Patients as Providers: Health Promoter Practitioners as the "Doctors" of Their Communities

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Patients as Providers: Health Promoter Practitioners as the "Doctors" of Their Communities

Guatemala
Organization type: 
nonprofit/ngo/citizen sector
Budget: 
$1 million - $5 million
Project Summary
Elevator Pitch

Concise Summary: Help us pitch this solution! Provide an explanation within 3-4 short sentences.

In impoverished communities abroad, where the greatest need for "patient empowerment" is creating access to decent and appropriate health care services, Concern America has developed programs that engage the community members themselves, known as "Health Promoter Practitioners,” who are trained to provide primary health care that is affordable, effective, and community-based.

About Project

Problem: What problem is this project trying to address?

We see in our world today a serious struggle to find a health care model that really works. Such a struggle is even more evident in most regions of "resource poor" communities, where the need for high-quality, low-cost, locally available health care services cannot be overstated. Too often, individuals have to travel long distances, through conflict zones, spending money they do not have, on the chance that an existing hospital or clinic would treat them with respect, in their native language, and actually meet their health needs. The fact that the members of many of these communities too often lack formal education does not, however, mean that they cannot be empowered to learn the skills necessary to become the health care providers for their communities. Through many years of work in Latin America with refugees, displaced communities, indigenous and Afro-Colombian peoples, and the war torn regions of Guatemala, El Salvador, Mexico (Chiapas), and Colombia, it is Concern America’s experience that the organization’s Health Promoter Practitioner model is very successful at overcoming the many obstacles to quality, patient-centered primary health care in these regions.

Solution: What is the proposed solution? Please be specific!

Concern America works in developing countries among materially poor communities with (1) few resources to dedicate to health care, (2) rural isolation, (3) language/cultural differences, and (4) sometimes populations living in regions of war. There is little hope that fully-staffed clinics and hospitals will be built in the near future, or that existing services will be improved and expanded to meet daily health care needs. In these regions, a big step towards “empowering patients” is to make available quality, affordable primary health care services that are provided by the “patients” themselves. Concern America has developed a successful “Health Promoter Practitioner” model in which some patients (from the local communities) are trained to be the primary health care providers in the communities and regions where they live. Once trained, these Health Promoter Practitioners can competently diagnose and treat patients, administer a wide range of medicines, and perform surgeries (such as tendon repairs – see the “three most important actions” section for a related story), all within a local system that comes from and responds to the needs of the community members. Concern America's four-year Health Promoter Practitioner training program, a model developed by the organization over the past 20 years and unparalleled in its quality of instruction and accessibility to individuals with little formal education, trains lay practitioners whose resulting depth of knowledge, skills, and ability to provide health care are comparable to the work of physician assistants and nurse practitioners in the U.S. As a result, in villages located hours away from health care centers and whose residents earn less than $2.00/day, high-quality, low-cost health care is a reality, saving and sustaining innumerable lives, using few resources.
Impact: How does it Work

Example: Walk us through a specific example(s) of how this solution makes a difference; include its primary activities.

The impact of Concern America’s Health Promoter Practitioner model is multilayered: (1) remote, economically impoverished villages get access to quality, affordable health care in which the patients, a Health Promoter Practitioners, are at the center of providing the care themselves; (2) the “patient-providers,” known as Health Promoter Practitioners, in addition to their work as volunteer health practitioners, become community leaders whose work transforms their villages and regions in numerous ways beyond providing health care services; (3) the advanced Practitioners become leaders in their training programs who “multiply” their knowledge and skills by training and accompanying the newer trainees, reducing the need for outside trainers. For Concern America, the best way to describe the impact of the Health Promoter Practitioner model is to share the words of the organization’s field personnel, the medical professionals who are volunteers with Concern America for at least two years and who are the initial trainers, accompaniers, and organizers at each Practitioner training site. “Milton is a broad-shouldered Afro Colombian man in his 40s with a gentle yet firm presence and a deep voice, perfect for his radio work in Riosucio. During a recent program Milton asks me what we have accomplished in the five years the Concern America program has been developing. Before I can answer he asks the invisible thousands of his listeners, “Who is your primary health care provider?” He responds, “In my own case, I finally have one." She is an Emberá Indigenous woman who was trained in this program. “Marta is my doctor” he states firmly and deeply. We have come a long way in four years, to have a young Indigenous woman treat a middle aged Afro Colombian man.”
About You
Organization:
Concern America
Section 1: You
First Name

Marianne

Last Name

Loewe

Organization

International Development and Refugee Aid Nonprofit Organization

Country

, CA, Orange County

Section 2: Your Organization
Organization Name

Concern America

Organization Phone

714-953-8575

Organization Address

2015 N. Broadway, Santa Ana, CA 92706

Organization Country

, CA, Orange County

Your idea
Country and state your work focuses on

, PE

Innovation
Do you have a patent for this idea?

Impact
Actions

When invited into a new region by a local, highly respected organization, Concern America takes the following steps: (1) Listening to the communities/patients to jointly develop a local plan; (2) Once the training and accompaniment of Health Promoter Practitioners begins, the Practitioners start seeing patients in their villages and managing medicines, in accordance with the level of skills they have attained (for example, once they learn to suture lacerations they are provided with the necessary anesthesia and suture equipment); (3) The community members/patients are involved in shaping the program as it grows, directly based on their expressed needs and concerns; (4) Over time, local leaders emerge from among the Practitioners; they are then trained to become the trainers and accompaniers of the newer groups, as well as local administrators of various project elements, continuing to build local capacity and to expand the reach of the project to include more communities; and, (5) Concern America is taking the important step of putting its model into a manual that will enable others around the world to implement similar programs (see below).

Results

The proven result of Concern America’s Health Promoter Practitioner model is the creation of high-quality, low-cost, patient-driven and centered primary health care services where none existed previously. In an effort to multiply the effect of this model, during the next three years, Concern America will continue to draw on the wisdom, experience, knowledge, and skills of its field team members (all medical professionals, two of whom have worked for more than 25 years in the field and several of whom have worked for more than 10 years) in the writing of a “manual” that can help western-trained medical professionals understand the Health Promoter Practitioner model of primary health care delivery. It is hoped that this “manual” will eventually be translated into various language and will be able to introduce an effective model of primary health care to thousands of communities that lack access to decent and appropriate health care.

What will it take for your project to be successful over the next three years? Please address each year separately, if possible.

For Concern America’s existing Health Promoter Practitioner training projects in Mexico, Guatemala, and Colombia, success over the next three years will require sustained funding and field personnel. Fortunately, in spite of the difficult economic situation facing the country and world over the past three years, Concern America has not needed to cut programs or layoff staff due to its strong and diverse base of foundation grants (30% of organization income) and individual donors/special events (70% of income).

For the Health Promoter Practitioner model training manual that is currently being written, success is as follows: 2010-2012: significant seed and ongoing funding has been secured, and much work has already taken place, so these three years will be focused on writing, field testing, and completing a final draft of the Manual; 2012: the focus this year will be on securing a publisher or self-publishing the Manual in order to enable the wide distribution of the same. It is worth noting that Concern America recently wrote and self-published the 440-page "Indigenous Q’eqchi’ Health Manual," written in the indigenous Mayan language of Q’eqchi'. This Manual is comparable to the invaluable "Where There is No Doctor" by David Werner, and is now providing Guatemala’s 300,000+ Q’eqchi' community members with the first and only health guide written in their native language.

Another very important step for Concern America and the Health Promoter Practitioner model in 2010/2011 is an expansion of the model to Africa and the country of Rwanda. Based on the quality and intent of the work of Concern America and the success of the Practitioner model, the organization was recently invited by the PICO National Network and its local partner, Congregations Rebuilding Community in Rwanda, to bring the model to rural communities in Rwanda. Concern America is honored by this request and energized by the challenges of bringing the Practitioner model to a new continent. In addition to the benefits this will bring to the communities and patients in Rwanda, it will enable Concern America to field-test the model in a context outside of Latin America. Some seed funding has already been secured and additional funds and field personnel are being pursued at this time.

What would prevent your project from being a success?

During its 38 years, Concern America has worked successfully in fifteen countries on three continents. Through training and accompaniment provided by experts (“volunteers,” totaling over 250 during the life of the organization, each committing to a minimum of 2 years) from a variety of disciplines (medicine, education, agriculture, water-engineering, income-generation, etc.), Concern America has made measurable differences in the lives of more than two million people in thousands of communities. Concern America has earned a solid reputation for working with formally encamped refugees, internally displaced peoples, and other materially poor communities in "developing" countries.

All of this is shared here to highlight the experience of Concern America working in difficult situations. Certainly, there are a number of local factors that could prevent the success of the Health Promoter Practitioner model in a given area, but as a model, the organization has proved its success in a variety of situations including refugees, displaced peoples, civil conflicts, extreme poverty, and rural isolation. In terms of the training manual based on the Practitioner model that is currently being written, the biggest challenge will be getting it published and widely distributed. As for expanding the Practitioner model to Rwanda, there is a risk that the Practitioner model won’t work as well in this context, or that the historical instability in the country might make working on the ground dangerous if clashes arise in the region of the project. However, Concern America is partnering with a locally based and respected organization which helps mitigate such challenges.

How many people will your project serve annually?

More than 10,000

What is the average monthly household income in your target community, in US Dollars?

Less than $50

Does your project seek to have an impact on public policy?

Yes

Sustainability
What stage is your project in?

Operating for more than 5 years

In what country?

, PE

Is your initiative connected to an established organization?

Yes

If yes, provide organization name.

Concern America, and various community-based organizations

How long has this organization been operating?

More than 5 years

Does your organization have a Board of Directors or an Advisory Board?

Yes

Does your organization have any non-monetary partnerships with NGOs?

Yes

Does your organization have any non-monetary partnerships with businesses?

Yes

Does your organization have any non-monetary partnerships with government?

No

Please tell us more about how these partnerships are critical to the success of your innovation.

As mentioned previously, Concern America always enters a new project through the invitation of a locally respected entity, and is intentional about creating strong relationships with a variety of institutions in order to bring many ideas and resources to the problems being addressed. Specifically, Concern America currently maintains important relationships with InterAction, an alliance of more than 160 US-based international development organizations (Concern America is both a founding and active member); the Fair-Trade Association; faith-based organizations (including health systems) of the Catholic, Episcopalian, and Presbyterian Churches; the Guatemalan Association of Community-Based Health Services, a leader in community health efforts in that country; the “Good Government Councils” of the indigenous communities of Chiapas, Mexico; the Committee of Associated Inter-ethnic Health Promoters in the Lower Atrato, Colombia, the community-based organization created through Concern America’s work in that country; the sister organization Concern Universal (of England); the Hesperian Foundation (for health materials); the IDA Foundation (for medicines), among others.

What are the three most important actions needed to grow your initiative or organization?

(1) TELLING THE STORY OF THE AMAZING WORK OF THE HEALTH PROMOTER PRACTITIONERS: Concern America and its Practitioner model have received some important recognition in recent years (see the Awards section of this submission) that are helping spread the word of this important model for patient empowerment through the development of local primary health care providers and systems. The stories are many, such as the following from a doctor from the U.S. who recently visited Concern America’s training project in Guatemala:

“While visiting Guatemala I had the chance to observe one of the health promoter practitioners repair a tendon injury in a young man. A teenager came in with a machete injury to his left index finger, and our team watched somewhat in awe as the promoter used meticulous sterile technique as he set up a sterile field, cleansed the wound and identified the two ends of the severed tendon. Grasping these ends he carefully tied each to the other using the appropriate absorbable suture and figure of 8 ligatures. After repairing and subsequently examining the repair, he closed the overlying skin with interrupted nylon sutures, followed by splinting and detailed instruction to the injured party on wound care, infection precautions and follow up.

“I came away from this experience deeply impressed with the quality, skill and service these health promoters provide to their community. I had no doubt that without this service this teenager would have been permanently disabled due to his injury. In the actions of this young promoter in this remote village in Guatemala not only had the young injured teen been touched and made better, but I had been touched and become a better physician.”

(2) WRITING THE HEALTH PROMOTER PRACTITIONER TRAINING MANUAL: The three-year effort to write a training manual that brings together all of the curricula, training materials, and methodology of Concern America’s Practitioner model will have the potential to share this effective model with institutions around the world who are looking for innovative solutions to the serious need for patient empowerment.

(3) BRINGING THE HEALTH PROMOTER PRACTITIONER MODEL TO RWANDA: Concern America is in the initial stages of expanding its Practitioner program to include communities in Rwanda, an important step of testing the model in a new context.

The Story
What was the defining moment that led you to this innovation?

Concern America’s Health Promoter Practitioner model did not come into existence through a single, defining moment, but rather from years of accompanying communities in Latin America that lacked access to quality health care and a voice in advocating for the minimal care they were able to receive. How does one develop a functioning, primary health care system in an area where neither government nor private solutions are possible in the foreseeable future? How can local people, even those with only a few years of formal education, be engaged in the provision of their own health care and the creation of a local health system that is directly based on their needs? These were the questions faced by Concern America in the early 1980s as it accompanied Guatemalan refugees living in camps in Mexico and Salvadoran refugees in camps in Honduras, all with a serious lack of access to health services.

It is during this period that Concern America began training community members to provide primary health care in the refugee camps. Then, as the Guatemalans and Salvadorans returned to their home countries when the peace accords were being signed in each country in the 1990s, Concern America continued health trainings in the new communities that they were creating and/or returning to. Simultaneously, Concern America field personnel remained in Mexico and Honduras and worked with existing communities in those countries that were also faced with a severe lack of health care and other services.

By the mid 1990s, the Concern America Health Promoter Practitioner model had taken shape. Since that time, Practitioner training has expanded throughout most of the indigenous communities of Chiapas, Mexico, the entire area of Petén, Guatemala (that country’s largest department), and northwestern Colombia, where there continues today to be a serious civil conflict taking place. Currently, the “defining moments” of Concern America’s Practitioner model are making it available worldwide through the writing of the training manual, and the expansion of the organization’s training and accompaniment to include Rwanda.

Tell us about the social innovator behind this idea.

Concern America carries out all of its work in a collective manner, and each field project is formed as a cooperative effort among the local communities and community members/patients, community-based organizations, the Concern America field personnel, and the organization’s home office staff. Utilizing this model, the Health Promoter Practitioner model grew out of years of training and accompanying local, lay health care providers, revising the curriculum and training materials, working with the Practitioners in their communities, and eventually creating a solid, four-year training program that has proven effective in North, Central, and South America.

It is worth further highlighting here both the field personnel (1) and the local community members/leaders (2) as key “innovators” in the work of Concern America:

(1) The work of Concern America “on the ground” is carried out by its FIELD PERSONNEL, all of who are “volunteers” (doctors, nurses, teachers, engineers, mental health professionals, etc.) who serve under contract for a basic monthly stipend ($550/month), health insurance, and an annual trip home. There are, on average, 20 volunteers in Concern America’s field projects, each working with approximately 25 villages; these field team members or “volunteers” organize and do the work of the field programs/projects and maintain good relationships and coordinate their work with local institutions with which the organization partners. In addition, each “volunteer” has 5-10 Concern America-trained trained local community members who collaborate in the work.

(2) Concern America’s work around the world helps to form new COMMUNITY LEADERS and introduce transformative processes both for the individuals and the community/region where they live and work. There are wonderful examples of hundreds of such leaders that have emerged through Concern America projects, most of whom volunteer to be Health Promoter Practitioners, literacy teachers, HIV/AIDS prevention activists, etc., despite their own lack of formal education or experience. The presence of Concern America in their communities has enabled them to cultivate their gifts of leadership and service: where non-formally educated women have become mayors of their communities or presidents of artisan cooperatives; where family farmers have become Health Promoter Practitioners and lead health committees or become teachers in an indigenous education system that has been locally created; where these same local leaders have now been invited to support community development efforts on a regional and international level, and are even teaching U.S. health students and professionals (nursing, medicine, midwifery, etc.) through Concern America’s International Health Immersion Program. In the long term, leaders like these provide life-saving services in their communities while building trust among villagers and working to change the structures that created the poverty and poor health in the first place.

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If through another, please provide the name of the organization or company

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