HIV/ AIDS prevention, life-saving treatment and care, and other essential health services.

“ Supporting our partners to build a robust and sustainable health workforce is critical to winning the long and difficult fight we’ve had with HIV/AIDS.”

Rep. Barbara Lee

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Rep. Ileana Ros-Lehtinen

Rep. Jim McDermott

It is critical to support our partners in building a robust and sustainable health workforce to win the long and difficult fight against HIV/AIDS. To this end, we led on the passage of the PEPFAR Stewardship and Oversight Act of 2013, which also received strong bipartisan support. Among other new reporting requirements, the law requires PEPFAR to provide to Congress an annual “description of efforts by partner countries to train, employ, and retain health-care workers, including efforts to address workforce shortages.” PEPFAR supports life-saving antiretroviral treatment for more than 6.7 million people living with HIV, and supported treatment to prevent mother-to-child transmission to 1.5 million HIV-positive pregnant women in the past two years alone. It has also provided testing and counseling for more than 60 million people. These are remarkable achievements, and they are a testament to what can be accomplished through an open debate and bipartisan consensus-building. As PEPFAR works to implement its blueprint for an AIDS-free generation, it will require reaching more remote and underserved communities. Frontline health workers who live and work in these communities will be critical in providing services to these hard-to-reach populations. Therefore, we must work with our partners to solidify and build on the service delivery platform that PEPFAR helped to establish, and continue to empower vulnerable communities to fight this pandemic. This will require a coordinated and cohesive plan to ensure that our efforts have maximum impact to save lives and achieve the goal of an AIDS-free generation. n

THE HEALTH WORKFORCE MUST BECOME THE IT ISSUE B Y V I N C E B L A S E R, D E P U T Y D I R E C TO R, F R O N T L I N E H E A LT H W O R K E R S C O A L I T I O N

n the last decade, I’ve become well-versed in the revolving door of global health’s “it issues” – those that mobilize policy change and increase investment from donors, governments and multilateral institutions. In the early 2000s, a focus on AIDS galvanized the creation of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria – enabling millions of lives to be saved. In recent years, the United Nations Every Woman, Every Child Campaign and the Global Call to Action on Child Survival have refreshed enthusiasm around ending preventable maternal and child deaths. Health workforce strengthening has yet to become global health’s “it issue,” though we’re seeing some signs that it’s on the verge. If those signs fizzle, much of the progress made in, and hoped for in strengthening the health workforce in the coming decades will be in jeopardy. Why? We don’t have nearly enough health workers in the places where most preventable deaths occur, and those we have need more support. As we work to end

VINCE BLASER is Deputy Director of the Frontline Health Workers Coalition, an alliance of more than 35 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. frontlinehealthworkers.org

infectious disease pandemics, and ensure mothers and children survive and thrive, it will require getting services to harderto-reach locales. The World Health Organization (WHO) estimates at least 83 countries lack the number of doctors, nurses and midwives to provide essential services to their entire population, even if they were equi-

also paid off. Nepal achieved its MDG 5 target early and is on track to achieve MDG 4 by 2015. Fifty-seven countries made concrete health workforce commitments last year at the Third Global Forum on Human Resources for Health in Brazil. Ireland was the only country that made a donor investment commitment.

“ WHO estimates that about 1 billion people have little-to-no access to a health worker.” tably distributed (which they are not). As a result, WHO estimates that about 1 billion people have little-to-no access to a health worker. So where are the signs that health workforce is emerging as an “it issue?” They have come from some of the countries facing the most acute health workforce crises. About 10 years ago, the Ethiopian government decided train, support and pay tens of thousands of frontline health workers in rural and neglected areas. This resulted in astounding progress. Two years early, Ethiopia met the Millennium Development Goal (MDG) 4 target of slashing child mortality by twothirds from 1990 to 2015. The country is expected to soon meet the MDG 5 target of decreasing maternal mortality by three-quarters, and since the introduction of PEPFAR in 2005, HIV incidence has dropped there by 90 percent. In Nepal, the government approached the issue differently, recruiting 50,000 women to volunteer as community health workers and formally linking them to the health system. This focus on improving access to frontline health workers has

However, we’re beginning to see donor governments step it up for health workers. USAID helped lead the charge in pushing for the world’s health ministers to agree on a global strategy for the strengthening the health workforce by 2016. The health workforce was also included in the draft post-2015 Sustainable Development Goals. Strategies with concrete targets and financial commitments need to follow these actions. At a recent Frontline Health Workers Coalition meeting, Martha Kwataine, executive director of the Malawi Health Equity Network, was asked if her alliance experienced any difficulty in mobilizing advocates who work on different health issues to push for health workforce improvements in Malawi. She said, “No, it was not difficult. It was a common secret – everyone knew we had to improve our health workforce.” To make global health progress that could bring transformational changes in well-being and prosperity, our health workforce deficiencies and inequities must be transformed from a “common secret” to an “it issue.” n

psi.org | impact

final word

TO STRENGTHEN HEALTH SYSTEMS, INVEST IN PEOPLE

dvances in technology have brought us revolutionary progress in global health: vaccines, rapid diagnostic tests, mHealth and more. Investment in developing these technologies has been critical – but just as vital is investment in delivering them. People – health workers in particular – are the ones who keep the long hours and walk the last mile armed with treatment, devices and information. They include midwives, community outreach workers, pharmacists, nurses and doctors, and they’re the vital link between the health system and the community. This is evident now more than ever as we try to contain an aggressive Ebola outbreak that is stalking West Africa. IntraHealth International and PSI operate programs in the region, where health workers are the backbone of our operations. The Ebola outbreak has shown that health workers are both key to containing the virus and also incredibly vulnerable.

KARL HOFMANN

PAPE GAYE

President & CEO, PSI

President & CEO, IntraHealth International

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A crisis of this magnitude chips away at the already fragile state of health systems across low- and middle-income countries. It also signals a necessity to invest in health systems and health workers more urgently than ever. The World Health Organization estimates a global shortage of 7.2 million doctors, nurses and midwives. If we fully utilized community health workers on the frontlines, the lives of more than 3 million children could be saved. We could also see a 40 percent reduction in newborn deaths with an increased labor and delivery workforce. In Ethiopia alone, rates of young children immunized, treated for pneumonia and given vitamin A doubled with the training and deployment of 38,000 frontline health workers. Investments must be made in training and retaining health workers at all levels; advocating for policies that allow lowerlevel medical practitioners to perform certain procedures, such as voluntary medical male circumcision; engaging and regulating the private health sector, where so many people seek health products and services; and investing in the next generation of health workers. And we must work together – community and faith-based organizations, international NGOs and the private sector – with national governments to build a stronger global health system that better supports health workers. Invest today, build the capacity of tomorrow, secure the health of our future. n

Health workers. When it comes to fighting disease and improving health, theyâ&#x20AC;&#x2122;re the most valuable resource we have.

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There is a shortage of 7.2 million health workers across the globe.

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