Investing in health workers, from the ground up

Investing in health workers, from the ground up

Veuillez trouver ce message en français ici.

Led by the Frontline Health Workers Coalition and partners, World Health Worker Week (WHWW) brings together advocates, health workers, leaders, and communities calling for more resources to support health workers.

Directed primarily at policymakers and global leaders, the goal of this week is to urge decisionmakers to follow through on global commitments and to invest in, protect, and support the health workforce, especially women.  The 2024 theme is Safe and Supported: Invest in Health Workers.

The case for investing in community health workers is clear and proven, with immense health, social, and economic returns. Though the financial return on investment for the primary health care workforce has been demonstrated to be as high as 10:1, the current funding gap for community health programs is estimated to be $5.4 billion annually.

Across the African continent, there are many contexts in which leaders and decisionmakers have made policy commitments related to investing in health, but have not yet implemented them.  In 2001, African Union countries set a target of allocating at least 15% of their annual national budgets to their health sectors, known as the Abuja Declaration. But achieving this goal has remained elusive. In Mali, before COVID-19 and the latest governance transitions, Mali’s spending on its health sector was around 4%.

How much longer will it take for more countries to be able to reach the Abuja Declaration targets?

While increasing spending on primary healthcare is necessary, investing in health workers cannot simply be a matter of increasing national spending, or increasing international donor funding.

Whatever the cause, it is clear that greater domestic and international investments in health systems and health workers have not been forthcoming. In the Sahel, even with willing policymakers and treasuries, armed conflict and transitional military governments are a growing obstacle to increased national investment in health. Furthermore, in decentralized health systems, increased national investment may not even necessarily reach primary care systems, as community health systems are not principally financed by the national government.

If not policymakers and leaders, who can do the investing in health workers that so many communities desperately need? Are there other strategies and possible investors? Especially in decentralized health systems?

Communities are being overlooked as essential partners for investing in community health programs.

The calls for increased health financing and investment usually end at the national level. Even the terms “local financing” and “domestic resource mobilization” are mostly used to refer to national budgets. But if we end our advocacy there, we neglect possible health financing that is more localized including district, community, household, and even individual health financing. 

Let us also not forget the Bamako Imitative of 1987, whose purpose was to increase the participation of the community not only in the decision making and governance of the primary care health system, but in its financing as well.

For the past several years, Mali Health has been seeking to expand the understanding of who can do the investing and supporting of health workers. In Mali’s decentralized health system, we are seeking to help build community-led solutions for investing in and supporting community health workers.

To be sure, we do not mean to suggest that primary care workers should not be a health policy priority for every national government, as they are in Mali. But as we continue to advocate for greater investment and the fulfillment of the ambitions of the Abuja Declaration, women and children need health workers now, and we can work on local solutions to support health workers now.

For example, there is already a source of health financing that is highly localized, largely due to the Bamako Initiative. In addition to external donor funding and domestic spending, out of pocket payments (OOPs) are a significant source of health financing in most African countries – matching and exceeding other types of spending in many cases. Regrettably, OOPs and user fees are inequitable and burdensome, but they are a critical component to how primary care systems are financed today, especially in decentralized health systems.

But user fees and OOPs represent just one method for community involvement in the financing of health services. As we advocate for replacements to OOPs and user fees, we have an opportunity to reallocate them and other community resources into more equitable, affordable and sustainable strategies that could channel local, community-led resources to invest in the health workforce. Rwanda provides an excellent example for how community-based health insurance can mobilize community and local resources for more equitable access to quality healthcare, alongside national and donor investments.

To improve health equity, meet urgent health needs, and overcome the expected health workforce shortage, we cannot depend alone on increased national budgets or increased donor funding. While part of a solution, they are not the whole solution. As we work with policymakers and leaders, let us also not forget those with proximity to these challenges, and who work hard to support health workers in their community every day. They have valuable perspectives and insights, not simply as the recipients of health worker services, but as investors in them.

Let us begin to think about investment so that all health workers can be safe and supported, not just from the top down, but also from the bottom up.

Training and supporting a high-impact team of community health leaders

Training and supporting a high-impact team of community health leaders

In January, our community health worker team celebrated another year of not losing a single mother or child in their care. Their achievement is remarkable in any given year, but the disruptions posed by the pandemic makes these past two years particularly extraordinary.

Community health workers are essential to our efforts to improve access to quality healthcare in peri-urban communities. Part of what makes our team so effective and resilient is their high level of knowledge and experience. Continual training and supervision are foundations of our community health worker program, but they’re not ones that we talk about very often.

Dr. Bathily oversees the medical aspects of our community health program, which includes training our entire team of community health workers (CHWs) at least twice per year. Regular training not only keeps their knowledge current, but it also offers opportunities for CHWs to talk through the different situations they face every day. Dr. Bathily helps our CHW team troubleshoot when challenges arise to help families prevent illness, or ensure that all children access care quickly when they need it.

Dr. Bathily standing before a group of CHWs at the Mali Health office
Dr. Bathily leads a training on family planning for community health workers

Dr. Bathily, and our Monitoring & Evaluation Coordinator Boubacar Fomba, keep in constant touch with our community health center partners, including monitoring the visit information of children in the program, so that the CHW team can target their health messages and counseling when needs arise, or if there is an increase in visits. This close collaboration ensures that the ongoing training and supervision of our CHW team is addressing the most urgent needs that health centers are seeing on the ground.

Boubacar Fomba presenting at CHW training
Monitoring & Evaluation Coordinator Boubacar Fomba presents data during CHW training

Dr. Bathily also serves as a quality improvement coach working with partner health centers where our CHWs refer families in need of care through our participatory quality improvement program. In this role, he keeps an eye on clinical care quality, to ensure that families referred by CHWs are receiving the best care and services available.

This integration ensures that both the standards of care and the health messages that families are receiving are consistent, whether at home from their CHW or in their health center. For example, as we are working to help more families access family planning services, our community health workers are receiving the same training about family planning services that we are offering to providers at our partner community health centers.

CHWs having a discussion
CHWs discuss family planning during a training

Through comprehensive trainings and close collaboration with health centers, our community health worker team is an essential, effective part of the peri-urban community health system. They are at the heart of our efforts to build locally-financed, participatory, equitable health systems that can deliver health for all.

How a strong community health system keeps mothers at the heart of primary care

How a strong community health system keeps mothers at the heart of primary care

In March, one of our health center partners, CSCOMSEKASI, reported 2 new malnutrition cases. That may not seem like many, but malnutrition is one of the leading causes of preventable deaths among children under age 5 in Mali.

One of the areas served by CSCOMSEKASI is Sibiribougou, a peri-urban community. The health center regularly sees some of the highest numbers of malnutrition cases in Commune IV. Sometimes, it has the highest number of cases in all of Bamako.

One of the children who became sick in March was Natenin, age 4. She and her younger sister, age 19 months, live with their parents in Sibiribougou and participate in our community health program.

Our team quickly got to work to organize a nutrition demonstration, a strategy used to help mothers learn to prepare foods which support their children’s development. Led by a nutritionist from the national health program, the session showed mothers how to prepare a porridge enriched with local ingredients, like carrots and pumpkin.

Nutritionist speaking to mothers
The nutritionist speaks to mothers about providing the nutrients children need to grow

The nutritionist shared that a major factor in malnutrition is repeatedly feeding children the same foods, which does not allow them to have a variety of nutrients. The porridge mothers learned to make is prepared with affordable local products that are available year-round; it provides balanced nutrition that ensures the good growth of children.

We invited 25 mothers with children under age 2 from our program to come to the health center for the demonstration. They were joined by our community health workers, the nutrition staff at the health center, and other mothers from Sibiribougou.

She began by sharing the recipe, explaining the ingredients, quantities, and the method :

2kg of sorghum
2kg of wheat
2kg of fonio
1kg of corn
1kg of rice
5kg of baobab flour
10 carrots
1 medium pumpkin
1 tablespoon of salt
10kg of sugar
1 small container of peanut oil

Wash each grain well separately
Mix them in the same container and grind them
Sift the mixed flour and set aside
Sift the baobab flour well
Mix the two flours and set aside
Wash the vegetables well
Boil and mash them

Then, she got to cooking, inviting mothers to help her at each step.

Boil 10 liters of water in a clean pot
When water is lukewarm, using a calabash and a ladle, slowly mix some water into the flour mixture until blended
Pour the solution back into the pot
Mix and stir until a homogeneous mixture is obtained
Then add the mash made of carrot and pumpkin to the porridge and simmer for about 5 minutes.
Then add the salt, sugar and a cup of oil
Let stand a few minutes before serving

Then came the best part – the tasting! All the children attending enjoyed the portions they were served, giving their full approval of this new dish. Mothers equally approved. They not only liked the taste, but appreciated that the ingredients were local and accessible. These nutrition demonstrations not only give mothers access to important health information, it also facilitates a permanent change to more nutritious meals in their households.

At the end of the session, Natenin’s mother addressed the group. She thanked the nutritionist for sharing this information and advice, and with it, vowed that her children would never know malnutrition again.

When mothers are supported with information and resources to keep their children healthy, the results are astounding. While a 2017 UNICEF study found the national rate of acute malnutrition in Mali rested at 10.7%, we had just 14 cases of acute malnutrition among the 2,350 children served by our community health program in 2020. Putting mothers at the heart of health interventions works. Strong community health systems react quickly to community needs by keeping women and mothers at the heart of local, accessible solutions.

An update from community health supervisor Kadidiatou

An update from community health supervisor Kadidiatou

Back in May, we shared the experience of Kadidiatou, one of our community health worker leaders, as she worked hard to keep her family and the families she serves as a community health worker (CHW) safe from COVID-19. As a CHW and supervisor for the other Mali Health CHWs serving Lafiabougou, Kadidiatou always knows what is happening in her community.

Kadidiatou is proud to share that Awa, the mother she told us was very reticent about going to the health center, did find her way back there, as did almost all of the families in Lafiabougou who had stopped seeking care due to rumors and concerns about COVID-19.  After Kadidiatou talked Awa through her concerns and let her know that the visits would be safe, Awa returned to the health center for her prenatal care, and gave birth in August without any trouble.

You may also remember that Kadidiatou had a niece who was infected with the coronavirus, which was a scary time for her family. Her niece recovered, and Kadidiatou went to see her in June to hear about her experience, which encouraged her to work harder to prevent others from going through the same thing.

Kadidiatou reports that she has been able to share the messages of preventing COVID-19 more widely. She has been able to convince her neighbors to adopt prevention measures, including installing hand washing kits at the entry of their homes. She reports that more people in her community are limiting their movements and wearing masks regularly.

Kadidiatou also noted that the training that Mali Health was able to do with community leaders about how to combat misinformation and to encourage preventive measures and behaviors made a noticeable difference in improving the knowledge and awareness of members of her community. With these precautions and the progress she has observed, Kadidiatou is confident that Lafiabougou is prepared and will stay safe :

I believe that today, my community is strong enough to avoid COVID-19.

Kadidiatou, Mali Health community health supervisor

Learn more about the work of Kadidiatou and our community health workers here.

Join Sonata on a visit to the Diarra family

Join Sonata on a visit to the Diarra family

Halfway up the face of a steep and rocky hill in the community of Sikoro lives Fatoumata and her family. Fatoumata, a mother of four, begins to share the story of when two Mali Health community health workers first visited in 2011. Alimata, Fatoumata’s mother-in-law, adds, “the women asked about my son and whether he worked and if that work came with a monthly salary.” She told the women then that her son worked odd jobs, but the jobs didn’t come with a reliable monthly salary – passing prayer beads through her fingers as she recounts the story. With a young toddler in the home and a low, unsteady income – the family was eligible for, and joined, Mali Health’s community health program.

Sonata Cissogo, a friend and neighbor, became their community health worker. Sonata shares, “The family’s first daughter, Amitou, was about three and a half years old in 2011. Since that time, I have been working with this family as it has grown from one to four children. The next three children were all enrolled at birth.” Fatoumata notes, “We have known Sonata for many years. Every day she comes over to greet us and the children. If the children show any sign or symptoms of illness she tells us to take them to the health center immediately.”

Amitou leans on her mother, Fatoumata
Amitou with her mother Fatoumata

Amitou, now a healthy nine-year-old enrolled in school, helps to look after her three younger siblings—a brother, Seydou, age 7, and sisters Aminata, age 5, and Niekoro, age 2. Neither Fatoumata nor Alimata work, leaving Fatoumata’s husband, N’Golo, the sole provider for the family. Alimata reflects on how the family agonized over what to do when their oldest child became ill: “before Amitou was first enrolled, my son would say to buy traditional medicine to treat her illnesses. Traditional medicine is cheaper, but it doesn’t always work. Now, since my grandchildren have been enrolled in Mali Health’s program, my son tells us to take the kids to the health center right away. Now he is content, and he and my daughter-in-law don’t struggle about it anymore.”

Amitou, Seydou and Aminata have grown up with access to basic primary care whenever they needed it – and today, they are strong and healthy. The youngest, Niekoro, is still covered and just recently became ill. Her mother describes her relief at being able to act quickly to take care of her daughter. “As soon as I recognized the signs, my husband and I agreed that I would take her to the local health center just down the hill. I bring the health card that Mali Health gave us and that helps a lot with the doctor. Before, without the card, the doctor would be scared that you would not have enough money to pay. Sometimes you would only have maybe $2 or $4 in hand, and the doctor and the medicine might be $6 – $10, or more. So, we wouldn’t be able to buy the medicine and would have to get traditional medicine instead. Now with the Mali Health card, the doctor is very nice, and he gives us the consultation and medicine, and we don’t have to wait long either.”

The benefits extend beyond just immediate access to healthcare for the Diarra family. “Now, with the money we would have spent on doctors and medicine, we use it to buy good healthy food, decent clothes for the children, and a bit goes to cover their monthly school fees too,” says Fatoumata. As she recounts her family’s story, she points to her daughter, Aminata, who, unprompted, grabbed a bucket and a bar of soap and is washing her hands. “Aminata learned to wash her hands with soap from Sonata. She taught everyone to do this regularly during the Ebola crisis, and Aminata has been doing it ever since.” Aminata turned five years old last June, graduating from the program.

“My son is thankful for Mali Health and for Sonata too,” says Alimata of her grandchildren’s participation in the program and the community health worker it has provided to their family. “We are all thankful.”

Sonata and Seydou
Sonata and Seydou
When Community Health Workers become Advocates

When Community Health Workers become Advocates

In 2014, Mali Health launched an mHealth program to help monitor the health of families in our care. The app guides our health workers through a standard set of questions and helps ensure consistent and efficient care. For example, the technology helps to accurately identify the severity of malnutrition by calculating a child’s height-to-weight Z-score. It can also help detect early warning signs to encourage intervention before a child falls into undernourishment.

As we roll out the technology and help our team become accustomed to it, they recently learned how powerful this new tool could be. During a routine visit, our community health workers found a child urgently in need of care. But when she didn’t receive it, they used their training, backed by their mHealth data, to become her advocate. Here’s what happened:

Last week, one of our community health workers visited a mother whose 20-month-old child was underweight. Using her training, our health worker instructed the mother to seek treatment at their health center immediately.

The next day, four CHWs returned to the home to learn how to do a malnutrition follow-up using their new mobile application. The follow-up requires the CHW to recheck the weight and the brachial measurement of the child. The brachial measurement is the circumference of a child’s bicep, a common method of identifying malnutrition, and is indicated by a range of green, yellow, and red levels. This child’s brachial measurement was red, and the weight-for-age calculated by the mHealth app indicated severe malnutrition. The child only weighed about 6 kg.

The mother explained she had gone to the health center that morning for the malnutrition program, but was sent home. The staff said her child didn’t meet the criteria for the program; the young girl was not malnourished “enough” to receive treatment. Our team then decided to accompany them back to the health center, because the child was clearly in need.

However, as soon as they arrived, they encountered intense resistance from the staff. One claimed she remembered the child from earlier and that she weighed 10 kg — far more than the 6kg our health workers had measured. Our team insisted they check again.

The staff measured the girl again and placed her on their scale, determining this time that she weighed 7kg. Looking at their weight-for-height chart on the wall, the health center staff stated the child was only mildly malnourished. Our team insisted they weigh the girl again on our scales (which every community health worker carries on home visits). The staff agreed.

When they did, everyone saw the child only weighed 6 kg based on the scales of two different health workers. The staff claimed the scales were not correct, so our team insisted they take the girl’s brachial measurement. After more protest, a staff member finally took the measurement, but did not fully secure the measuring tape. She left a small gap between the tape and the child’s arm, so the result was yellow instead of red. When our team pointed out the error, the staff member stated that was how she learned to conduct a brachial measurement.

At this point, still determined to demonstrate the young girl needed care, one of our CHWs took the child to weigh her on the health center’s scale herself and, contrary to the staff’s measurements, and measured her at 6 kg. They continued to push for the child’s inclusion in the malnutrition program. After several minutes of discussion, the staff relented. A staff member retrieved several sachets of Plumpy’Nut, an effective nutrition supplement, and gave them to the girl’s mother.

Once home, our health workers explained how to deliver the supplement to her daughter most effectively. They encouraged the mothers to return to the health center each Wednesday to have her child weighed and to receive more of the supplement until she reached a healthy weight.

It took guts for our four health workers to stand up to the team at the health center. Without their intervention, the little girl never would have received care. Without care, a child with such severe malnutrition could die; in fact, it happens often. Mali Health CHWs are well-trained and they demonstrated their knowledge with confidence, even going against higher authorities in the health system when they knew those authorities were at fault.

Their story illustrates why a strong team of community health workers are so essential to advocating for mothers and children in their community. We are so very proud that ours had the courage to do exactly what they are trained to do: to make sure every mother and young child in their community has access to the best care possible.