Category Archives: Data for Decision Making Series

Scale-up of Community Health Worker Programs – What’s the Point of Data?

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Our interview series on the need for data and information on community health workers (CHWs) continues. This week, we hear from Lesley-Anne Long, Global Director of mPowering Frontline Health Workers on how much data is needed, what kind, and how it can help strengthen health systems and support CHWs at scale.

mPowering Frontline Health Workers is a public-private partnership focused on ending preventable child and maternal deaths.  As Global Director, Lesley-Anne provides strategic leadership to mPowering and coordinates across mHealth, maternal and child health advisors, program implementers, government officials, private sector, NGOs and others focusing on sub-Saharan Africa and South Asia. A former family law barrister, and Dean of a Faculty of Health & Social Care, she has a strong track record of academic publications in law, global health and child rights.

A quick look at any 2015 global health calendar of events reveals continuing interest – some might say an obsession – in two topics: ‘scale’ and ‘big data’.

Let’s look at scale first. Why, after years of expert consideration, thoughtful research and a global health community focused on a shared goal, have we spectacularly failed to scale up community health worker (CHW) programs (with a handful of notable exceptions)? What are the challenges to scale and, more importantly, what can we do about them?

The Journey to Scale, commissioned by the Bill & Melinda Gates Foundation, released by PATH last year, sets out some of the key components for scale, all of which could be applied to CHW programs:

  • Ministry of Health providing the mandate and drive for national solutions
  • An increasing emphasis on interoperability and shared standards
  • Committed leadership from implementing organizations
  • Systems and tools designed to be used by thousands and in some case millions of users.

Seems straightforward. But consider this. The quality and supervision of CHWs varies widely, and their training is routinely ineffectual, inappropriate and infrequent. CHWs are often burdened by unfeasible workloads yet may be under-valued by their communities, other health workers and Ministries of Health. Add to these challenges the fragmented activities of the global health development players – where collaboration is vital but consistently fails to move from rhetoric to reality, and where funding so often ring-fences aspiration for impact. It’s hard to see how scale is ever possible.

Can smart use of data offer solutions to these challenges? Is the reason that we’ve failed to scale simply that we haven’t collected the data we need to make great decisions to reach more health workers, more effectively? Could the right data generate new insights and unlock the barriers that block progress towards our goal of scale? And if yes, what is the ‘right data’?

Do we need more data on data?

We’re increasingly hearing about the importance of data (especially ‘Big Data’) for better decision-making. Many believe that applying the insights of big data in developing countries could help NGOs and governments solve some of their biggest health challenges.

But can data really help scale-up CHW programs? Perhaps it can, but not on its own, and here’s why.

The challenges to scale outlined above are not data-related, they’re human-centered. They require effective communication, relationship-building and shared aims. If we want to improve the quality of training, we need to provide CHWs with relevant, quality content. And train the trainers to help deliver better learning outcomes. If we want to go to scale but focus simply on quantitative statistical data, with little or no qualitative information about the priorities and perspectives of CHWs themselves, we’ll fail to tackle human elements (inequalities in professional development, support, and pay) that will help us achieve our goal.

Is data the super-highway to scale?

Increasingly, the opinion of the global health community is an emphatic yes. Accurate and consistent health workforce data on CHWs is seen as the foundation for improved decision-making, better national dialogue on health workforce development and increased potential to scale up CHW programs effectively. In its 2014 report, A Commitment to Community Health Workers: Improving Data for Decision-Making, the Frontline Health Workers Coalition sets out a compelling case for documenting country-level data on CHW numbers and the services they deliver.

Data would allow CHW cadres to be “studied, researched and evaluated in detail” whereas the current lack of data is seen as “significantly constrain[ing] national decision-making within ministries of health”. The report continues: “Better data will provide […] key workforce analytics indicators that will monitor, manage and optimize CHW performance [and] encourage the planning that takes into account the possibility of career advancement for CHWs within the health system …”

In other words, the more we know about CHWs, the more likely it is that governments can develop national strategies to train, support and integrate these critical health workers into their national health systems.

From data to scale: what’s needed?

Clearly there are multiple and nuanced components that involve the transition from documenting and analyzing data to achieving scalable CHW programs. Three critical elements stand out:

  1. Investment in national CHW databases – for documenting numbers, deployment and services – will be an important step for governments on the road to scaling their CHW programs. Such databases would enable national decision making and global analysis of comparative data across countries, as well as help chart global trends and progress over time.
  1. Exploit the exponential opportunities that mobile technologies offer. Mobiles can automate data collection, disease surveillance, improve accountability, and strengthen the interconnections between health workers, health facilities and health ministries.
  1. Promote effective coordination, via shared information networks and common standards. Interoperability frameworks such as OpenHIE can be used to identify shared information resources (such as health worker registries), inform policy planning and potentially trigger the financing needed to scale up community health programs.

Global health development is a complex and dynamic field. A strong health system requires effective leadership, governance and accountability mechanisms; adequate financing; sufficient supplies and equipment; robust infrastructure (including information systems) and a well-trained, motivated workforce from the community level upwards. Data can document and chart many of these, but measurement does not equal meaning. Data can flatten and simplify the landscape, and reduce lives and needs to numbers. The danger is that data is the ‘Instagram’ of development – capturing a moment, but failing to tell the story behind it.

Good decision-making and getting to scale needs quality information and data. So let’s count CHWs by all means. But let’s not forget to listen to them as well.

Data for Decision Making Series: Julia Bluestone

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To continue our interview series on the necessity of acquiring data on community health workers, this week the Campaign spoke to Julia Bluestone, Sr. Technical Advisor at Jhpiego and Chair of the Frontline Health Workers Coalition. A senior public health official and certified nurse-midwife, Ms. Bluestone has had 15 years of experience in international education and training implementation, working with national ministries of health and professional associations to improve national education and training efforts in African countries.

What are the most pressing challenges in the development of scale-up of CHW programs today?

The most pressing challenges are rationalization and harmonization of partners and approaches. The harmonization framework rightly points out the need for partners to align and harmonize so ministries of health can select a rational skill mix of health workers based on their national health priorities and burden of disease. When multiple partners support a variety of CHWs with varied skills and compensation (or lack thereof), scale up is not feasible.I see adherence to a core set of expected skills, with some room for variation, obviously, key for countries to be able to rationally determine how to involve CHWs in the community health team.  What CHW skill set will best complement, support and extend services provided by nurses and midwives in communities? Health workers do not work in isolation but in team. The global community needs to work together to overcome gaps and fragmented program efforts. Policies and actions that are integrated and harmonized will undoubtedly produce greater results than if each partner acted on its own. Tapping into our synergy will facilitate sustainable scale-up.

Why is data on frontline health workers, particularly CHWs, important?

As a nurse-midwife, I think data on all health workers is critical. During my time improving health worker education and training efforts around the world, I have seen firsthand how access to properly trained frontline health workers can save lives and foster healthier, safer and more prosperous communities. As countries seek to extend service into communities, they need accurate data on their workforce. Without this data governments can’t make rational, data driven decisions.How many health workers do they have? What skills do they provide? How quickly do they turn over? How many do they need? All of this needs to be calculated into future health workforce projections. The answers to these questions are essential.

In your opinion, what type are the largest gaps in data on frontline health workers, particularly CHWs, right now?

The main challenge with CHW data is that unlike data concerning health professionals, CHW data is often not tracked at a central or national level. This means that governments are blind to what they have and don’t have available for their health workforce projections. And if CHWs are not counted at the national level, they do not count. If CHWs are not salaried, it becomes even harder to count them. I see the largest gaps being first in sheer numbers—questions such as, how many do they have, how long are they retained, what is the return on investment, and secondly being in varying roles and responsibilities. Some countries have established CHW cadres with a clear scope of work, but many do not, and without information on skill mix, governments can’t plan for their health workforce.

In what ways is your organization using innovative solutions to collect data on frontline health workers?

In Pakistan and in other countries, we are using tablets to collect data on CHW performance, including locations served and services provided. Mobile technology is a powerful tool that can support health workers, efficiently share information, track services and service coverage and support adherence to national guidelines or care protocols such as mother-to-child transmission of HIV, essential newborn care, pneumonia treatment and immunization. I think many countries are exploring use of mobile technology to support and track delivery of services and frontline health workers.

As stated earlier, the harmonization framework and related monitoring and accountability framework does a lovely job of providing recommendations on CHW programs, and I won’t repeat them here. My bias, given my past work in health professional regulation, is that CHWs should have an agreed upon expected core competency set, and that set is used by countries as the starting point from which to modify and adjust competencies to meet their burden of disease. The ILO CHW competencies are a good starting point. I know that many argue that CHWs can’t be held to a specific set of skills, but understanding expected performance is critical for any decisions about appropriate skill mix for health teams.  Countries that want to move services into communities will need to know what CHWs can perform and how they work with nurses and midwives on the health team. Having data on both numbers needed, and understanding how to rationally integrate CHWs based on national health needs is the cornerstone for improving CHW programs and decision-making.

Data for Decision Making Series: Diana Frymus

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We are joining the One Million Health Workers Campaign in a series of interviews, to hear from the experts why data on community health workers is so critical, and what needs to be done.

This week, we spoke with Diana Frymus, Health Systems Strengthening Advisor in the Office of HIV/AIDS at USAID in Washington, DC. She focuses on strengthening health systems to achieve HIV goals and sustain national HIV programs. Her focal areas of emphasis are on human resources for health, including CHWs, and quality improvement. She is the USAID co-chair of the PEPFAR HRH Technical Working Group and the Health Systems Global Technical Working Group on Supporting and Strengthening the Role of Community Health Workers in Health System Development.

What are the most pressing challenges in the development of scale-up of CHW programs today?

The top three pressing challenges in the scale-up of community health worker (CHW) programs are 1) data availability 2) alignment and integration of CHW programs with national health systems and 3) harmonizing partner support for CHW cadres. Addressing these challenges would strengthen accountability of CHWs and lead to greater effectiveness and sustainability of CHWs as a cadre of the workforce. These were key issues that were put forward by the Global Health Workforce Alliance (GHWA), USAID, Norad and the Frontline Health Worker Coalition at the 3rd Global Human Resources for Health (HRH) Forum in 2013 in Recife, Brazil. The resulting CHW Partner Commitment reflects awareness of these challenges and agreement on the need to address them. This work has been widely disseminated, but the extent of its use at the country level and adhered to these principles are unclear. To investigate this further, the USAID ASSIST project is currently working to conduct country case studies to inform further implementation of the CHW Partner Commitment.

Why is data on frontline health workers, particularly CHWs, important?

Globally, the the limited availability of robust and routine health workforce data remains a challenge for effective human resources management and for answering key policy and management questions affecting health service delivery. These include addressing the development and deployment of health workers to where they are needed most. The constraints of not having robust and up-to-date HRH data have been further demonstrated in countries that have been fighting Ebola this year. HRH data availability has been a key area of focus in the recent global consultation on health workforce that has been coordinated by GHWA and supported by USAID and the World Bank, and will be used to inform the development of the WHO-mandated Global Strategy for Health Workforce 2030. It’s clear that HRH data availability will be a key element of advancing HRH in the post-2015 agenda. As an increasingly recognized key cadre of the broader health workforce, it is integral that data on CHWs be included into these broader efforts.

In your opinion, what type are the largest gaps in data on frontline health workers, particularly CHWs, right now?

At the moment, HRH data can be pieced together across a variety of sources at both the global and country level. These include various CHW data collection efforts that have been created in recent years, aligned with the increased focus on CHWs. Yet, as identified through the recent global consultation process on health workforce, the use and comparability of this data is due to the diversity of definitions used and lack of standards across HRH measurement tools. There has been an effort to align national human resource information systems (HRIS) with a minimum data set that would help address some of the alignment and interoperability issues. Building in-country HRIS and the capacity to utilize them is critical for ownership and sustainability. USAID has made robust investments in the development of iHRIS, which is an open-source HRIS currently being utilized in 19 countries. But there is still much work to do! For example, at the moment, CHWs are not always captured as part of national HRIS systems. To further guide their integration within health systems and broader health workforces, there needs to be further attention to ensuring that they are captured in these systems.

In what ways is your organization using innovative solutions to collect data on frontline health workers?

As an implementing agency of PEPFAR, USAID has been a key supporter of PEPFAR efforts to strengthen the health workforce needed for the delivery of sustained HIV and AIDS services. In PEPFAR 3.0, we have placed a greater focus on the use of data to achieve epidemic control, and we are working to better capture and utilize health workforce data and measure the impact of HRH-focused activities. The new PEPFAR HRH Strategy announced by Secretary Kerry on World AIDS Day in 2014 reflects this shift. Community health workers have played an essential role in HIV prevention, care and treatment by improving linkages between those that need care and those that can provide it, and supporting retention and self-management for improved clinical outcomes. Recognizing the important role of CHWs for HIV/AIDS, many community-based cadres were developed in the emergency phase of PEPFAR to fill specific needs for the HIV response. Now we are strengthening the sustainability of these cadres and supporting their integration into national health systems – an example of alignment with the principles of the CHW Partner Commitment!

How can we begin to close data gaps?

There needs to be increased emphasis on coordination and collaboration regarding data collection efforts and data sharing. USAID, along with the World Bank and WHO, will be hosting the Measurement and Accountability for Results in Health (MA4Health) Summit in Washington, DC in June. The Summit will bring together decision makers, thought leaders, and implementers to advance a common agenda for post-2015 health measurement. Since health workforce data will be one of the technical areas covered, this summit will be a key opportunity for further discussion on incorporating CHWs into broader health workforce data efforts moving forward.

Data for Decision Making Series: The Importance of CHW Data Collection with Dr. Sonia Ehrlich Sachs

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We are joining the One Million Health Workers Campaign in a series of interviews, to hear from the experts why data on community health workers is so critical, and what needs to be done. This post originally appeared on the One Million Community Health Workers Campaign blog.

We recently sat down with Dr. Sonia Ehrlich Sachs, Director of the One Million Community Health Workers (1mCHW) Campaign to talk about the important work that CHWs do and the pressing need for the scale-up of CHW programs. Dr. Sachs is a pediatrician and public health specialist. She has practiced medicine for over 20 years, 14 of which she spent at Harvard University Health Services. In 2004, she joined the Earth Institute and currently also serves as the Director of Health for the Millennium Villages Project.

What are the most pressing challenges in the development of scale-up of CHW programs today?

The single biggest obstacle standing in the way of national CHWs programs in countries of sub-Saharan Africa is the unwillingness of official international donors to partner with low income countries in helping finance their evidence-based, and feasible roadmaps to deploy and manage outreach health workers at national scale.We confronted this obstacle first hand in the Campaign’s work in Liberia just prior to the Ebola outbreak. We worked closely with the Liberian Ministry of Health on a strategy for a national scale outreach Roadmap and on assisting with donor outreach. Ironically the international community did not make the funding available, considering CHW program scale-up in Liberia to be a low priority. Unfortunately, a few months later the whole world learned that CHW program scale-up in Liberia was a priority beyond imagining in the face of the galloping epidemic of the Ebola virus. Our work at the Campaign, whether in response to the Ebola epidemic or in the day-to-day scale-up discussions with the Ghanaian government, reinforces one key message: CHWs save lives and should be a high priority of all African governments and their international partners.

Why is data on frontline health workers, particularly CHWs, important?

CHWs are an important cadre responsible for reducing disease burden and saving children’s and maternal lives in low-income settings. The outreach cadre offers a vital link between households and the clinics but they can also help keep track of disease outbreaks at the very earliest occurrence i.e. at the households before the escalating diseases come to the attention of the health system at the clinic level which is often in the advanced stages of a disease spread. So CHWs are a key component of public health surveillance.

When planning a scaled CHW program it is crucial to know the demography, topography, infrastructure of the communities, and the existing programs of what is mostly volunteer village health workers. It’s impossible to achieve successful scale-up of CHW programs unless the government knows exactly where CHWs are needed, and what resources, training, supervision and remuneration to provide them in order to service the assigned communities..

We promote integration of broadband and mobile health technologies into primary care health system as a low cost way to improve the quality of health service delivery. CHW’s use of smart phones with an application of, for example, CommCare provides decision makers, managers with near real time information facilitating continuous quality improvement. The rapid turn around of data allows adaptive management, quality control supervision, and surveillance that can quickly detect emerging diseases.

In your opinion, what type are the largest gaps in data on frontline health workers, particularly CHWs, right now?

Two main data gaps exist. One is the survey-based data that would help with situation analysis on the basis of which a national professional outreach cadre would be planned. The second is the on-going, real time data that informs the day-to-day functioning of the program, such as provided by CommCare and similar smart-phone based applications. To encourage the international community to fill these gaps and support the strategic expansion of CHW systems, the Campaign built the Operations Room, a data platform that is an interactive online inventory of public, private, and NGO-operated CHW programs in sub-Saharan Africa. We foresee expanding the Operations Room to include health workforce analytics and real time data on CHW activities.

In what ways is your organization using innovative solutions to collect data on frontline health workers?

Our goal is to promote the informatics system that has proven to be effective in Millennium Villages, where CHWs are provisioned with a smart phone based application, CommCare which has been effective in reducing child and maternal mortality by providing: (1) decision support at point-of-care, (2) performance monitoring and (3) data-based adaptation and surveillance all of which improve the quality of care of health care delivery in the community.This actionable data flow is in the context of an existing package which consists of curriculum, job aids, training and supervision for CHWs and their supervisors.