The past twelve months have been deeply challenging. The COVID-19 pandemic has claimed the lives of more than 4.5 million people and emerging data suggests that for every COVID-19 death, more than two women or children have died as a result of disruptions to health systems.1 Health systems are struggling under the weight of the pandemic. The health workforce shortage, already estimated at nearly 18 million people, has grown.
Further, where you live has continued to determine your access to care, leaving half of the world’s population behind. COVID-19 vaccines have been distributed along lines of power and privilege, with only 6% of people in low-income countries having received at least one dose. 2
In Liberia, community health workers, when adequately supported and equipped, were able to maintain routine visits during the pandemic. And it’s not just in Liberia. Research by the Community Health Impact Coalition indicates that community health workers who were supported to respond to the pandemic were able to maintain speed and coverage of care across four countries.
This moment of global crisis presents an opportunity to reimagine a world where everyone is able to access the dignified healthcare they deserve, regardless of where they live.
Ruth David was recruited to become a community health worker in 2018, when Liberia’s national program expanded to Grand Bassa County with the support of Last Mile Health. Before the program, Ruth and her neighbors could not access essential health services due to distance. Pregnant women often went without prenatal care and parents had inconsistent access to medication for their sick children. Now, Ruth says, “The way of living in the community has changed because of my work.”
Ruth David was recruited to become a community health worker in 2018, when Liberia’s national program expanded to Grand Bassa County with the support of Last Mile Health. Before the program, Ruth and her neighbors could not access essential health services due to distance. Pregnant women often went without prenatal care and parents had inconsistent access to medication for their sick children. Now, Ruth says, “The way of living in the community has changed because of my work.”
To serve her neighbors and conduct active disease surveillance, Ruth is paid a salary, trained on topics like malaria treatment and contraceptives, supplied with essential medicines and a smartphone to collect and track her patients’ health information, and supervised by a nurse.
She also has access to training and education resources while on the job. When COVID-19 began to spread across the country, Ruth needed to know how to keep herself and her community safe. She is able to access the latest information through in-person training and digital tools.
Importantly, she is also integrated into the health system. To enable last-mile health workers like Ruth, we need to start at the first mile: the health system in which Ruth works requires strong governance, long-term financing, and tools and processes to assess and drive high-quality performance and delivery.
Lisha McCormick
CEO, Last Mile Health
Ruth David was recruited to become a community health worker in 2018, when Liberia’s national program expanded to Grand Bassa County with the support of Last Mile Health. Before the program, Ruth and her neighbors could not access essential health services due to distance. Pregnant women often went without prenatal care and parents had inconsistent access to medication for their sick children. Now, Ruth says, “The way of living in the community has changed because of my work.”
To serve her neighbors and conduct active disease surveillance, Ruth needs to be paid a salary, trained on topics like malaria treatment and contraceptives, supplied with essential medicines and a smartphone to collect and track her patients’ health information, and supervised by a nurse.
She needs access to training and education resources while on the job. When COVID-19 began to spread across the country, Ruth needed to know how to keep herself and her community safe. She is able to access the latest information through in-person training and digital tools.
Importantly, she also needs to be integrated into the health system. To enable last-mile health workers like Ruth, we need to start at the first mile: the health system in which Ruth works requires strong governance, long-term financing, and tools and processes to assess and drive high-quality performance and delivery.
At Last Mile Health, we are partnering with governments in five countries in Africa to work across three pillars – strengthening community health systems, upskilling the community health workforce, and delivering effective community-based care – to build exemplary community health worker programs that can meet the everyday needs of patients, during moments of crisis and calm.
We have seen first-hand the incredible impact of community health worker programs on patients’ lives. To succeed, these programs need to be nationally prioritized, financed, and actively managed.
We work with governments to design and strengthen high-quality, data-driven community health systems. Together, we develop the programs and policies that guide teams of health workers and health leaders to deliver high-quality care in remote communities.
Armed with the evidence from nearly 15 years of delivering community-based primary healthcare in Liberia, we know that professionalized community health workers are the first line of defense against future threats and are foundational to resilient health systems that leave no patient out of reach. In 2020, we partnered with Africa CDC, a specialized technical institution that provides guidance and support to countries in Africa, to strengthen national community health workforces across the African continent, during the pandemic and beyond.
Together, we are working to guide governments, implementing partners, and aid organisations to build stronger health systems with community health workers. We are doing this through:
Prior to 2015, community health programming in Liberia was fragmented and lacked oversight from the government. As Liberia emerged from the Ebola epidemic, Last Mile Health worked alongside the government and other partners to develop the National Community Health Assistant Program, which aims to put a community health worker within reach of everyone living in rural and remote communities.
Together, the Government of Liberia and Last Mile Health are now undertaking a policy revision process, integrating lessons learned from the past five years and setting the strategic direction of the program through 2030 to improve the reach and quality of care. Our work includes the development of 74 distinct policy recommendations to help guide the way forward, from increasing access to family planning options to adopting recruitment and training practices that promote gender equity.
More than 15 million people in Malawi live in rural and remote areas. Improving community health information systems is essential for addressing the health challenges they face. Digital health systems lead to better access to essential medicine, greater efficiency and efficacy of care, and better informed health policies. 3
Last Mile Health is working with the Government of Malawi, the Department of Computer Science at the University of Malawi, UNICEF, and other partners to develop an integrated digital community health system (iCHIS) that provides real-time data to health workers and decision-makers. Community health workers, known locally as Health Surveillance Assistants, will be able to register patients, record basic data on service delivery, and take action to address individual and community health program needs. The iCHIS system will be standardized across the entirety of Malawi’s community health worker program, and has the power to improve the integration of primary health care services, disease surveillance, community health worker performance, and the quality of service delivery.
Since 2016, a dedicated coalition of partners has provided funding for Liberia's National Community Health Assistant Program. Together, their financial commitments have deployed community health workers who are serving over 800,000 people, and have delivered over 1.8 million treatments and malnutrition screenings to children under five to-date.
Building community health systems requires more than a one-time investment; durable funding represents one of the greatest challenges to effective and enduring community health systems. As an example, in the face of unexpected funding gaps this year, Last Mile Health worked with the Ministry of Health and partners like the Global Fund and USAID to maintain funding for the program across all counties – underscoring the strength of the coalition behind this program and the need to continue advocating for investment in these programs.
Tracking and maintaining cohesive funding for Liberia’s national program is a key priority. In the years ahead, the Government of Liberia will work to increasingly fund the program domestically by adding community health supervisors to the government payroll and implementing innovations to reduce costs. Our recent shared work includes a costing study of the National Community Health Assistant Program to inform program sustainability.
In recognition of the role community health workers played responding to the Ebola outbreak, the Sierra Leone Ministry of Health and Sanitation embarked on a redesign and revitalization of the country’s National Community Health Worker Program. In 2020, we launched a partnership with the Ministry of Health and Sanitation to support these efforts, focusing on ensuring the community health workforce has the knowledge and capabilities to manage, deliver, and sustain community-based primary care in all communities.
The initial activities in our partnership include the design of a new training package for over 8,000 community health workers and their supervisors that is aligned with the country’s revised strategy for community health, as well as supporting the country’s COVID-19 response efforts. We are proud to be part of a larger effort led by the Ministry of Health and Sanitation and partners to strengthen the country’s community health workforce on a national scale, which will extend essential primary healthcare to all Sierra Leoneans.
For many people living in rural and remote communities, community health workers like Ruth David are their primary point of contact with the health system. Continuous training is needed at every level of the health system to ensure Ruth is able to provide high-quality care in her community and effectively respond to new challenges like COVID-19.
We partner with governments to train and grow the community health workforce and to build the community health expertise of national health leaders by leveraging innovation, like digital tools, to increase knowledge gain, cost-effectiveness, and scale.
Ethiopia's Health Extension Program - the country’s flagship community health worker program - has contributed to remarkable improvements in health outcomes since its launch in 2003. However, challenges like equitable access to high-quality care in rural areas remain, so the government is now investing in education and training to strengthen community health worker performance.
As part of these efforts, we've developed an innovative in-service training on reproductive, maternal, neonatal, and child health in partnership with the Ethiopia Ministry of Health. We are piloting the training with an estimated 1,170 community health workers serving 2.9 million people. Utilizing blended learning, the training includes both digital tools and in-person facilitated learning and contains innovative multimedia content in three languages. The training has the potential to be scaled nationally in the future -- reaching all 40,000 community health workers in the national program who serve close to 100 million people.
To build and sustain effective community health systems, health leaders need specialized knowledge and technical resources. Our Financing Community Health Programs for Scale and Sustainability course, developed with the Financing Alliance for Health, helps leaders understand financial needs and mobilize resources for community health.
In January 2021, we kicked off a facilitated track of the course with 138 learners primarily from four of our five country programs - Liberia, Sierra Leone, Uganda, and Ethiopia. Over 16 weeks, we brought participants together through weekly course work, discussion boards, group activities, and live events. A final project — an investment plan for community health — allowed participants to apply the skills and knowledge gained throughout the program, and receive tailored feedback from experts at the Financing Alliance for Health.
During moments of crisis, governments need to share information in real-time and rapidly train health workers as part of an effective response.
In Ethiopia and Uganda, we partnered with the Ministry of Health to leverage the power of digital technology to rapidly fill training and information sharing gaps. Together with our partners, we designed and launched applications to reach community and frontline health workers with up-to-date information and training content on COVID-19 directly on their mobile devices – bolstering their ability to respond to the pandemic while keeping primary health services going.
In Ethiopia, more than 7,400 health sector professionals have downloaded at least one of the eight courses available, which range from clinical case management to vaccine administration. In Uganda, 1,670 health sector professionals have downloaded at least one of eight courses, which include case management, home-based care for COVID-19 patients, vaccination training for health workers and logisticians, and maintaining continuity of essential health services during the pandemic.
Professionalized community health workers deliver an integrated package of lifesaving health services in communities previously outside the reach of the health system. When properly equipped, they save lives through disease surveillance, and the delivery of maternal and child health-care, malnutrition screenings, malaria treatment, and more.
At Last Mile Health, we partner with communities to equitably select, train, pay, supervise, and supply the community health workers who bring primary healthcare to their remote communities.
Emerging data estimates that for every COVID-19 death, more than two women or children have died as a result of disruptions to health systems since the start of the pandemic. This is often the reality during a crisis; during the 2014-2016 Ebola epidemic, Liberia experienced a three-fold decrease in facility-based care.
Despite this, there is hope to be found in professionalized community health workers. Data from Liberia’s National Community Health Assistant Program suggests that in places where funding remained consistent, routine visits by community health workers held steady during COVID-19. And it’s not just in Liberia. Research by the Community Health Impact Coalition indicates that community health workers who were equipped and prepared for the pandemic were able to maintain speed and coverage of community-delivered care during the pandemic period.
The role of community health workers at the forefront of the COVID-19 pandemic can put them at great risk, if they are not adequately protected. We also know that they can serve as powerful allies in the fight against vaccine hesitancy. For these reasons, we have joined a chorus of voices advocating for priority access to COVID-19 vaccines for community health workers.
Alongside the Government of Liberia, we have worked to get vaccines from tarmacs into the arms of people in rural and remote communities. In the three counties where Last Mile Health directly manages the national program, 97% of community health workers have received their first dose of the COVID-19 vaccine and 88% have been fully vaccinated. Nationwide, 66.5% of the community health workforce has received at least one dose.
As first-line responders, community health workers need personal protective equipment (PPE) – including masks, gowns, and gloves – to ensure they can stay safe while they continue providing essential primary health services to their neighbors.
We delivered more than 6.2 million pieces of personal protective equipment to community health workers, health facilities, hospitals, and partners across Liberia, Uganda, and Malawi. This has enabled community health workers to ensure their communities have continued access to life-saving care during the pandemic.
