The Last Mile In Community Health: Reaching The Hardest To Serve

Editor’s note: This article is part of a series of blog posts by leaders in health and health care who participated in Spotlight Health from June 25-28, the opening segment of the Aspen Ideas Festival. This year’s theme was Smart Solutions to the World’s Toughest Challenges. Stayed tuned for more.

In the wake of the West African Ebola crisis, we—as a global community—have had time to reflect on the striking inequities in health systems, the intersections between health and global security, and the lessons learned about coordinated emergency efforts. Ultimately, though, as our colleague Raj Panjabi from Last Mile Health reminds us, while illness is universal, access to care, even in 2015, is not.

The West African Ebola crisis has been traced to a single two-year-old boy in rural Guinea — a two-year-old boy living in a part of the world without health systems able to fully respond to his needs. This caused Ebola to rapidly spread — leading to a crisis of over 27,000 cases, 11,000 deaths, and billions of dollars of combined in-country economic losses and international aid spending. Ebola reminded us that we all are at risk if even one health system in a remote village in Guinea is not functioning.

It also provided us with an unfortunate platform to expose long-known vulnerabilities in global health systems. To address these weaknesses in global health systems, both for shorter-term needs with the Ebola outbreak and longer-term needs to build health systems, innovative approaches, partnerships, and investments are needed.

Community Health Innovation

To that end, the U.S. Agency for International Development (USAID) has taken a leading role in engaging the global community to identify innovative ideas and approaches that deliver practical and cost-effective innovations in a matter of months, forge innovative public-private partnerships, and provide funding to get promising ideas to the field more quickly. These innovative ideas are not only related to developing products or technologies, such as improved personal protective equipment for health care workers, but also are related to strengthening health systems to prevent future outbreaks.

In recent years, health leaders have recommended the development and scale-up of cadres of community health workers (CHWs) to strengthen health systems and provide care to those hardest to reach. When integrated within primary health systems, CHWs can be an important lever to respond to health crises, provide routine care, and serve as a link to health systems for hundreds of millions of people.

The report “Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Requirements,” recently published by the World Bank, Partners in Health, The Clinton Foundation, MDG (Millennium Development Goals) Health Alliance, and the governments of Ethiopia and Liberia, among other contributors, cited that expanding access to key interventions provided by CHWs could prevent up to 3 million deaths per year in sub-Saharan Africa, resulting in an economic return on investment of up to 10:1.

Yet even with mounting evidence regarding the social and economic benefits of community health programs, efforts to implement and strengthen these programs have faced significant challenges. It is difficult to coordinate and synchronize programs both within and across countries, and often this coordination is not happening at the MoH level. Stakeholders involved in the implementation of community health programs, ranging from MoHs, non-governmental organizations (NGOs), private sector companies, and foundations, have cited a lack of collaboration as a challenge in scaling these programs.

From “Ideas To Action”

It was in this vein that The Aspen Institute recently held its inaugural “Ideas to Action Incubator.” The Incubator directly preceded Spotlight Health and was a day-long, invitation-only convening of health systems experts charged with creating collaborative and innovative approaches to bring health care to the hardest to reach. Leaders from MoHs, academia, finance, and both international and domestic NGOs incubated solutions to accelerate the strengthening of community health systems.

The solutions incubated then formed the basis of the Spotlight Health panel entitled “The Last Mile in Community Health: Reaching the Hardest to Serve.” This action-oriented panel featured pitches from the incubated solutions, followed by broader participation from attendees to get their thoughts, input, and commitments.

Leadership For The Last Mile

USAID’s Center for Accelerating Innovation and Impact (CII), in partnership with MDG Health Alliance and The Aspen Institute, have been involved in the design and implementation of one of the incubated solutions, Leadership for the Last Mile (LLM). LLM aims to address health systems challenges in high-burden countries by providing in-country managerial, financial, and strategic expertise to MoHs, while simultaneously creating a platform for collaboration and knowledge-sharing across sectors and countries. The impetus for LLM came from in-depth conversations with a range of stakeholders—including MoHs, private sector companies, nonprofits, and foundations—who indicated that a root cause in strengthening community health systems may relate to government capacity and resources.

Many MoHs have indicated that while its employees have strong technical expertise, many lack the financial, strategic, and managerial expertise needed to design, develop, and implement community health system strategies. Furthermore, many MoHs cite a lack of resources to recruit or train staff with the necessary skills to develop or implement such programs.

To that end, over the last year, CII, MDG Health Alliance, and The Aspen Institute have been designing LLM with significant input from partners. Leadership for the Last Mile is a collaboration between multi-sector partners, including the private sector, NGOs, foundations, donors, and MoHs, that will strengthen community health while building the next generation of global health leaders in Africa.

Leadership for the Last Mile will provide a menu of support opportunities to strengthen management and leadership capacity in MoHs, leveraging private sector expertise in management and leadership to respond to needs of MoHs. Key MoH staff will have opportunities to access training, mentoring, and joint problem-solving through the creation of local mentor networks and cross-country convenings, enabling South-to-South best practice-sharing and capacity building.

Leadership for the Last Mile will also provide demand-driven support to MoH teams as needs arise during the partnership, for example by providing planning/strategy tools and relevant analytics. The program will directly add capacity to MoHs by placing top-tier professionals (“Management Partners”) with significant private sector expertise and complementary skills to work on pre-identified, high priority, and catalytic community health projects. In addition to providing and building financial, strategic, and management expertise within MoHs, LLM will serve as a catalyst for dialogues between diverse partners on the cutting edge of health systems design — enabling joint problem-solving and learning. It is envisioned that LLM will operate at scale in 10 countries within three years.

A Business-Minded Approach

CII’s mission is to apply business‐minded approaches to the development, introduction, and scale-up of health interventions to accelerate impact against the world’s most important health challenges. To be successful in our mission, though, we know we can’t just focus on applying business-minded approaches to develop and scale lifesaving health technologies and products — we also need to apply private sector best practices and principles to develop systems, organizations, and people. For example, in the United States, organizations spend over $150 billion per year on training and development programs for employees.

What if more international aid similarly went to further training and developing talent in-country? Could this strengthen health systems to reach the last mile? Leadership for the Last Mile is a catalytic program that aims to do just that through equipping MoH leaders with additional skills to develop and implement the strategies that they themselves see as the highest priorities in achieving universal health coverage.

We’re actively building the Leadership for the Last Mile collaboration. Please reach out in the comments section below to share your thoughts, ideas, and input. Let’s enable and equip countries with the tools they need to design and deliver effective, high-quality health care programs that all can access.