In response to COVID-19-related stress and a 16 percent increase in domestic violence reports after the onset of the pandemic, HP+ developed and delivered a three-day training for 43 staff members from eight of Honduras's health regions in psychosocial first aid and guidelines for mental healthcare and psychosocial support for victims and survivors of all forms of violence, with a special emphasis on care of survivors of domestic and sexual violence. The training was held virtually in late April 2022. The average knowledge gain among participants who completed the pre- and post-tests was 23 percent. In addition, HP+ developed posters and a pamphlet for health facilities to inform healthcare workers and raise awareness of the critical topics of mental health and psychosocial support associated with the COVID-19 pandemic. The Ministry of Health plans to distribute the materials to approximately 400 of the country’s prioritized primary care centers.
For seven years, HP+ has worked with government and partners across Mali’s health system. Results and accomplishments were highlighted Thursday, June 9 with an end-of-project event in Bamako. Over the last two years, HP+ in Mali focused on health financing, health system strengthening, and health equity. Representatives of Mali’s National Health Insurance Fund and Devolution and Decentralization Support Team emphasized the importance of the in-depth health financing analyses HP+ conducted to support Mali’s health system. Analyses have focused on provider payment systems, health finance flows, and efficiency and equity at all levels, and were completed in collaboration with key partners. Also noted at the event was HP+’s role in advancing advocacy for community health worker (CHW) rights and legal status. These efforts led to the recent adoption of a decree enshrining the formal status and rights of CHWs, marking a transformative step toward making essential community healthcare sustainable and accessible for all Malians. In closing her remarks at the ceremony, Director of Health at USAID/Mali Julia Henn emphasized, “Although HP+ is coming to a close, we are still with you and will continue to support the Malian population.”
Many health workers and patients are not aware of the rights guaranteed to them by Madagascar’s new reproductive health/family planning (RH/FP) law adopted in 2019, nor of the duties required of health workers regarding RH/FP care. To support broader dissemination, HP+ Madagascar worked with Madagascar’s Directorate of Family Health to develop a job aid highlighting health workers’ RH/FP rights and obligations, including excerpts of the law adapted into simpler language to aid comprehension. The intended impact of the job aids is twofold: (1) to enable health personnel to educate their patients on the RH/FP rights and benefits protected by the law, and (2) to remind health workers of their own rights and responsibilities as outlined in the law, as well as the penalties for neglecting their duties. The job aid will be disseminated throughout USAID’s 13 regions of intervention in Madagascar.
The Government of Mali’s Ministerial Council voted to approve a decree formalizing the status of community health workers (CHW) as an official cadre of health personnel. The adoption of this policy is the culmination of seven years of HP+ partnership with Mali’s Ministry of Health and specifically its Devolution and Decentralization Support Unit (CADD). HP+’s support of CHWs began in 2015 with a diagnostic situational analysis and has since included the development of a dynamic GIS data mapping tool, resource mobilization, capacity strengthening, advocacy, and more. This is a transformative achievement which will protect the status and rights of more than 3,000 CHWs across Mali and mandate the payment of CHWs’ stipends with domestic resources rather than external funds. Dr. Baboua Traore, director of the CADD, noted, “This entire process started when your organization [HP+] drew the health department’s attention to the termination of work contracts of this type of personnel [CHWs] in the regions of Kayes and Sikasso.”
On February 8, 2022, the Nurses and Midwives Council of Malawi (NMCM) held an event to roll out nursing standards developed and piloted with HP+ support in four facilities using a quality improvement (QI) approach. The technical standards for the provision of healthcare for children, adults, oncology, and breastfeeding will help ensure the delivery of high-quality care and accountability. At the event, Deborah Banda, a nursing officer representing Kamuzu Central Hospital, assured the other nurses that QI is doable, “When you implement those you achieve a great improvement and clients are satisfied.” The pilot brought forward champions for change, who pushed for support of the QI activities. NMCM expressed gratitude to USAID and HP+ and interest in continued support to develop standards in areas such as community health, midwifery, intensive care, neonatal health, accident, and emergency. A guide and presentation based on the Malawi pilot on how to rollout standards following a quality improvement approach is available.
Community health workers provide essential healthcare at local levels, but their status and funding are uneven, often sitting outside official health systems. Momentum is building and the case is being made to formalize and fund these essential health service providers as part of national and subnational health systems throughout many low- and middle-resource countries. HP+ teams in Mali and the West Africa Regional office developed videos to support advocacy for formalization and greater investment for this important cadre of health worker. Interviews for The Place and Role of Community Health Workers in Achieving Universal Health Coverage took place during a high-level meeting of health officials hosted by HP+ West Africa in Lome, Togo in 2019, with participation from the World Health Organization, the West African Health Organization, the United Nations Population Fund, and USAID West Africa. In addition, Togolese community health workers provided testimonials on their work in the community. Mali’s video, The Importance of Investing in Essential Care Provided by Community Health Workers, was developed to support stakeholders to advocate for greater support and funding from the Malian government.
HEP+ Guatemala held a virtual conference on May 6 for more than 480 healthcare and hospital workers about therapeutic options to treat COVID-19. It was the first in a series of 27 training sessions to develop capacities among frontline healthcare workers to improve quality of care for COVID-19 patients in Guatemala. Conference keynote speaker Dr. William Checkley, associate professor of medicine at Johns Hopkins University, shared resources to improve clinical practice in the care of COVID-19 patients. The session also featured remarks from Dr. Francisco Coma, vice-minister of hospitals for Guatemala’s Ministry of Public Health and Social Assistance; Dr. Yma Alfaro of USAID/Guatemala; and Herminia Reyes, country director for HEP+ Guatemala. The session improved understanding of current, evidence-based options available to treat patients diagnosed with COVID-19 and promoted the exchange of experiences, challenges, and improvements in patient care.
In a recent blog post, HP+ deputy director Sara Bowsky argues that community healthcare workers and advocates for the marginalized need a seat at the table where governance decisions are being made. The call comes as the COVID-19 vaccination rollout has exposed inequities in access in both the United States and developing countries. She weighs the advantages and disadvantages of local and national responses to the pandemic. “But what’s needed is a balanced, adaptable approach—one that draws on the power and actions of communities in conjunction with federal and state agencies, and the collaboration needed to reinforce such a response,” she writes.
Mali has taken a step forward toward ensuring the sustainability of its community health worker program. The country’s inter-ministerial council in March reviewed a draft decree that would formalize CHWs’ status, rights, and responsibilities, and would obligate the government to finance the CHW program. Securing government support for CHWs—particularly the decree’s formal commitment recognizing the CHWs as a health worker cadre—will boost the sustainability of the program, which has historically relied almost entirely on external funding. HP+ Mali has consistently supported advocacy efforts in favor of government recognition of CHWs as a formal cadre, including supporting numerous workshops during which a draft decree was produced, helping draft the roadmap to adoption, and helping to mobilize the Ministry of Health, as well as its subdivisions and partners, to sponsor the decree. If approved by the inter-ministerial council, the decree will move to the council of ministers, over which Mali’s president presides, for adoption. Finally, the decree will pass to the National Assembly for voting. No timetable is set for these steps. Read more about Mali’s CHW efforts.
Policy implementation requires information, insight, and effective decision making, but if policymakers are unable to digest and act on new information we have fallen short. The community health worker programs in Mali used data visualization to illustrate how community health workers serve rural communities in Mali and how such scarce human resources might be better used. It’s crucial to better understand how these systems do and could work, says HP+ researcher Patrick Pascal Saint-Firmin. “Nearly 60 percent of sub-Saharan Africa’s population lives in rural areas and relies extensively on community health workers; however, the long-term financial sustainability of these programs is in question,” he says. In a Health Worker Week blog, Saint-Firmin reflects on HP+'s work to inform efforts around Mali’s community health worker program and argues that analysis isn’t enough. As data practitioners, how we make the case using data visualization matters.
A recent peer-reviewed journal article by HP+ staff and consultants explains how Mali can reduce its spending on community health workers without sacrificing quality. The article in Global Health Science and Practice concludes that US$13.01 million expended in 2015 for a package of 23 services, including contraceptive injections and oral contraceptives, could have been reduced to US$8.36 million, if standard care protocols were followed. The article also notes that geographic targeting in rural areas is a particularly productive strategy for optimizing service delivery. The analysis appears at a time when 88 percent of funding for Mali’s community health workers is derived from donors and is thus vulnerable to declines in international funding. The publication is part of a 15-article supplement Communities as the Cornerstone of Primary Health Care: Learning, Policy, and Practice, which explores how countries are reinvigorating primary healthcare systems with communities across diverse settings. The supplement’s editorial notes HP+’s innovation in finding efficiencies and geographic targeting to reach underserved communities.
While some patients with SARS-CoV-2 infection require hospitalization, most can be cared for at home. HP+ developed a new visual guide, COVID-19 Home-Based Quality Care: A Practical Guide for Healthcare Workers, to help healthcare workers educate patients, their families, and other household members on how to care for patients at home and prevent transmission of the virus. The guide also provides healthcare workers with information on caring for special conditions and identifying the need for timely referral to a hospital. The guide is equally useful for personal use or when caring for a household member with COVID-19. The guide is available for download in Spanish and English from the HP+ website and via the UCSF Open Critical Care Portal.
The Malawian Ministry of Health in January officially endorsed and adopted the updated Respectful Maternity Care (RMC) Charter: The Universal Rights of Women and Newborns, which sets an international standard for the rights and services women and newborns should receive when seeking care. The charter was updated in 2019 by USAID, HP+ partner White Ribbon Alliance, and other partners to ground the charter in widely accepted international and regional human rights instruments. To advocate for adoption of the charter, WRA Malawi coordinated with key nursing and midwifery institutions including, the Directorate of Nursing and Midwifery Services and the Kamuzu College of Nursing to present, provide feedback on, and approve the updated charter. The effort was buoyed by the What Women Want campaign, whose survey had found the top priority among women and girls was respectful and dignified care. WRA Malawi also introduced and advocated for adoption of the charter with key decisionmakers, such as the Safe Motherhood Technical Working Group and the Reproductive Health Directorate and hosted the official launch event where the MOH officially endorsed and adopted the charter. The MOH and nursing and midwifery training institutions will translate the document into Chichewa and update their curricula to be in alignment with it. WRA will support the Reproductive Health Directorate in distributing the charter to all health facilities in Malawi and will begin introducing the charter to women and health workers.
HP+ has helped coordinate the donation of 50 ventilators, facilitated by USAID, to the Guatemalan Ministry of Health. In early December, HP+ provided more than 100 medical and paramedical personnel from five Guatemalan hospitals in-person training in the use of ventilators. Equipped with improved treatment protocols and patient care options, healthcare workers will be able to immediately use the ventilators to treat COVID-19 patients. They will also be able to provide other necessary therapies for adults and children in need of ventilator support. In upcoming weeks, HP+ will provide training for two additional hospitals and will continue to provide technical assistance to ensure adequate use and handling of the equipment.
A journal article authored by HP+ project staff in collaboration with local partners was published this month in a special issue of AIDS. The article, which describes the development and implementation of a three-stage approach to reducing HIV stigma in health facilities, features the approach that HP+ implemented in Ghana and Tanzania. It is an evidence-based, adaptable, scalable approach that has proven successful in generalized and concentrated epidemic settings and can be used to address stigma toward any population. Results of endline evaluations in both countries demonstrate the intervention’s effectiveness, showing significant reduction in drivers and manifestations of stigma and discrimination among facility staff.
The New Security Beat, a Wilson Center blog, published a piece by Sara Stratton, HP+ technical director for family planning and maternal and child health. Pandemic Preparedness: Strengthening Family Planning Policies Today to Secure Essential Services for Tomorrow discusses the COVID-19 response and threats to contraceptive access for women in low- and middle-income countries. It sets out policy recommendations to ensure essential services for women and girls are maintained during this and future pandemic responses, including policies on task sharing with private sector suppliers such as pharmacies; policies on self-injection of contraceptives; and gender-informed policies for a female-dominated healthcare workforce.
This month, a project-authored article on reducing stigma and discrimination in health facilities in Ghana was published in the Journal of the International AIDS Society. The article, which evaluates the impact of a “total facility” stigma‐reduction intervention on the drivers and manifestations of stigma and discrimination among health facility staff, found that respondents at stigma intervention facilities were 19 percent more likely to report that staff behavior towards people living with HIV had improved over the last year, compared to those at non-intervention facilities. These results provide a solid foundation for scaling up health facility stigma‐reduction within national HIV responses.
Malian mayors, community health associations, and communities mobilized over 7,850,000 FCFA (approximately US$13,305) in local resources to support payments of community health worker (CHW) stipends in Mali. The funds, mobilized by local stakeholders in the regions of Kayes and Sikasso between October 2019 and January 2020, enable CHWs to continue to continue providing essential care following the end of funding from USAID via the SSGI Project this past September. CHWs, who reach Malians who live more than five kilometers from community health centers, have contributed to increased modern contraceptive prevalence. According to the 2018 Mali DHS, modern family planning use among married women age 15-29 increased from 10% in 2012-13 to 16% in 2018.
A blog post co-authored by HP+’s Director for Family Planning and Reproductive Health, Jay Gribble, and gender adviser Beth Rottach discussing the importance of gender considerations amid the COVID-19 pandemic response was published by the Infectious Diseases Society of America’s ScienceSpeaks blog. The article was also cross-posted to the International Conference for Family Planning 2021’s COVID and Reproductive Health blog. These platforms reach a wide audience of infectious disease and family planning experts, offering recommendations to ensure that the ongoing health needs of women and the people who care for them are positioned at the forefront in the global response to the pandemic.
The HP+-supported Healthcare Federation of Liberia is working alongside the Ministry of Health and the National Public Health Institute of Liberia (NPHIL) to scale-up trainings to private sector providers across Montserrado County to address COVID-19. The three-hour rapid training, conducted by NPHIL with social distancing measures in place, will cover infection prevention and control, case management, and emergency response protocols. Up to 250 private providers (from 150 facilities) will be trained in two weeks, covering over 50 percent of Liberia’s health facilities.
In Malawi, cervical cancer data management and program monitoring systems are generating crucial data to be used in decision making at national and district levels. With technical support from HP+, the Ministry of Health and Population’s Cervical Cancer Task Force developed quality assurance standard operating procedures, guidelines, and data tools, and trained health workers on how to screen for and treat cervical cancer. The tools have been integrated into the country’s health information system to support evidence-based decision making. Over 180 health facilities have received screening and treatment equipment, and linkages and referrals for specialized treatment and care have been strengthened as a result.
Early results from districts in Malawi where hospitals have been accredited as baby-friendly (BFHI) have revealed great success: on average, in the nine hospitals HP+ has trained, early initiation of breastfeeding increased from 43 to 75 percent. In Dedza, exclusive breastfeeding contributed to a reduction in neonatal deaths from 24 to 13 percent over six months. Learning from prior experience, HP+ adapted the BFHI program to train hospitals sequentially. The revised approach provides immediate feedback and ongoing mentorship and ensures that at least 80 percent of clinical staff are trained in each facility, as well as support staff and community mentors.
In Mali, three members of the Association of Malian Municipalities (AMM) are independently facilitating advocacy meetings to mobilize local financing for community health workers (CHWs), following a HP+ training in AFP SMART methodology. The AMM has secured funding from the Aga Khan Foundation to advocate for communes to assume financial responsibility over their CHWs, and two municipalities have signed service contracts with 210 CHWs to ensure stipend support. Increasing domestic financing for CHWs will increase access to services for women and children, particularly those living more than 5 km from a health facility.
The HP+ “total facility approach” to reducing stigma and discrimination in health facility settings is being featured on the PEPFAR solutions website. This showcases the work carried out by HP+ in Tanzania and Ghana as an important solution for the HIV response. PEPFAR Solutions are impactful, data-proven approaches intended to guide others in program design and implementation. U.S. government staff and partners around the world use the solutions website as a resource for HIV program design. Having the stigma-reduction approach featured also makes it accessible to mission staff around the world as they embark on their COP20 planning processes.
Members of the U.S. House of Representatives Foreign Affairs committee were briefed on US-funded health programs in Burkina Faso on October 4, 2019, during the delegation’s visit to Ouagadougou. The delegation of Karen Bass and Representative Sheila Jackson-Lee joined U.S. Ambassador Andrew Young, staff of the Centers for Disease Control and Prevention and USAID partners to share successes in health support and discuss challenges related to the ongoing strike of health professionals, security, and support for internally displaced people. Modibo Maiga, HP+ country director, and other implementing partners highlighted the strong collaboration between the US and Burkina Faso and the important role that community leaders, including religious leaders and youth, have played in mobilizing domestic resources for health and catalyzing policy change in support of family planning, adolescent reproductive health, and HIV/AIDS. Maiga also briefed the delegation on efforts by the Ministry of Health to integrate community health workers into its health workforce and stressed that the formalization of this cadre of workers at the community level will reduce the impact of the striking health professionals and will help defuse security tensions in communities.
Government and civil society health leaders from nine Francophone countries of West Africa called for the integration of community health workers into their nations’ health systems at a ground-breaking meeting in Lomé, Togo. The three-day workshop, held from September 16 – 19, gathered health officials and implementing partners, and local community health workers, who shared their perspectives. Senior officials from Togo’s Ministry of Health, WAHO and WHO’s West Africa office, along with U.S. Ambassador, Eric Stromayer joined a high-level opening ceremony. Eleonore Rabelahasa, the Senior Health Systems Strengthening and Policy Advisor in USAID’s regional health office, also participated in the three-day workshop. Five Togolese CHWs, who deliver a range of family planning, malaria and health consultations interventions, discussed the challenges and opportunities they face as front-line health workers and their perspectives to improve their capacity to improve equitable access to health services. The delegates developed action plans for each country with a goal to convene key stakeholders and put in place a plan of action by June 30, 2020.
The impending completion of the USAID-funded High Impact Services (SSGI) project threatens to leave 799 community health workers (CHWs) in the regions of Kayes and Sikasso without funding. Community health workers are an important lever for increasing access to quality health services in Mali whose work is essential to be sustained, so HP + worked with partners at the national and local levels to mobilize local resources to fill the gap until the nation’s new health reforms go into effect in 2022. As a result of the work done by HP+ and partners, the Decentralization Support Cell of the Ministry of Health and Social Affairs sent a memo at the beginning of August 2019 to the Minister of Health to transfer funds gained from replacing oil refrigerators with those that are solar powered to finance the community health worker program. This commitment and resource gap filling came as a result of meetings with regional and administrative authorities in these regions who identified the cold chain petrol budget line item as an opportunity. HP+ has also garnered support for better CHW job accountability and security by implementing employment contracts between mayors and health workers – as of July 2019, 105 community health workers have signed contracts across 26 municipalities in Sikasso and 105 health workers have done so across 43 municipalities in Kayes.
HP+ worked with Madagascar’s Directorate of Family Health and the Ministry of Public Health’s Health Promotion Team to create a poster and job aid for health workers to disseminate information about a 2018 law on reproductive health and family planning and its associated decree. Since the law’s passage, the ministry and HP+ have been working to ensure that all Malagasy citizens know of and understand their rights to voluntary, rights-based reproductive health and family planning services, and that health providers understand their responsibility to provide these services to all. The job aid and poster outline the key points of the law in a simple, comprehensible format in the Malagasy language to aid understanding of and ownership over the rights and responsibilities defined by the law.
On December 28, HP+ Mali participated in the presentation of the Segou Declaration, in favor of the essential health care (EHC) package, to the president of Mali's National Assembly. HP+ Mali has been integral to this initiative, conducting a pivotal assessment on the funding of community health workers (CHWs) and leading ongoing advocacy in favor of these workers and the EHC package. HP+ provided technical and financial support for a preparatory workshop to draft the declaration and participated in its official presentation. At the event, the president of the National Assembly welcomed an initiative promoting women and children's health, recognizing the role that CHWs have played in reducing malnutrition and managing cases of diarrhea and upper respiratory infections, and the important potential impact on development that these efforts have had. As a result of the presentation, the president encouraged stakeholders to continue to invest in CHWs to build knowledge and capacity, and urged parliamentarians to prioritize issues pertaining to EHC and CHWs in the upcoming legislative session. This public declaration of support is a critical step in promoting the passage of a community health law to regulate and protect CHWs and the EHC program, which HP+ has spearheaded since 2017.
USAID and PEPFAR, through the Health Policy Project’s (HPP) follow-on, Health Policy Plus (HP+), shared best practices, resources, and the project’s current work to reduce HIV-related stigma in health facilities during a recent webinar. The HPP/HP+ stigma-reduction package is comprised of a series of tools (assess, train, and sustain); includes a total-facility approach to reducing stigma and discrimination; and is based on a globally validated measurement tool, participatory training materials, and experiences from Africa, the Caribbean, and South and Southeast Asia. The stigma-reduction package has been implemented globally, with work ongoing in Ghana, Tanzania, and Jamaica. During the webinar, Suzie Jacinthe of USAID/Ghana commented, “We’ve never been able to quantify [stigma-reduction activities] in a way to show that what we’re doing is measurable change. With this activity, the beauty about it is that we…do questionnaires for the health facility as well as questionnaires from the PLHIV perspective of their experiences with those facilities to: gauge both [perspectives], come up with interventions out of the findings of the assessment, pilot them…and measure that change.” Jacinthe went on to say that HP+’s current effort to also cost these interventions, a first, will help governments demonstrate the real costs, alongside the measurable benefits, of implementing and replicating stigma-reduction interventions.