Annual Report 2014: Building Healthy Communities by Bringing CHWs to Scale

ANNUAL Building Healthy REPORT Communities by 2014 Bringing CHWs to Scale

The mission of the One Million Community Health Workers Campaign is to support governments, global partners, and national stakeholders dedicated to Community Health Worker (CHW) scale-up in the context of health systems strengthening.

We aim to achieve this by: • Advocating for the recognition of CHWs as a formal cadre of health workers

• Providing technical assistance to governments seeking to enhance and scale-up nationally recognized CHW programs

• Urging financing organizations to support CHWs and motivating countries to demand this support from donors

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TABLE OF CONTENTS

pg. 4 A Message from the Director of the 1mCHW Campaign pg. 6 Working Towards Universal Health Coverage: Campaign Country Operations pg. 15 Epidemic Response: Using mHealth to Address the Ebola epidemic pg. 17 Counting and Tracking CHWs pg. 21 Health Workers Count: Advocating for UHC pg. 24 Thank You to Our Donors & Partners

3 ANNUAL REPORT 2015 ANNUAL REPORT 2014

FROM THE DIRECTOR OF THE CAMPAIGN

This January marked the two-year anni-

fected countries. Of course, the need is far more general. Around

versary of the One Million Community

subSaharan Africa hundreds of millions of people in rural areas still

Health Workers

lack access to trained health workers.

(1mCHW) Campaign.

Launched two years ago at the African Union, the Campaign was created on the

Nevertheless, the Campaign continues its work and its advocacy

basis of experience from the Millennium

with even more resolve and dedication. In Fall 2014, the Campaign

Villages Project (MVP) and academic liter-

and Earth Institute were asked by President Alpha Conde of

ature that community health workers

Guinea to help design and implement a national Ebola response

(CHWs) can be a decisive force for saving

and to build epidemic-control capacities at the local level, includ-

lives and reducing disease burdens in low income settings. All of

ing the deployment of CHWs to perform contact tracing with

our work since then, whether in response to the Ebola epidemic

mobile information systems to transmit data between CHWs and

or our day-today discussions with the Ghanaian government,

district, regional, and national health teams. With the support of

reinforces one key message: CHWs save lives and should be a high

the Campaign, there are already more than 200 CHWs and CHW

priority of all African governments and their international partners.

supervisors trained and deployed in Guinea, each equipped with a smart phone that, supported by Dimagi’s software CommCare, has

There could not have been a more painful reminder of the urgent

an Ebola-specific application for contact tracing and data trans-

need for a network of trained CHWs than the Ebola epidemic in

mission. Once the Ebola epidemic is over, this national network

West Africa. We all know that Ebola is a controllable epidemic,

of “Ebola detectives” will be trained to become a national cadre

indeed with a relatively low rate of transmission when a basic

of CHWs responsible for bringing health care to community door-

public health system is in place. However, it spread from Guinea to

steps.

Sierra Leone and Liberia, becoming a massive killer, only because there were not effective local public health services in the region

The Campaign’s Ebola response work does not end with Guinea.

to stop it from escalating. The lack of CHWs meant that these West

The team is also working with Ghana’s health experts and govern-

African countries lacked a first line of defense.

ment officials on the rapid deployment of a fully functional CHW program in six districts of the Ashanti region. The government

There is a special irony here. Prior to the Ebola epidemic, the

aims to scale-up CHWs at the national-level in subsequent years.

Campaign had canvassed the international aid agencies and

The systematic deployment of CHWs at district scale in Ghana,

multilateral health institutions to support the scale-up of a CHW

supported by a generous grant from GSK, will provide a roadmap

program in Liberia. We worked closely with the Liberian Ministry

for other countries in Africa and will begin to strengthen Ghana’s

of Health to prepare the government’s strategy and assist with

first-line defense against Ebola and other epidemics. We are look-

outreach to donors. Yet, the international community did not make

ing forward to forging ahead in Ghana this year and are excited

this funding available, considering the CHW program in Liberia

about expanding our efforts to work towards universal health

to be a low priority. Unfortunately, we soon learned that it was

coverage across sub-Saharan Africa.

a priority beyond imagining, but too late. Now there is much talk globally about the need for scale-up of health systems in Ebola-af-

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Sonia Ehrlich Sachs

“UHC IS WHERE ALL DISEASES COME TOGETHER, ALL COUNTRIES HAVE PRIMARY HEALTH SYSTEMS, ALL AGES AND ALL CLASSES HAVE CARE.” PROF. JEFFREY D. SACHS, DIRECTOR, EARTH INSTITUTE

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Working Towards Universal Health Coverage: Campaign Country Operations The Campaign actively supports African Ministries of Health (MOH) in planning for CHW scale-up in the context of health systems strengthening. We guide MOHs in the development of a Roadmap – a strategic financial and operational plan for implementing CHW programs at scale. These plans—developed as a coherent part of national health system strengthening efforts—capability mapping, implementation planning, supply chain management, and the identification of potential funding sources (both external and domestic).

Throughout this planning process, we work to empower decision makers with tools and best practices to inform CHW system upgrades. Once countries have completed a Roadmap, we engage with donors, NGOs, the private sector, and other partners to garner support for governments and facilitate a harmonized approach to human resources for health (HRH) deployment.

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Ghana This past year marked a busy and exciting one for Ghana, where the Campaign has been supporting the MOH and Ghana Health Service (GHS) in the design and costing of their national CHW Program. In April 2014, Ghana became the first Campaign country to finalize and publically release its CHW Roadmap – Ghana’s comprehensive operational plan to achieve CHW scale-up over 10 years.

The cornerstone of this plan is to integrate CHWs into Ghana’s existing Communitybased Health Planning and Services (CHPS) program to improve access to essential health services within the community. With assistance from World Vision International and World Vision Ghana, the MOH, GHS, and CHW Technical Advisory Group (TAG) have begun developing an integrated training curriculum for this CHW cadre. This curriculum is a key step toward making the Government’s vision for integrated health service delivery a reality.

Following completion of the CHW Roadmap, the Campaign assisted the MOH and GHS in mobilizing funds to support implementation of the CHW Program. To keep up with the Ghanaian government, we placed a field specialist in Ghana, who works closely with the MOH and GHS to build upon the existing operational Roadmap and transition into implementation planning. To culminate this work, this past December we hosted a delegation from the MOH and GHS in New York City to meet with Professor Jeffrey Sachs and our team. The visit provided a prime opportunity to strategize and build a work plan for implementation of the program in 2015, beginning with the training and deployment of CHWs across six districts in the Ashanti Region of Ghana.

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WORKING TOWARDS ACHIVIEVING UHC

Burkina Faso In June 2014, Burkina Faso developed a CHW profile for a national CHW program. With support from the Bill and Melinda Gates Foundation, the Campaign’s field specialist in Burkina Faso has been actively engaged with the MOH to assist with planning the scale-up of a national CHW program. Through the past year, we have worked closely with partners such as WHO, UNICEF, and Johns Hopkins University to move scale-up forward.

With our collaboration, the MOH Health Promotion Team developed a draft Roadmap for a national CHW program, which will serve as Burkina Faso’s operational plan for scaling-up their community-based health program, Santé à Base Communautaire (SBC).

The draft version of the Roadmap has been presented to partners for finalization, and we are optimistic that the Roadmap will be submitted for validation by the Minister of Health in 2015.

The Campaign has offered critical technical support to Burkina Faso to ensure that the government is on track to achieving its maternal and child health (MCH) goals, as well as universal health coverage (UHC). While work in Burkina Faso has not moved as quickly as we had originally expected and planned, due to domestic circumstances beyond our control, the support provided is viewed as a valuable service to the MOH. As we move into the final stages of Roadmap development, Burkina Faso will eventually begin planning for implementation of their national CHW program.

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Kenya In 2014, the Campaign continued to assist the Kenyan Ministry of Health (MOH) with operational planning and stakeholder engagement, which resulted in a draft Roadmap for scaling-up Community Health Services (CHS). The first draft of the Roadmap was completed in March 2014, and the document has since undergone several revisions.

The final draft is expected to be finalized in 2015 after all counties have reviewed the document. Once completed, the document will be presented to the Cabinet Minister of Health for endorsement and will be used as an advocacy tool for scale-up and to improve CHS across the country.

In addition to operational planning, advocacy for implementation of the Roadmap was also initiated at a national “County Advocacy and Standards Workshop for CHS� in July 2014. At this workshop we assisted the MOH with advocating to Directors of Health, Focal Persons for CH Services, and Chief Executive Council Members about including the implementation of CHS and employment of Community Health Extension Workers (CHEWs), who are the main cadre providing services at the community level in Kenya, in their county health budgets. We anticipate that implementation of the Roadmap in the counties will begin in 2015.

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WORKING TOWARDS ACHIVIEVING UHC

Liberia This past year the Campaign, in partnership with Tiyatien Health, supported Liberia’s Ministry of Health and Social Welfare (MOHSW) in finalizing Liberia’s Community Health Roadmap. In July 2014, two members of the Campaign Secretariat traveled to Liberia to conduct a costing and implementation planning workshop with the MOHSW to assist with strategies for scaling-up the general Community Health Volunteer (gCHV) program across the country.

Unfortunately, the Ebola epidemic struck Liberia particularly hard, shedding light on the necessity of a strong public health system supported by CHWs. The Campaign is in the process of reengaging with partners, such as Tiyatien Health, and working with UNFPA and other public health leaders to coordinate an Ebola response strategy utilizing CHWs for contact tracing and Ebola sensitization.

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Nigeria In 2014, the Campaign continued to support the Nigerian National Primary Health Care Development Agency (NPHCDA) with operational planning and stakeholder engagement. Our field specialist in Nigeria conducted an operational planning and costing workshop with the leadership of NPHCDA to finalize Nigeria’s program design and estimated cost, which resulted in the completion of a Roadmap for scalingup village health workers (VHWs) across the country. After this workshop the Roadmap was distributed throughout NPHCDA for comments, and a final draft of the Roadmap was sent to the Minister of Health in the fall of 2014. During this time, the Campaign’s field specialist worked with NPHCDA and the Federal MOH (FMOH) to begin coordination between the two agencies for implementation planning. The Campaign has offered technical support to the government of Nigeria, which has helped strengthen the current VHW program and prepare it for comprehensive scale-up across local districts.

However, due to changes within the FMOH, as of December 2014, the Roadmap is still in the office of the Minister of Health awaiting review and signature.

A new MOH was appointed in the winter of 2014, so NPHCDA has continued to pursue the adoption of the Roadmap, seeking assistance from the Campaign when needed.

We have been asked to assist NPHCDA with planning a stakeholder meeting to discuss roles and opportunities for implementation in 2015. The goal of the meeting will be implementation planning for scale-up of the VHW program, including determining the reporting framework, operational plan, financing framework, and VHW recruitment and deployment. 2015 will be an exciting year for Nigeria, as NPHCDA plans to kick-off the implementation planning process by performing a landscape analysis to determine where current VHWs are deployed, which will inform new strategies for VHW recruitment and deployment by government, partners, and private sector for scale-up.

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WORKING TOWARDS ACHIVIEVING UHC

Tanzania In March 2014, Tanzania’s Ministry of Health and Social Welfare (MOHSW) requested the Campaign’s assistance with the costing and operational planning of a CHW program for Tanzania’s community health strategy development. A preliminary costing exercise was conducted with the national CHW taskforce in the absence of a written program design.

Throughout the year, we have continued to work closely with key in-country partners that are supporting the MOHSW in implementing the Community Based Healthcare Strategy.

In October 2014, the Campaign, in partnership with the MOHSW, conducted another operational and financial planning exercise at a costing workshop sponsored by Jhpiego. During this workshop, we assisted the MOHSW with finishing the first draft of the national CHW program design. The Campaign team looks forward to continuing to to the MOHSW this upcoming year.

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Uganda The Campaign began conversations with the Ugandan Ministry of Health in Fall 2013, and Uganda officially joined the Campaign in February 2014. The Ugandan MOH plans to create an operational and financial Roadmap to upgrade Uganda’s national CHW platform, the Village Health Team (VHT). While 112 districts in Uganda are currently serviced by VHTs, the MOH intends to support the formalization, recruitment, training, and deployment of additional VHTs to ensure that 100% VHT coverage is achieved in rural Uganda.

In partnership with UNICEF and IntraHealth International, we will be assisting the MOH with creating a national VHT registry and linking it to our Operations Room. We are excited that Uganda will be one of the priority countries for implementation of the next phase of the Operations Room in 2015 with the aim of making CHW data more usable and interoperable. This year, we anticipate integrating the impact and scope of VHT activities into the Operations Room’s interactive map.

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Photo credit: NIAID

“AS TRANSMISSION DECLINES IN LIBERIA, GUINEA, AND NOW HOPEFULLY SIERRA LEONE, BATTLING THE EPIDEMIC DOWN TO ZERO WILL REQUIRE EVEN MORE PRECISE, DATA-DRIVEN ACTION TO STAMP OUT THE CASES THAT REMAIN.” DR. RANU S. DHILLON, SENIOR HEALTH ADVISOR, EARTH INSTITUTE

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Epidemic Response: Using mHealth to Address the Ebola Epidemic The Campaign has been engaged, as part of the Earth Institute’s Ebola Response Team, to assist in the rapid deployment and scale-up of CHWs for Ebola response in Guinea. The Ebola Response Team is currently working with the Government of Guinea to train CHWs as contact tracers in affected prefectures. To date, over 200 CHWs and supervisors have been trained. These CHWs are deployed with CommCare, an mHealth application that supports a real-time informatics system for enhanced Ebola response. Applying lessons learned from implementing mHealth in the Millennium Villages Project (MVP), the Ebola Response Team – in partnership with the Guinean Government and UNFPA – is supporting the implementation and scale-up of a robust CHW system for emergency response that will transition over to primary care once the epidemic is contained. Data collected from CommCare has helped CHW supervisors and the National Coordination Committee (NCC) for Ebola Response assess the effectiveness of contact tracing efforts and identify gaps in epidemic response. This has been critical to improving Guinea’s contact tracing strategy. In 2015, we will continue to move this work forward by assisting the NCC and the MOH with preparations for the transition of the CHWs in Ebola recovery planning, which will include operational planning and costing of a fully scaled national CHW program.

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“WE HAVE A GREAT OPPORTUNITY TO HARNESS THE POWER OF DATA TO SUPPORT THE GLOBAL HEALTH WORKFORCE.” MICHAEL BZDAK, DIRECTOR OF CORPORATE CONTRIBUTIONS, JOHNSON & JOHNSON 16 ONE MILLION COMMUNITY HEALTH WORKERS CAMPAIGN

Counting and Tracking Community Health Workers The Operations Room is the signature information system platform built by the

Campaign in partnership with Direct Relief and ESRI to track CHW activities and operations across sub-Saharan Africa (SSA). The Operations Room has undergone two phases of development since its inception in November 2013, which has helped shape the current strategy.

Phase 1 provided the very first visual interface to explore CHW data, which promoted our goal of increasing the public’s understanding of CHWs. This first iteration of the Operations Room was a map of SSA with various CHW programs and their descriptions “pinned” onto the corresponding country. To assist with data collection during this phase, we worked with various partners including American Red Cross, MDGHA, A Promise Renewed, and UNICEF to develop CHW program profiles that provide snapshots of CHW program components, key bottlenecks, and

other issues across 17 countries. We also conducted a “utility survey” to collect more information on CHWs and CHW programs in SSA and to better understand program providers’ needs for a CHW data-sharing platform. Overall, organizations appreciated the Operations Room as a hub for sharing and gathering useful information on CHW programs, global best practices, and innovation in the field.

The full report can be found on our website.

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ANNUAL REPORT 2014

COUNTING AND TRACKING CHWS

From the information gathered through the utility survey, we upgraded the Operations Room into an instrument that will help estimate gaps in human resources for health (HRH) in Phase 2, which was launched in October 2014.

Improvements marked the platform’s shift from being a descriptive tool to an analytical tool that can support CHW gap analyses and planning in HRH. We specifically focused on improving the user experience to ensure easier access to data. Currently, the Operations Room contains data on CHW counts, health indicators, and population coverage, which empowers governments and partners with information on the CHW landscape. The data on the Operations Room has provided the Campaign with some staggering statistics. The data points show that: •

Over 130,000 CHWs are deployed across SSA

• Over 27 million people are covered by CHWs in SSA • The average CHW-to-household ratio was 1 CHW to 149 households • The top three most common services provided by CHWs are: community health promotion and counseling, referrals to/from health facilities, and monitoring of malnutrition and other danger signs

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We expect to launch Phase 3 of the Operations Room in 2015. Phase 3 will offer near real-time data visualization and analysis of operational activity through an innovative approach to data collection via mobile technology and an integrated data infrastructure solution. This will result in the development of a comprehensive analytics tool that can be used to support country-level registration and tracking of CHWs. We plan to complete this through the integration of data from mobile technology and other information systems, such as iHRIS or DHIS2, which will provide improved data insight for all users.

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ANNUAL REPORT 2014

“IF CHWS ARE USED TO DELIVER THE INTERVENTIONS THEY ARE CAPABLE OF DELIVERING AND IF 100% COVERAGE COULD BE ATTAINED, THEN THE LIVES OF 3.6 MILLION CHILDREN WOULD BE SAVED EVERY YEAR. ISN’T THAT A SIGNIFICANT MOTIVATION FOR GREATER INVESTMENT IN CHW PROGRAMMING?” 20 ONE MILLION COMMUNITY HEALTH WORKERS CAMPAIGN

DR. HENRY PERRY, SENIOR SCIENTIST, JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH

Health Workers Count: Advocating for Universal Health Coverage Working to Improve CHW Training Programs The Campaign, along with mPowering Frontline Health Workers, began leading the effort in advocating for the adoption of a standardized core curriculum for CHWs. In the summer of 2014, the Campaign and mPowering Frontline Health Workers published two papers on CHW training programs. The first, titled The Current State of CHW Training Programs in SSA and South Asia is a landscape analysis highlighting best practices,

lessons learned, and training gaps. This report provides clear recommendations for the international community on how to improve CHW training standards and curricula. We presented this paper during a series of global consultations in Washington DC, London, and Geneva. Taking the recommendations and feedback from these consultations, we authored a second report, An Integrated Analysis of Current Research on CHW Training, and shared it with the World Health Organization (WHO) and Global Health Workforce Alliance (GHWA). Conversations with the WHO are ongoing, and we are eager to continue this critical advocacy work with mPowering Frontline Health Workers in 2015.

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ADVOCATING FOR UHC

A Commitment to Community Health Workers: Improving Data for Decision Making The Campaign, as a member of the Frontline Health Workers Coalition (FHWC), along with Jhpiego, Johnson & Johnson, and IntraHealth International, has continued to help lead the effort in advocating for the creation of a “State of the World’s CHWs Report” (SOWCHW Report). Throughout the course of 2014, the SOWCHW Report Committee developed a short report on the need for the collection and dissemination of CHW data.

We were appointed to co-manage the construction of this document and worked closely with a technical writer to finalize content. Included within this report is a “Call to Action” that designates the Operations Room as a source for hosting the requested global CHW data. This advocacy document was completed in time to be presented at a side-session organized by the SOWCHW Report Committee at the Third Global Symposium on Health Systems Research, in Cape Town, South Africa, in September 2014. We plan to continue to work with the FHWC and Johnson & Johnson to further this important work in 2015.

Putting the Spotlight on CHWs This past year the Campaign team planned and participated in two high level events at the United Nations General Assembly (UNGA) in September 2014. The first event, in partnership with Johnson & Johnson, focused on the importance of real-time data with respect to frontline health workers and gave the audience a sneak peek of Phase 2 of the Operations Room. The second event, in collaboration with the Rockefeller Foundation, KOICA, the Permanent Missions of Zambia, Senegal, and Japan, and other partners, highlighted the critical role of CHW’s in achieving UHC. Both of these well-attended events

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brought wide attention to two critical areas of our advocacy work: the importance of health workforce data and UHC. We are excited about the advocacy opportunities that 2015 brings with the development of the sustainable development goals (SDGs), and we intend to plan a follow-up event on health workforce and UHC for the UNGA this year.

Working Towards Creating a System to Count Community Health Workers In November 2014, the Campaign, in partnership with iHEED, IntraHealth International, KOICA, and USAID held a side session at the 2014 GETHealth Summit in Dublin, Ireland.

Guided by the fact that current data available on the international health workforce, particularly CHWs, is incomplete and inconsistently managed, we hosted an interactive working session that examined current practices and innovative solutions for health workforce registries. Through audience participation, we learned how to approach Campaign countries with the idea of including CHWs in a formal health worker database. We are hopeful that Campaign country partners will begin to work together to build strong CHW information systems and ensure that CHWs are captured as part of countries’ formal health worker databases. To fulfill this ambition, we plan on beginning this process with the Ghanaian government in 2015.

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Thank You to Our Donors & Partners We are grateful to our donors and partners: the individuals, corporations, foundations, organizations, multilateral organizations, bilateral funders, and sub-Saharan African governments who are working together to campaign for one million community health workers in SSA. With your generous cooperation and support we are able to continue to progress a global movement towards UHC that helps build healthy communities across sub-Saharan Africa.

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