Frontline health workers: the key to increasing access to health care for the poor

Dr. Joia Mukherjee, Chief Medical Officer, Partners in Health, and Associate Professor, Harvard Medical School, joined Frontline Health Workers Coalition partners on Capitol Hill in early June to urge the U.S. Government to invest in frontline health workers as part of a comprehensive approach to strengthening health systems in resource-poor settings. Read a shortened version of Dr. Joia Mukherjee’s testimony below.

Dr. Joia Mukherjee with other members and supporters of the Frontline Health Workers Coalition in Washington, D.C.
Top L-R: Dr. Joia Mukherjee, PIH; Dr. Hailu Tesfaye, Save the Children/Ethiopia; Kelly Walker, Association of Women’s Health, Obstetrics, and Neo-natal Nurses; John Donnelly, Burnes Communications; Mathew Taylor, Intel Corporation. Bottom L-R: Sheena Curry, USAID Maternal and Child Health Integrated Program; Mandy Moore, Actress/Singer/Songwriter/Philanthropist

By Dr. Joia Mukherjee

Death, while the inevitable path of all human beings, is not distributed equally. Unequal is the suffering and disability that precedes the death of the poor. Unequal is the rate of death that occurs before the life cycle is complete -- during childbirth, infancy, childhood, and young adulthood. These inequalities are markers of the cruelest form of injustice: lack of access to health care.

If the United States leveraged our enormous power in the world to increase peace, justice, and prosperity, while improving access to health care the stark inequalities in life expectancy would be diminished and these measures would have the greatest of impacts among the poor.

But increasing access to medical care for the poor, the marginalized, and the vulnerable requires a strategic rethinking of how to achieve physical proximity to the communities who suffer most from these disparities. Partners In Health has committed to doing just that for 25 years; in our work, we have found that the most critical part of this equation is frontline health workers. Nurses, midwives, and doctors make a major commitment by living in the communities they serve, often sacrificing better pay in more comfortable urban surroundings in order to serve the vulnerable.

Our organization has more than 8,000 community health workers in the field who provide a variety of interventions from treating a malnourished child to accompanying an expecting mother to antenatal care. They make certain that patients living with HIV/AIDS, diabetes, or schizophrenia remain adherent to the prescribed treatment for their chronic diseases. They are local people who receive both longitudinal training and compensation for their work, thus creating accountability and economic development for communities. And they are supervised and supported by nurses as part of a larger health system--clinics and hospitals that have staff that are well trained and just as adequately supported to live and work in rural areas.

Partners In Health has documented that this network of frontline health workers significantly improves the retention of patients in HIV care. In Rwanda, adherence to the antiretroviral cocktail is good nationally -- 86 percent after one year. But it is even better at PIH sites -- 92 percent after two years. In Malawi, where from five to 30 percent of persons living with HIV/AIDS are lost to follow up, the PIH village health workers together with MOH clinics and staff have documented less than 2 percent of patients lost to follow-up. This difference could represent 500,000 lives annually.

The shift to frontline health workers does not only mean increasing the number of community health workers. It also means providing adequate training and compensation to nurses who are based in local clinics. In many poor countries "nurses" have a high school certificate and receive little support while being charged with delivering babies and diagnosing and treating diseases such as HIV/AIDS and tuberculosis.

Official development assistance typically funds training of trainers (TOT); this often involves taking health care workers out of the field, “training” them by PowerPoint, and paying them per diem, creating huge problems with absenteeism. This is not the side-by-side mentored training I was privy to as an American health professional. This approach to training is driven by an aversion to paying recurrent costs and does not afford frontline health workers the type of preparation they need to save lives.

In Rwanda, we have piloted a program called MESH -- Mentoring and Enhanced Supervision for Health -- where we have created a mentoring and quality improvement program in conjunction with the Ministry of Health. This program works where health workers are based, generating much better understanding and implementation of evidence-based protocols that are saving lives.

Partners In Health, in collaboration with governments and other partners, believes that donor dollars will be most effective when they help to support frontline health workers through adequate and ongoing training as well as appropriate compensation. Implementing governments need to be allowed to allocate their budgets to this goal -- to professionalize, certify, and compensate frontline workers through the public sector rather than being forced to have "volunteers" who receive a one-off training in the name of "sustainability." These practices only sustain the grossly unequal health disparities in this world.

We believe a million more frontline health workers must be trained, compensated, and integrated into government budgets in order to have the long-term effect of providing high-quality, accessible care to the poor and vulnerable.