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Why Investments in Frontline Health Workers Matter: Preventing needless deaths through trusted healthcare relationships

 This guest post has been co-authored by Samalie Kitooleko, Nurse In-Charge of Uganda Rheumatic Heart Disease Registry & and Belinda Ngongo, Global Health Leaders Fellow, Public Health Institute. Samalie is a recipient of the Heroines of Health Award 2017, and Belinda is a part of GHC’s delegation to the 70th World Health Assembly (WHA70)

Samalie Kitooleko during our panel session, Against All Odds: Strengthening Health Systems to Better Serve Women and Children

Samalie’s Story

It all started when I nursed a young female university student with Rheumatic Heart Disease (RHD). As a teen she had received a mechanical valve replacement requiring her to take an anticoagulant daily, which she did without fail. During her third year, she became pregnant and stopped taking her anticoagulant medication without medical consultation, thinking she was looking out for the best interest of her baby. Several days later, she lost her baby and I saw her passing away on her graduation day, suffering from valve thrombosis, a condition which could have easily been prevented if she hadn’t defaulted her medication. In that moment, I vowed to never see another woman die of preventable complications. No one should die because they lack appropriate healthcare knowledge in today’s world.

I began counselling women intending to undergo mechanical valve replacement, educating them about necessary medications and lifestyle changes. Initially, I dealt with very few women however in 2013, when the RHD register was established in Uganda, the numbers become rather overwhelming so I developed novel ways of addressing them at scale, forming a patient support group on WhatsApp. Patients used this platform as a way to pose questions to the broader group and it became an incredible group to share knowledge with.

As a nurse in Uganda, I spend most of my time caring for patients affected with chronic cardiovascular illnesses such as congenital heart disease, myocardial infarction, and rheumatic heart disease (RHD). My typical day starts at 7 AM and ends at 9 PM. During this time, my work involves updating the RHD registry with new patients, those that have died and identifying those that are lost to follow-up. I then spend the day in the outpatient clinic counseling patients, enrolling patients in the RHD registry, and administering Benzathine Penicillin injections in the Coumadin clinic which I run concurrently. Due to limited staff, I also work closely with patients affected by all other noncommunicable diseases including diabetes, hypertension and cancer. I’m proud to provide a patient-centered approach during delivery of care, spending time getting to know and following up with the women I serve.

The Case for Frontline Health Workers

Like Samalie, there are many other frontline health workers (FLHWs) in developing countries committed to caring for patients and pressured to work long hours under poor conditions in deplorable infrastructure and limited sundries. To make matters worse, their hard work is rarely recognized and they are compensated poorly for their incessant efforts to improve health and wellbeing of populations. The exodus of FLHWs from the health sector can be attributed to some of the current chaotic and constrained environment. The pursuit of non-health related employment opportunities compromises the quality of care already aggravated by the major shortage of staff in most health care facilities.  It is therefore important that we answer these questions – Why do we need to care about FLHWs? What do we need to do to retain, satisfy and support FLHWs?

Undoubtedly, to improve service delivery and lower staff turnover, appropriate compensation and recognition of frontlines’ efforts is imperative for increased motivation and morale. Such recognition can be in form of being acknowledged as best performers of a given period, promotions and better wages and including them in critical global health and health systems conversations. FLHWs need to be well equipped with knowledge and skills and understand trends and strategies to accelerate the implementation of appropriate interventions to effectively combat disease. They also need to be provided with ongoing training and career advancement opportunities in order to ensure persistent delivery of quality services.
One stumbling block in the health systems arises from the fact that FLHWs have limited decision making power and their potential contributions are hindered by certain rules and regulations. For example, in Uganda nurses are now allowed to provide a prescription but are limited to making a nursing diagnosis and care plan. Policies need to be reviewed and where appropriate influence of frontline should to be augmented and task shifting implemented. Promising models of how FLHWs are managing NCDs can be found here.

The gender lens aspect is important to ponder when alluding to FLHWs, especially since it is recognized that 75% of global health work is done by women. Women deliver the bulk of health care worldwide in the formal and informal sectors. Most FLHWs are women. They usually work under pressure to balance family and societal responsibilities in resource – limited settings, leaving their lives and those of their families at stake. Despite working tirelessly to restore the health of other people, on many occasions’ health and life of FLHWs are not carted and likewise despite their important contribution to global health and the dependence on women as providers of health care, according to a recent report women have very few leadership positions in the health systems.

FLHWs play a vital role in initiating the referral process through timely and comprehensive communication, provide ongoing support and care to patients and their families. Referral of patients may affect treatment and continuity of care and can affect clinical outcomes and costs thus  clear guidance from facility staff is critical. They need to be part of the referral process.

In summation, FLHWs deserve to be recognized for their dedicated and generous contribution towards the health and wellbeing of the populations they serve. In return, they also need to be healthy in all aspects, valued, respected, supported, protected, compensated adequately and work in appropriate.

This week, WHA70 gives us an opportunity to further elevate the voice of FLHWs to encourage further investment and support for those saving lives on the frontline. Join us in helping to elevate their voice!

Learn More: 

Global Health Security: Why Women Matter
Maternal child health

As the world responds to a new outbreak of Ebola in the Democratic Republic of Congo, many may not realize that women tend to be at greatest risk. If this outbreak follows previous patterns, as many as 75% of those infected will be women, which has massive implications for families and society at large.
To help women survive and thrive, it is imperative that health security efforts focus not only on building response capacity to emergencies like the last Ebola pandemic, but on creating more resilient health systems. As I prepare for the World Health Assembly which begins May 22 in Geneva, Switzerland, I hope to help bring more attention to key components of effective healthcare delivery: the availability of quality assured medicines, and the human workforce to sustain services in the face of pandemic threats.
If these efforts are to have a lasting impact, it is critical that women, already the traditional caregivers in many communities, be part of those efforts.

Women’s Disproportionate Burden

Women are disproportionately affected during health crisis situations for several reasons. Lower socioeconomic standing means women often have poorer nutrition and lack access to education and basic health services. Traditional gender roles means women are more likely to be exposed to disease because they are the primary caregivers. Women prepare meals, care for the sick and attend to the dead. Women also make most health care decisions in the family.  Simply put, women are at the center of global health security.
High-profile emergencies, such as Ebola, Zika and Influenza, demand responses that require not only effective services, but also effective treatments. But in low- and middle-income countries regulatory authorities often face daily challenges assuring medicines quality, even outside a crisis situation. The growth of online distributors, according to the WHO, now means there is not a single country that is untouched by this problem of substandard or falsified medicines.
Shortages in quality-assured medicines hamper health emergency responses during outbreaks, they undermine continued efforts to reduce the impact of the tuberculosis, malaria and HIV/AIDS epidemics and impede improvements in maternal and child health outcomes.

Women Leaders in Science, Policy and Practice

Resilience during public health crises requires investing in health systems and people, especially women, as agents of change.
USP collaborates with the WHO, national medicines regulatory authorities, manufacturers and other partners to increase the supply of quality-assured essential medicines by building technical capacity and human resources at all levels. In Africa, for example, in 2015 USP created the Women in Science Exchange (W.I.S.E.), a program to empower and mentor female students and professionals in science and help them to advance into leadership positions. Recognizing that women are under-represented in the African health workforce, the program paired female students with mentors, African women who are established leaders in pharmaceutical, medical or regulatory science.
In a recent visit to Myanmar, I was struck by the efforts of the head of the recently accredited National Medicines Quality Control lab, Dr. Khin Chit, to mentor her staff, over 90% of whom were young women, reflecting a similar shift in opportunities in Southeast Asia.

Women leaders in science

USP also provides on-site training for quality-assurance professionals around the world. In 2016, USP facilitated the training of over 1,000 individuals from 19 countries – over 500 of which were women. Together these efforts seek to improve the pipeline of future women scientists. We can all do better to support women in science as part of building resilient health systems.

Looking to the Future

Neither pathogens nor medical products respect national borders. Substandard and falsified medicines may be uncommon in the U.S. and other industrialized and middle income nations but global supply chains and travel make all of us vulnerable to health threats associated with poor quality medicines. They fail to treat infectious diseases and contribute to drug resistance, elevating the risk of further spread, locally and globally.
To achieve the Sustainable Development Goals, everyone needs medicines that are accessible, affordable and  quality assured. USP is committed to investing in women and strengthening systems across the globe so the medicines people take are quality-assured, no matter their gender or where they live.


Global Health and the Future Role of the United States Report Released
The National Academy of Sciences, Engineering, and Mathematics is releasing a report today on Global Health and the Future Role of the United States. In the report, the project committee makes the case for global health in light of current and emerging world threats. The report assesses the changing landscape of global health and outlines priorities for the U.S. government and key mechanisms by which global health engagement can be strengthened. A report launch event in Washington, DC, will be held on May 15, 2017, at which committee members will discuss the recommendations.

PATH Celebrates 40 Years of Innovation
On May 12, 1977, three family planning researchers – Gordon Duncan, Rich Mahoney, and Gordon Perkin — formed a small nonprofit organization with a mission of availing effective forms of modern contraception to couples around the world. The organization came to be known as PATH, and after succeeding at its early goals in contraceptive technology, it expanded its focus to include an array of health technologies. Today, PATH reaches an average of 150 million people in over 70 countries a year with life-saving innovations. The organization has garnered a reputation for excellence and collaboration, for partnering with the private sector, and for smart, effective solutions to global health problems. Congratulations PATH on this incredible milestone; GHC is proud to have you as a member. Read more.

A Call for Accountability to End Attacks on Health Facilities
The Safeguarding Health in Conflict Coalition (SHCC) released a new report which documents the alarming incidence of deliberate and indiscriminate attacks on health workers, patients, and health facilities during periods of armed conflict and civil unrest across the world. The report, Impunity Must End, is based on information received from UN agencies, independent non-government organization researchers, and local and international media in 23 countries that faced political turmoil and violence in 2016. SHCC is a coalition of more than 30 non-government organizations working to protect health workers and services threatened by civil war and unrest. Their latest report calls on the United Nations Security Council and countries to take concrete steps towards preventing attacks and ending impunity, as recommended last year by the UN Secretary General. Read the full report.

Integrating Health and Development to Save More Mothers
Johnson & Johnson, FHI 360, and UNICEF are working on a project to encourage the development of cross-sector partnerships delivering integrated solutions to end maternal and newborn deaths. The project, an online data tool, focuses on bridging critical data gaps in 16 countries where 70% of global newborn deaths are concentrated. Once completed, the Newborn Survival Map will provide a platform to expose cross-sector opportunities for closer collaboration among partners currently in close geographic proximity. In addition, the map will reveal critical gaps in cross-sector services that could prevent the deaths of many more pregnant women and newborns. To join this effort and get your project on the map, please create a new profile online.

Vaccines Work: Leaving No Child Behind – How Pediatricians Can Contribute to Global Vaccine Coverage

This guest post was written by Louis Z. Cooper, MD, American Academy of Pediatrics. It originally appeared on the Centers for Disease Control and Prevention blog.

Today, more children are saved by vaccines than ever before, but over 19 million children are still missing out on these critical life-saving vaccines each year across the world (WHO, 2017). To put that in perspective, that’s almost the entire population of the state of Florida. Globally, coverage for the first dose of the measles vaccine has reached 85%, a remarkable accomplishment. Yet, in Somalia, progress in measles coverage has stagnated in the past five years, with coverage holding below 50%. While I celebrate our achievements, it is these missed children in vulnerable communities who keep me up at night.

Louis Z Cooper
Louis Z Cooper

Whether we practice in Long Island or Lagos, pediatricians’ number-one job is to keep children healthy. We often come together to share our experiences, learn from one another, and improve the practice of pediatrics globally. Our discussions over the last several decades helped me become a better clinician for the children I served.The American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) have sought to solidify these informal knowledge exchanges by partnering in a multiyear project focused on reaching the goals of the Global Vaccine Action Plan. The plan, also known as the GVAP, is a roadmap to ending inequity and extending the benefits of vaccination to everyone, regardless of where they are born.

Because they are uniquely trusted, pediatricians and their national societies can play a special role in strengthening the vaccine delivery system; helping to ensure children and families understand the importance of vaccines and supporting public health vaccine programs. I have been fortunate to serve as a senior advisor on this project, which aims to harness the power of pediatricians by building a cadre of pediatric advocates dedicated to improving vaccine access. The lessons we learned through training our members here in the U.S. to become strong advocates for children has provided a curriculum of competencies that AAP can share with other national pediatric societies. The curriculum is then tailored to meet the specific needs of their country. Partnering has begun with societies in six priority countries in our first two years. We have worked closely with pediatric societies in Kenya, Nigeria, Ethiopia, Nepal, Indonesia, and the Philippines.

The GVAP calls for a coordinated response across partners to meet its global targets; the AAP, the CDC, and our six country partners, believe pediatricians and pediatric societies are especially well-positioned to support this effort. Pediatric societies play an important role cutting across all aspects of vaccine delivery—getting routine vaccines to kids, championing new and under-used vaccines, educating future child healthcare providers. Our country partners work to build country-owned strategies for improving healthcare services for all children, while urging their patients and their governments to consider how best to protect their children from vaccine-preventable diseases.

In just two years of implementation, we have developed new partnerships, strengthened existing institutions, and improved linkages between the public and private sectors. In Indonesia and Philippines, our colleagues are working to improve surveillance by linking vaccine service delivery data between public and private sectors. In both Nigeria and Ethiopia, they are committed to working closely with policy-makers by providing evidence-based, community driven information so children’s needs receive deserved high priority. Pediatricians in Kenya and Nepal have focused on educating the workforce to ensure that healthcare providers at all levels know why vaccines are important and how they are playing a significant role in children’s health. In many countries, pediatricians are not the ones giving vaccines, so we’ve found it is important to expand communications with the individuals who are administering them, the frontline vaccinators. We can provide the why’s of vaccines, but without vaccinators, we will not know enough about the how’s and the challenges they and we face to immunize all children.

When polio vaccine was licensed in 1955, I could not imagine how immunization would save millions of lives in my lifetime and how vaccines would change child health and the practice of pediatrics. While we deservedly rejoice at the momentum facilitated by GVAP, globally one in five children remain unprotected from vaccine-preventable diseases, and immunization rates have plateaued. This reality warrants deep concern and increased, creative effort from all of us.

The public/private partnership of AAP and CDC builds on the collaborative foundation of GVAP.  Its mission aligns with the core value of pediatrics, the inherent worth of every child. Working and learning with our global colleagues is reinforcing our collective commitment and can give the extra push to eradicate polio, measles, and rubella and to expand access to the still underutilized newer vaccines. Until no child left is behind, our work continues.