Products to People: Episode 2 – Supplies Beyond the Health Facility

Transcript

Tiwonge Mkandawire: You are listening to Products to People, an integrated public health supply chain. I’m your host, Tiwonge Mkandawire, bringing you guests from the global health sector to discuss the importance of integration for building equitable, people-centered, resilient, and sustainable public health supply chains.

During this episode, we are going to talk about how we can move to delivering supplies beyond the health facility. In most countries, public health supply chain planning often stops at the health facility. This rests the burden on the patient to find means of getting to these clinics, even if it means losing a day of work, or spending the last bit of money that they have, to get there. If health products are not reaching the communities, if we’re not getting them into their homes or in other locations that are more convenient for them, many people will continue to not have access to life-saving medicines and vaccines.

There are several options that have been tried and tested over the years, everything from mobile clinics, parcels that have been pre-packed and made available at pickup points. Another model is using community healthcare workers. These are people that are a part of the community that have made themselves available to not only provide health promotion services, diagnostic and curative services, but they also carry these medicines from the health center and ride or walk them that last mile into patients’ homes; which is why community healthcare workers are an important vehicle for getting Products to People, and why this episode will focus on this very, very critical workforce cadre, and how we can work towards making sure that they are integrated as part of holistic health systems, and part of holistic public health supply chains.

All right. Let’s talk to the experts.

Let me introduce you to Madeleine, who is from the Community Health Impact Coalition. She is the Executive Director. Madeleine, can you tell us a little bit about you, as well as CHIC and what you guys do?

Dr. Madeleine Ballard: Sure. Thank you, Tiwonge. Wonderful to be here with you on the podcast.

The situation is effectively this: Millions of community health workers are not paid, supported, or supplied – 70% are women, and so, we see these dual-sided human rights issues; CHWs are exploited, and they’re less effective for patients. And so I direct the Community Health Impact Coalition, which is making professional community health workers the norm worldwide by changing guidelines, funding, and policy. The result is professional community health workers who are salaried, who are skilled, who are supervised, and to your point, who are consistently supplied. And ultimately, quality of care for all, including those who provide it.

Tiwonge Mkandawire: Thanks for that, Madeleine. Maybe for those who might not be very familiar with the roles that community healthcare workers generally play and the type of work that they do, can you share a little bit about the contributions that they bring to the health system?

Dr. Madeleine Ballard: So, despite decades of global health investment, 1 billion people still do not have access to basic health services and basic health products. Those people live in both rural and urban areas, commonly defined as the hardest-to-reach communities. And the traditional model demands that families find their way to a doctor or hospitals for their healthcare. But millions of families live hours, sometimes days, from the nearest clinic. Others live in cities but face transportation or financial barriers to accessing care.

In either case, it’s an automatic death sentence. The standard solution, building more clinics, hiring more doctors, is necessary. But it’s also insufficient because new clinics have conspicuously failed to reach those living, again, in the most remote communities, and health for all requires delivery for every person, in every village, in every city. And we can get there by seeing new opportunity in an old idea. So, enabled with sophisticated training, supervision, digital tools, community health workers extend the reach of the healthcare system to underserved or rural remote populations.

And so, it’s a really remarkably simple idea, but the impact is immense. If we look at the research, rigorous studies indicate that community health workers, by using this proactive door-to-door model, can effectively deliver health services as diverse as birth control injections to HIV care management. And those research studies also show that CHWs, on a population level, can ultimately reduce the level of sickness in a population and the number of deaths. And all of this is actually quite cost-effective as well. We know that for every $1 invested in community health workers, returns about $10 to the economy in terms of lives saved and jobs created.

Tiwonge Mkandawire: Thanks, Madeleine.

Also, we’ve got Dickson Nansima Mbewe, who’s talking to us from Malawi. Dickson, you know exactly what it is to be a community healthcare worker. Can you share a little bit how you go about delivering primary healthcare services to the clients that you serve?

Dickson Nansima Mbewe: Thank you so much, Tiwonge. I’m so glad to be on this platform.

I’m a Community Health Worker. In Malawi, we call them Health Surveillance Assistants. So, I was actually promoted in 2015 to be a Senior Health Surveillance Assistant. In that regard, I always supervise more than 50 solo health workers. So, I’ve been in the service for now about 17 years, working with the Ministry of Health. As a Health Surveillance Assistant, my main role is to take the services from the health facility to the communities.

We have got a lot of services that we offer there in the communities; the first one being doing disease surveillance, and the other task is to do immunizations. We move from the facility, and we go deep into the communities giving routine immunizations – we open some small village clinics that we offer our medications to under five children. In brief, that’s what I can say about my duties and some of the assignments that I’ve been given.

Tiwonge Mkandawire: Thanks for that, Dickson.

So, Madeleine, we heard Dickson say he’s been providing these services for 17 years in Malawi. I’m curious, what in your mind are some of the inroads that have been made towards getting CHWs being considered as an integral part of the health system?

Dr. Madeleine Ballard: I shared that rigorous studies indicate that community health workers can ultimately reduce the level of sickness in the population and the number of deaths. But the research actually also tells us something else – that community health worker programs do not move the needle on morbidity or mortality. And so, why is that? I would say it’s because the key ingredient is often missing. CHWs are often, despite the fact that they’ve been around for a long time, insufficiently trained, insufficiently equipped, supervised, not paid. 85% of the community health workers on the African continent are unsalaried, and so, what we’ve been seeing is that too many health systems do not actually set CHWs up for success.

By 2030, the World Health Organization estimates a global shortage of about 18 million health workers; CHWs are poised, ready, key to filling that gap. So, there’s not really a shortage of labor. Instead, what we’re seeing is exploitation. And to close the healthcare access gap, we need to do things differently, we need to begin to treat CHWs like professionals, and to your question, Tiwonge, that’s already happening in many places – in Rwanda, over half of malaria cases are treated by CHWs. Ethiopia has long had a professional national CHW cadre, but they’re rapidly being joined by others. Liberia has a professional CHW cadre, Malawi has a professional CHW cadre that Dickson works in. CHWs in Kenya and South Africa are organizing to be paid.

So, there’s a huge amount of movement on this and many inroads, as you say. And the question is really whether we will rise to the challenge in making professional CHWs the norm worldwide, not just in the countries that I mentioned, so that every community health worker can fulfill and achieve their full potential. And we can actually get healthcare to everybody.

Tiwonge Mkandawire: That is definitely a key goal. One of the things that we are working towards is making sure that every single person, no matter who they are, or where they are, or what they can afford or can’t afford, is able to access health services. And from what you’re describing, I think we are making progress towards doing that through CHWs and getting them professionalized, but there’s definitely a long way to go.

Dickson, you mentioned earlier how you’ve been doing this work for over 17 years. When you think back over that time, what are some of the changes that you have seen?

Dickson Nansima Mbewe: Since I started working in the ministry, there have been changes, maybe, in the population – people have been growing, but in the same areas. At first, as we were starting this job, we would have maybe a population of maybe around 5,000, 7,000 community health workers to cover. But now, as time is going, the ministry has been employing a lot of community healthcare workers so that they cover the rise in population.

But the negative thing that maybe has never changed is the issue of reaching those populations with good services. As of now, we are talking of a community, walking over 10 kilometers, 5 kilometers to the nearest health facility first, to get service. So, this has been also a challenge to us as community health workers, within the communities. Community health workers in Malawi, most of the time, we move on foot for covering the areas of maybe a radius of 15 kilometers to give a service to a certain community. These things have also been affecting our work. There are pushbikes, motorbikes, but we are not supplied with those things. So, this has also been a challenge.

The other thing that maybe has also changed is the rising of outbreak of many, many diseases. Currently, we are running up and down trying to give vaccination and to reduce the incidences of polio the incidences of COVID-19. So, this time around, we’ve got a lot of challenges but few resources to fight those challenges.

Tiwonge Mkandawire: Dickson, you mentioned how, as an HSA, you and your colleagues have to walk such long distances, not only to go to the health facilities, to get access to the things that you need to offer services but also to then walk to people’s homes to offer those services.

Can you tell me a little bit about what your job entails when it comes to handling commodities – the medicines or the vaccines?

Dickson Nansima Mbewe: Oh yeah, that’s another good question. We have got the central vaccine stores, which is maybe as the center point. When the vaccines have been shipped from outside the country, they reach to that central point. From there, is when it is distributed to the district points. From the district points the health centers get the vaccines from the district; now it’s for me to take the vaccine to the communities. So, this is where the challenge is because I’m not provided with any transport. I need to find my own ways on how I can then take the vaccines to that particular community for maybe a vaccination organization.

Even if we are talking of the village clinics, we are not given any transport so that we give those services to that particular community. So, maybe he or she can cycle 15, 10 kilometers from his or her respective area and collect the vaccines from the health center. So, you take the vaccines to the community, you administer the vaccines for the sake of keeping the vaccines in the cold chain system,  he or she has to take back the vaccines to the health center.

So, you can say a community health worker can walk maybe 30, 40, 50 kilometers a day to bring the vaccine to the community, back to the health center for maybe cold chain system. So, in terms of collection, in terms of delivering the vaccines to the community, it’s up to the community health worker to do all this. So, it means if you have failed to find any means of transferring the vaccine to the respective area, it means that month, the clinic has been canceled. It’s a very big challenge because it only depends on you, how you plan, and how you’ll get transport to reach those communities.

Tiwonge Mkandawire: Thanks, Dickson. Madeleine, I’m listening to Dickson talk about the kind of distances that are being covered. You know, we are talking 15, 30, 40, that is a lot of cycling. You know, I’m struggling, at the moment, just to get myself to exercise and cycle, you know, 10 kilometers a day.

So, when we look at some of these countries that seem to be making some more progress, at least when it comes to professionalizing the role that community healthcare workers play, how have they overcome this challenge of mobility for the sake of community healthcare workers, but also for protecting the life-saving commodities that they’re carrying into people’s homes?

Dr. Madeleine Ballard: Community health delivery is, by definition, proximate delivery. And I think what we’re hearing from Dickson is that often he’s being asked not just to serve the community in which he lives but to travel to many different communities across great distances. And I think this speaks a lot to the idea of coverage ratios. And what I mean by that is, how many CHWs are there for a given population? And particularly in rural areas, over what distance, and how quickly can that distance be covered? Is there a bus? Is there a bicycle? Are you hiking through a dense rainforest?

All of these factors play into how many community health workers need to be trained, need to be equipped, need to be supervised in order to get care to everyone, again, without putting an undue strain on health workers like Dickson. I think what we’ve heard from Dickson is that he’s doing it, he’s willing to do it, but I think we can all agree that community health workers shouldn’t have to be heroes for people to get healthcare.

And as you hinted at, Tiwonge, when we set health systems up like that, with too few health workers for the population, or health workers that are too far from the people that are trying to reach, we endanger not only the community health worker, not only the supplies or materials that they’re carrying that might spoil or be stolen, but the patient themselves.

Enjoying the conversation? Shocks and disruptions in a health system prevent people from accessing medicines when and where they need them. Building equitable, people-centered, resilient, and sustainable supply chains requires integration.

Download the integration framework now at: www.productstopeople.org. You can also find links to the framework and other materials on this episode in the show notes.

Tiwonge Mkandawire: Madeleine, one school of thought that I’ve bumped into every once in a while, particularly from the more traditional healthcare workers in the health system, so doctors, nurses, pharmacists, is they raise concerns about maintaining the quality of particularly the products. And so, there tends to be this certain level of reluctance to hand over commodities to community healthcare workers so that they can actually be provided into people’s homes.

Madeleine, from a broader policy and health system perspective, what are some of the immediate and priority actions that can be taken to help move the needle?

Dr. Madeleine Ballard: We know that community health workers can only achieve their potential if they’re set up for success. And to do that, community health systems actually need to be designed to deliver, designed to engender the confidence of patients, of community health workers themselves, and the facility-based workers. And I’ll highlight, I think, three ways that we could do that: the first is financing, which, obviously, remains one of the most significant systematic barriers to scaling and sustaining community health services. Africa alone sees a $4 billion financing gap for community health that was calculated by our friends at Financing Alliance for Health. And Health Systems under-invest in community health workers, and consequently, community health workers underperform, and the health of people suffers.

So, if all you’ve ever seen as a facility-based worker is a community health worker who was selected in a corrupt way,  who was last trained, you know, seven years ago, with the USAID PowerPoint, and never again, who hasn’t been supervised in six months, then yeah, I think you’d be a little bit hesitant to give them the supplies.

At the same time, if we shift that vision and we say, “Actually, you know what, these healthcare facility workers are evidence-based practitioners. Everything they do is based on rigorous evidence, and we have the rigorous evidence that when community health workers are salaried, skilled, supervised, and supplied, they can make an immense difference.” And so, piece one is the financing.

And then piece two is really applying that financing, is countries, you know, choosing to reform and invest in their community health programs with that robust system design and implementation that make the programs successful. So, not just saying, “Here, we have a national volunteer program,” and being content with that, but to say, “No, we want our community health workers to be as high-performing as every other piece of our health system, as every other health worker in our health system. And so, we’re going to support them in the same way. We’re also going to give them ongoing training. We’re also going to pay them. We’re also going to ensure that they get coached by folks that have been around longer the type of work that Dickson does.” And I think, again, that creates confidence, because you see what you believe.

And third, I’ll just focus on that last piece about supplies because I think you’re right to note that sometimes there’s apprehension on the part of facility-based workers to pass out drugs. And we see that in the literature, but I think there’s also a larger question at play. Community-level stock-out of essential medicines constitutes a serious threat to universal health coverage and equitable improvement of health outcomes.

And actually, recent research that we did at the Community Health Impact Coalition shows that CHWs face essential medicine stock-out up to 1/3 of the time. It showed that community health workers were out of stock significantly more than the health centers to which they’re affiliated, which indicates that maybe there might be some hesitancy on the part of that health system or health center, to pass out drugs, but also too, that the health centers themselves were often out of stock. And so this can be explained by the fact that community health workers are often not counted – they’re often not included in health worker registries used for supply forecasting, and also, that they’re sometimes last in line to receive essential supplies in the event of unforeseen shortages.

And unfortunately, the evidence that we synthesized demonstrated that these stock-outs are getting worse rather than better. And I think that’s why this podcast series is so timely because if left unattended, this stock-out question could cause severe setbacks for achieving health for all. And ultimately, you know, if we don’t get our act together, it’s patients who are most affected in terms of out-of-pocket expenses, poor adherence to medical regimes or medicine regimes, and low service utilization. So, there’s plenty of things that we can do and, ultimately, pick up progress.

Tiwonge Mkandawire: Very, very sobering words there – if we don’t get our act right, patients will suffer, and there will be those who will lose their lives as a result.

Dickson, the comment that was made just now about how sometimes Health Surveillance Assistants or other community healthcare workers are usually last in line to receive commodities, especially if they’re coming from the health facilities, is that something that you have experienced, and can you share some ways in which maybe that can be addressed with the pharmacist, pharmacist assistants, or whoever it is that’s responsible for giving you those commodities?

Dickson Nansima Mbewe:Thank you, Tiwonge. The first thing that I would suggest from the government is to equip the community health workers with good trainings, good knowledge on how to handle these issues of supply management. Sometimes, a health worker could take vaccines to the communities which are have already lost its potency. Why? Just because he or she does not know how to handle those vaccines. So, the first thing is to give enough training to community health workers on the issues of supply management. And sometimes, you find that maybe there’s a routine outreach clinic somewhere, maybe 15 kilometers from the health center. If you inquire about the vaccines, you will be told that the vaccines are not there. You need to order from the district stores. So, the time it takes for the vaccines to move from the district stores to the community, which is the last point, maybe it takes about five, six hours. So, the community is waiting for that. So a very big challenge.

Secondly, government should also provide enough mobility means. If we are provided with good transportations, maybe, motorcycles, this would maybe lessen this burden of traveling long distances on foot, or cycling, which would maybe will reduce the effect of getting the right access or right drugs to the community that you serve.

And the other thing that I was suggesting is government should make a deliberate effort so that we build enough health services at the nearest point to the communities. So, maybe if these health posts are provided with fridges to keep vaccines, or they’re provided with small pharmacies to keep these drugs, at least at a radius of 2 kilometers for a community, that would also help to reduce our challenges.

But as it is now, we are just very far from reaching this. But I’m sure if we can do much effort to do this, some of these challenges will be reduced, and the services going to the communities will be more effective, and more convenient.

Tiwonge Mkandawire: Very clear call there to governments and others to bring health services closer to the people. Thank you so much for that.

I’d like to touch on one other area, and this is related to comments that you’ve both made about stock-outs. So, Madeleine, you noted how CHWs are out-of-stock a third of the time, partly because, yes, they may be last in line for getting access to the commodities, but predominantly because they’re not actually included when plans are being made for allocation of commodities within the health system.

And Dickson, you mentioned how, you know, in certain cases, you have to kind of go upstream to the district level to make sure that the needs of the communities that you serve are known, which brings me to the question of data. So, Madeleine, let’s start with you. What’s the state of the availability of that data, and how it’s being collected and made available to those who are responsible for planning for the allocation of commodities in those countries?

Dr. Madeleine Ballard: I’d say the data often doesn’t exist in the first place. But what I mean by that is what you just mentioned, that community health workers, because they’re often not fully recognized professionals in the countries in which they work, they’re not actually counted as part of the health system, like other healthcare workers or like health facilities; which means that it’s very difficult to then create projections around how much supply might be required. So, a community health worker might get drugs to do integrated management of childhood illness, so to treat malaria, to treat diarrhea, to treat pneumonia. And when they do that treatment, that data doesn’t necessarily always flow back to the central level where these projections are made. And certainly, aggregated data, even if it gets to the central level, doesn’t then flow back down to the health facility or the community health worker to improve projections over time.

So, there’s a couple of different gaps that starts with community health workers not being counted, and it continues with this lack of data feedback loops.

Tiwonge Mkandawire: Thanks, Madeleine. Very clear there – let’s get them counted. Let’s know who they are, how many they are, where they are, but also shift from where we are right now, to a better data feedback loop, so that not only is data flowing from the community healthcare workers to where the actual planning is being done for commodities. That information flows up, but also closing the loop going down, so that community healthcare workers, or their supervisors, are aware of the commodities that are coming through.

Dickson, are there any thoughts you’d like to share related to that?

Dickson Nansima Mbewe: Actually, in terms of data, we do that. We save data, we make orders, at the end of the month, we need to write a report, or we make some requests about the commodities that we did. The only challenge is that currently, in Malawi, we still use paper-based reports – we depend much on paper-based registers, paper-based templates, to send reports, and all other things. It’s just very recently that we are piloting using maybe tablets when doing village clinic services. But in huge numbers, most of the community health workers use paper-based materials. So, you find that maybe you want to consolidate a report, a fellow community health worker tells that you that the register has got lost, maybe some pages have been torn out – it’s a very big challenge. So, you start thinking, “What should I write?” So, most of the reports, yes, we send them, but they’re not accurate just because of those other reasons. So, I’m suggesting if we roll out these technological things, maybe tablets, smartphones, so that we send these reports, we capture our data using those tools, maybe, that will help. But as of now, this is a very, very, very big challenge – we send data which is not trusted because some part of it, maybe it’s not there, maybe the figures have been exaggerated. So, we do that, but that’s how it is being done here.

Tiwonge Mkandawire: Okay. Thank you both so much.

Madeleine, are there any additional thoughts, ideas that you’d like to share around how we can move the needle on making sure that community healthcare workers are supplied?

Dr. Madeleine Ballard: I think it would be a great place to end – by painting a positive picture of what’s possible. We’ve been through quite a lot, as a world, over these last three years, have we not, with COVID. And one of the big risks in pandemics is actually disruptions to regular health service delivery, and those types of disruptions can ultimately kill more people than the pandemic itself. And we saw, during COVID, data from around the world that showed that the use of commodities declined by up to 50%, but not everywhere. And new research again, that was conducted by the Community Health Impact Coalition shows that community health workers who received just basic respects and recognition in the form of training, in the form of supervision, pay, and critically, who were equipped with PPE, and with the commodities that they need to do their jobs, were able to maintain health services in their community despite COVID.

In other words, they saved thousands of lives. And those results, I have to say, come from nearly three years of data from about 27 districts across four countries, and they’re important because they provide sort of a critical counter-narrative to some of the dynamics that you’ve been talking about to the prevailing discourse that community health workers are not worthy of our respect recognition, that can’t be trusted with our commodities, or that essential health service delivery is expected to be disrupted during health events like COVID or other pandemics.

Disruptions to healthcare are not inevitable, and if we change the story from one in which the majority of community health workers globally remain unpaid, unequipped, largely unsupported, which is where we are now, to one in which community health workers get that respect, get that recognition, are treated like professionals, that they can perform as if they receive what they need, then I think we’re going to be set up not only better in our day-to-day lives, but more resilient to future health shocks, which we know, unfortunately, are going to become more and more frequent.

Tiwonge Mkandawire: Madeleine, that is such a fantastic point to end on – that if we can get our act together when it comes to incorporating community healthcare workers as a part of the broader systems, we can actually have systems that are not only resilient, they will be patient-centered.

Dickson, any last comments that you wanted to share with the people listening to this podcast?

Dickson Nansima Mbewe: I think the best is to give full support to community health workers. You know, community health workers are the main players in the supply management system; they’re the main players in this service. So, if we support community health workers in terms of giving appropriate training, that will help to give proper services. Sometimes, the community health worker will not do his or her best duty, maybe just because she or he is demotivated. So, the first thing is to motivate the community health workers – train them and also equip them with all the necessary tools. Provide with them the good transportation so that they cover the hard-to-reach areas.

The other thing is building small structures of health posts because these small health posts are just very close to the communities that we serve. So this also reduce the time of traveling from the health facility to that last end of the communities. So, these things, if they are provided adequately to the community health workers, I’m very sure the services will be much, much, much beneficial to the community health workers.

Tiwonge Mkandawire: Thank you so much, Dickson.

So, in closing, I just want to reflect a bit on some of the things that I have learned listening to both of you:

If we get our act right in making sure that community healthcare workers are paid, that they are equipped, they are trained, they’re properly supervised, and ultimately, you know, have them recognized as being a key and integral part of the health system,

We’ve talked about how there’s definitely a lot that needs to be done, and one of them is that funding – $4 billion that’s needed, as you mentioned, Madeleine, to bridge that gap for Africa. And when we think about the billions and billions of dollars that are spent not only on commodities but on the health system, I would argue that that is a worthwhile investment.

One of the things we talked about is the data – we need to get to a point where the right data is flowing up from where the community healthcare workers are providing services, up through the necessary channels to where the decisions are being made, and make sure that the necessary feedback loops are closed so that those that are providing services at the community level know what’s coming to them, what’s going to be made available, and where. And to do that as much as possible, where we are looking at shifting from paper-based systems that seem to be prevalent in quite a lot of places, as you’ve mentioned, Dickson, to digital solutions that might streamline that movement of the data.

And last but not least, take a look at the investment in infrastructure so that we are getting the health posts, as Dickson mentioned, as close to the communities as we can get so that we reduce the burden on the community healthcare workers who then have to take that last step to get these services and commodities to the patients.

Thank you so, so much for your time. I have learned a lot, and I am sure that our listeners have also benefited from your knowledge. And I look forward to a point, a few years down the line, when we will all be celebrating some victories along this journey of getting community healthcare workers recognized as an integral part of the health system.

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