Re-envisioning Community Health Workers and the Promise of a Homegrown Primary Care Workforce for the Rural Poor in Liberia

Re-envisioning Community Health Workers and the Promise of a Homegrown Primary Care Workforce for the Rural Poor in Liberia

LiberiaUnited States
Organization type: 
nonprofit/ngo/citizen sector
Budget: 
$50,000 - $100,000
Project Summary
Elevator Pitch

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

Founded by survivors of Liberia’s civil war, Tiyatien Health partners with the Liberian government to pioneer a model community health worker (CHW) system that is redefining how post-conflict nations rebuild rural public health services. Filling the massive health worker shortage in rural Liberia, our CHWs form a novel locally-led primary care workforce that delivers comprehensive home-based medical and social services -- providing access to care for the poorest of the poor.

About Project

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

Using CHWs to increase access to care is not new. But, past CHW strategies have failed to reach full potential. Historically, CHWs programs have largely delivered single disease interventions (e.g. vaccinations), neglecting those affected by other diseases in the community. Most CHWs are treated as volunteers, leading to poor retention. Finally, CHW pilots created by private NGOs fail to adapt and scale in weaker public sectors, especially in post-conflict nations. TH’s CHW model transforms rural health care in post-conflict nations plagued with workforce flight, unemployment and weak public systems. Rather than treating single diseases, TH’s CHWs deliver comprehensive packages of services, creating value by leveraging each worker against an array of diseases as well as poverty. Our CHWs also receive living wages, improving retention while creating jobs. Finally, TH partners with the Ministry of Health, generating research and advocacy to build a new health workforce within the public sector.
Impact: How does it Work

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

Bridging workforce gaps, our CHW system links public clinics with rural communities in a remote rainforest of 200,000 Liberians. Our program features 3 parts: 1. DELIVER COMMUNITY-BASED HEALTH & SOCIAL SERVICES CHWs deliver integrated home-based treatment, care and prevention for prevalent diseases (e.g. HIV, depression). CHWs also act as organizers, creating women’s and farming cooperatives to break poverty-related barriers to care. 2. BUILD PUBLIC SECTOR SUPPORT SYSTEMS TH’s support systems enhance CHW performance by providing a living wage and supervision from public clinics when patients require advanced care. 3. ESTABLISH LONGITUDINAL TRAINING TH will create novel and robust curricula to iteratively train CHWs to provide higher levels of care, like clinical child and maternal services. Advanced CHWs will form a new cadre of primary care practitioners, filling clinician shortages at abandoned clinics. TH pairs services with research and advocacy, working in partnership with the Ministry of Health to prepare our CHW model for national scale.
About You
Organization:
Tiyatien Health
About You
About Your Organization
Organization Name

Tiyatien Health

Organization Phone

617-297-7482

Organization Address

PO Box 426133, Cambridge, MA 02141

Organization Country

, MA, Suffolk County

Country where this project is creating social impact

, GG

How long has your organization been operating?

1‐5 years

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Innovation
What stage is your project in?

Operating for 1‐5 years

Tell us about the community that you engage? eg. economic conditions, political structures, norms and values, demographic trends, history, and experience with engagement efforts.

The world faces a shortage of 4 million health workers. The atrocious gap is especially acute in Africa, which bears 33% of the world’s maternal and child disease, yet has only 2.8% of the global health workforce. Nowhere is the crisis worse than in rural areas of post-war nations like Liberia, where conflict decimated the health system, leaving 51 doctors to serve 4 million people. Conventional hospital-based services have failed to reach rural Liberians, 60% of who lack access to health care.

This project serves residents of Grand Gedeh County, a marginalized remote region of 200,000 farmers, hunters and refugees living in the rain forests of southeastern Liberia. Historically, Grand Gedeh and southeastern Liberia have suffered the worse health disparities. HIV prevalence in the southeast is the highest in Liberia, with prevalence estimates as high as 13% according to the most recent Ministry of Health antenatal survey. Infant, child and maternal mortality rates are among the five highest in the world. Indeed a 2007 survey confirms that compared to women in any other region, women in the southeast have less knowledge of contraceptive methods, received fewer prenatal care interventions (e.g. iron tablets) and fewer had their births attended by a skilled provider. Compared to children in any other region, children in the southeast have less complete vaccination coverage, experience higher rates of malnutrition and have less access to clinical care, including antibiotics or anti-malarial medicines for fever.

Share the story of the founder and what inspired the founder to start this project

At age 9, Raj Panjabi narrowly escaped a bloody civil war in his home country of Liberia. Against steep odds as a refugee in America, Raj worked hard, training as a physician at Johns Hopkins University and Harvard University, where he is currently a Clinical Fellow. Fifteen years after leaving, Raj returned to Liberia to serve those he had left behind. Raj first worked as a policy advisor to the Liberian government and then began to build TH with other war survivors.

Social Impact
Please describe how your project has been successful and how that success is measured

As an organization, TH has not only survived, but thrived in a remote rainforest community that others had written off. TH’s efforts to build a community-led rural health model began out of a gutted bathroom in a war-torn hospital with Liberians who had never graduated secondary school. Through persistence, patience, and a strong focus on local empowerment, TH was born. Due to TH’s pilot success delivering rural health care, TH has been the only rural NGO invited to the committee rewriting Liberia’s 10-year National Health Plan and has recently been recognized by Scientific American and a 2010 Social Innovation Fellowship at PopTech, the global thought leadership network.

1) Revolutionized Rural Access to HIV Treatment: In 2007, Tiyatien launched the first and largest rural public AIDS clinic in the country. Lessons from our clinic were adapted by the Clinton Foundation to launch 6 other HIV treatment sites.

2) Put Mental Health on Liberia’s National Agenda: Groundbreaking data that over 40% of Liberians suffer depression, revealed in a joint 2008 TH-Harvard study, was cited by the National Mental Health Policy.

3) Rural Health System Reconstruction: Based on our pilot work, in 2010, TH entered a multi-year partnership funded by the Ministry of Health and in consortium with Merlin to support the expansion of the Basic Package of Health Services at all 17 public clinics in Grand Gedeh -- using our community-based model as a blueprint.

How many people have been impacted by your project?

1,001- 10,000

How many people could be impacted by your project in the next three years?

More than 10,000

Winning entries present a strong plan for how they will achieve growth. Identify your six-month milestone for growing your impact

In 6 months, TH will engage 2 dozen community health workers in our annual training institute and launch pilot programs in 3 new remote communities farther from the hospital where we currently work.

Task 1

Update and revise our current training curriculum - Our clinical advising team will help TH review our training materials and write new modules for an improved 5-day training institute in October.

Task 2

Expand our services into new communities - Identify, recruit, and train 5-8 additional community health workers to serve in three rural villages outside of TH's current catchment area.

Task 3

Strengthen monitoring & evaluation (M&E) systems - To allow for strong internal feedback loops and external model dissemination, TH will grow our M&E team and strengthen data collection processes.

Identify your 12-month impact milestone

Currently, our CHW primary focus is on the delivery of care and treatment for patients with HIV/AIDS, depression, and epilepsy. In 12 months, we envision a broad-based CHW trained in additional areas.

Task 1

Expanded trainings - To address other major health drivers of morbidity and mortality, TH will expand its training curriculum to include maternal & child health, tuberculosis, & women's empowerment.

Task 2

Leverage mobile technology - TH will implement mobile technology for its community health workers in order to improve data collection and promote public health messages and lessons.

Task 3

Disseminate model - To widen the impact of our work, TH will share our training materials through open-source online platforms and publish our results in peer-reviewed journals.

How will your project evolve over the next three years?

TH’s long-term goal is to build a model rural health system for post-conflict areas by creating universal access to primary health care for the 200,000 people in Grand Gedeh County. Gedehians have low rates of access to three core National Health Plan services: HIV testing (2.4%), prenatal care (12%), and mental health care (6.2%). By 2015, access to HIV, mental health, and maternal health services will increase to 50%. By 2021, access will increase to 80%. Where access is created, we will measure impact on outcomes: reductions in AIDS and maternal mortality and mental health morbidity among the poorest 10%.

These targets are realistic. Published research from Zwedru, our pilot site, demonstrates increase in HIV testing to 49.1% since TH’s launch.

Sustainability
What barriers might hinder the success of your project and how do you plan to overcome them?

Internally, we must continue to ensure that those who bear the brunt of the suffering in Liberia remain the primary vision-setters, especially as we engage more advisers, funders, and stakeholders. The success of our community-based strategy depends on preserving these roots. We will incorporate within our strategic plan clear commitments to equitable decision-making and strong local leadership development.

Looking outward, our long-term success will be more likely with changes to government policy. While the government recognizes CHWs as an essential component of reconstructing post-conflict health care, the ways to best incorporate them remain unclear. Experts disagree, for instance, with giving CHW salaries and added responsibility (and concomitant management and training support).

In response, TH has pushed for a more progressive CHW policy using research and advocacy to demonstrate the extraordinary value of a well-paid, highly trained CHW with better management systems. Based our published work demonstrating 60% increased survival among HIV patients supported by a CHW, in 2010 the Ministry of Health circumvented its own policy, authorizing scale-up of a paid, well-trained CHW pilot at several additional public treatment sites.

Tell us about your partnerships

Liberian Ministry of Health & Social Welfare (MoHSW): Through the Health Sector Pool Fund, the MoHSW finances the facility-level delivery of the Basic Package of Health Services at 17 public health clinics, where TH’s CHWs refer patients and receive direct supervision. The Pool Fund also finances the training workshops of CHWs in HIV, tuberculosis, mental health, and maternal and child health.

Global Fund for AIDS, Tuberculosis, and Malaria: The Global Fund has made a fraction of the investment necessary to scale our model to 17 national HIV treatment sites around the country. Currently, the Global Fund grant provides approximately $100,000 annually to support the stipends of 95 CHWs -- all of them people living with HIV/AIDS -- to provide home-based care to other patients with HIV/AIDS.

Partners In Health (PIH): Through our partnership with Partners In Health and advising from Drs. Paul Farmer, Joia Mukherjee and other programmatic staff, TH has benefited from technical assistance, strategic guidance on its CHW curriculum, strategy, and planning since 2007.

UN Refugee Agency (UNHCR): UNHCR provides limited funding support for administrative costs associated with the project as well as in-kind loan of TH’s only vehicle.

Merlin: Merlin is TH’s primary partner on the MoH’s Pool Fund project. Since 2006, TH and Merlin have partnered to support health services in Grand Gedeh County. Forming part of a model collaboration between an INGO (Merlin), a local NGO (Tiyatien) and the Liberian government (Ministry of Health), Merlin provides logistical, administrative and capacity building support to local partners, including TH.

Explain your selections

Since our origins, TH’s innovative work has depended heavily on bold individuals and foundations who are willing to invest in programs typically denied by traditional policymakers and funders. Indeed, our unconventional model was launched out of a suitcase of donations from Dr. Panjabi’s wedding.

Today, this approach continues in our current strategy, which focuses primarily on growing communities of individual donors in Boston, New York, and Chapel Hill through a combination of online giving, social media, and community events hosted in supporters’ living rooms. Additionally, early investments from family foundations and social innovation prizes, including Echoing Green and the Rainer Arnhold Fellows program have support TH's initial growth.

Furthermore, in Liberia, we have persuaded the Liberian government to invest over $400,000 in rehabilitating public clinics in Grand Gedeh, partly covering administrative and support systems for our CHW pilot.

By 2015, we see governmental and multilateral grants providing 60% of our revenue. The remaining funds required for continued innovation and new interventions will come from US corporations/foundations (20%), major gifts (10%), and grassroots support (10%).

How do you plan to strengthen your project in the next three years?

TH will continue to strengthen its project through continued development and expansion of CHWs knowledge and skill base through longitudinal training and clinic-based support, while expanding its work to more rural communities in Grand Gedeh County through a community-based model of care. Furthermore, TH will continue to develop and utilize rigorous monitoring and evaluation systems to track progress and success, with the intention of continually reflecting upon and improving systems, as well as disseminating findings for further strengthening of rural health care systems in post-conflict areas. Continued and expanded partnership with the Ministry of Health will help TH strengthen our project in working towards a model for national scale-up.

Challenges
Which barriers to health and well-being does your innovation address?
Please select up to three in order of relevancy to your project.

PRIMARY

Lack of physical access to care/lack of facilities

SECONDARY

Limited human capital (trained physicians, nurses, etc.)

TERTIARY

Lack of affordable care

Please describe how your innovation specifically tackles the barriers listed above.

War destroyed the Liberian health system. Today, half of the Liberia’s population lives in extremely remote villages, sometimes many days’ walk through thick jungle from the nearest health facility. Only one physician remains for every 100,000 people in rural Liberia.

TH is built around a robust backbone of CHWs who provide the missing infrastructure necessary to connect people to the care they need, when they need it.

Each year, TH’s CHWs conduct over 10,000 home visits to people and communities affected by HIV, and other maternal and child diseases, and refer over 2,000 sick individuals from rural communities for early curative care and preventive primary care services.

How are you growing the impact of your organization or initiative?
Please select up to three potential pathways in order of relevancy to you.

PRIMARY

SECONDARY

Influenced other organizations and institutions through the spread of best practices

TERTIARY

Enhanced existing impact through addition of complementary services

Please describe which of your growth activities are current or planned for the immediate future.

Based on TH’s pilot work, the Global Fund, TH, and the Ministry of Health have launched a two-year partnership to pilot the scale-up of a community-based delivery model for delivering HIV/AIDS treatment at 21 national sites.

TH’s Liberia team is supported by a robust volunteer network of global health experts and practitioners, based at prominent universities such as Harvard, Johns Hopkins, and Georgetown University. Our global network allows TH to provide substantive technical assistance to the Liberian Ministry of Health and Social Welfare and advocate at national and international levels for essential policy reforms. For instance, a recent Lancet publication by TH’s Medical Director sparked an international call to action to convene a United Nations Summit on global mental health.

Do you collaborate with any of the following: (Check all that apply)

Government, NGOs/Nonprofits, Academia/universities.

If yes, how have these collaborations helped your innovation to succeed?

Public sector collaboration with the Liberian Ministry of Health (MoH) has been instrumental in supporting and scaling our CHW model. TH works closely with the MoH to strengthen clinical services in southeastern Liberia, providing a strong referral arm for patients seen by our CHWs.

Internationally, TH partners with similar health and social justice organizations including Partners In Health, Nyaya Health, Village Health Works, and others to form learning communities and share resources. Practitioners from these organizations regularly meet to discuss best practices and share operational tools.

Partnerships at Harvard and Johns Hopkins ensure institutional rigor for our data collection and analysis, as well as providing channels of dissemination throughout the global health field.