The following is from a posting by Dr. Prabhjot Singh Dhadialla, our CHW team leader, on the ICT4CHW mailing list, an excellent discussion, started by Neal Lesh and others, on using technology to enable CHW programs.
CHW Programs within MVP
I’m currently the Community Health Worker and Health System advisor to the MVP. In this post I’ll give some background about the Millennium Villages Project, the Health component/CHW program and then a bit about our approach to technology usage. It may seem like a long preamble to getting to the ICT, but I’ll say something about why I’ve done this at the end. In addition, I’ll speak about ongoing scale-up work:
The Millennium Villages Project
The MVP was designed to consolidate the world’s current implementation knowledge about achieving the Millennium Development Goals and put them into action throughout challenging terrains in Sub-Saharan Africa. Located in 10 countries at 14 sites, the first wave of Millennium Villages are clusters of about 40 to 80 thousand people — ~450,000 in total. The clusters were identified through a process that requires a national government to request MV presence in the country [1]. This triggers a process of identifying areas of high need and then working with the districts to find candidate communities where there was enthusiasm for the process.
This is a high profile development project for a number of reasons:
- It’s not the first example of integrated rural development, however, there are some significant design features including a tightly budgeted/costed model ($110/per/year, inclusive of community contribution, government per capita expenditure, local or NGO contributions in the vicinity — the gap is what the MV financing model provides), emphasis on upgrading ICT infrastructure, evidence-based interventions with experienced practitioners and the development of expert sub-systems.
- This adds up to a ‘systems approach‘ that articulates with a variety of formal and informal institutions.
- Focus on the operations/mechanics — “how to” of implementation of evidence-based interventions that have been long-documented but rarely integrated due to the inability to align scales of activity from the community to government
- sequenced roll out of key interventions determined by local teams across community development, agriculture, infrastructure (including ICT — will come back to this), water and sanitation, health, education and business development (I’m sure I’m missing a few)
- focused upon meeting the Millennium Development goals while providing guidance to a broader community about how to do this from a technical perspective, a costing perspective, a monitoring and evaluation perspective and an implementation mechanics/operational perspective; the project kicked off in 2006 with most MVs beginning at that time with 5 years of financing and another 5 years of substantially decreased financing anticipating the development of sustainable businesses and absorption of services into government budgets.
- Jeffrey Sachs, the director of the Earth Institute at Columbia University and thought leader of the Millennium Villages project is a vocal advocate of practical approaches
The gist of the idea is that for most of the communities, subsistence farming is the way of life [2] and increased crop yields through a judicious and soil-sensitive addition of fertilizer and improved irrigation techniques [3] leads to surplus income. Part of this income goes to community inputs (i.e. grain bank for school feeding programs) while the rest is available for investments in family health, business development and so on. It’s not as simple as this and as one’s intuitive sense may convey — people don’t just fall into line and spend disposable income on health, savings and education for building a better tomorrow. But it is catalytic and the integrated approach creates an environment where there are a multiplicity of reasons to make less resource constrained decisions. And our mid-term data shows that this approach has been remarkably effective in key areas, along with some glaring stagnancies that reflect, to varying degrees, the state of “best practice.”
When you go to a MV, you’re immersed in rural village life and it may be difficult to see the political supportive apparatus that ensures that the problems and successes are telegraphed to multiple scales of audiences. This is done through strong Monitoring and Evaluation (M&E) platforms and an increasing investment into real-time monitoring via ICT so information is used as a management/process improvement tool. Over this year and next there will be a lot of data from the MVs that will be publicly presented and people from many communities will be asked to help us figure out what’s going on beyond some clear cut findings — especially those that are cross-sectoral and difficult to disambiguate using traditional statistical techniques. This will come up later.
Finally, it’s worth noting that despite having a standard core of available practices, the national policy/practice environments and local capacity to implement results in a large degree of natural variation. We’re looking for particular signals related to the MDGs and other crucial aspects that have emerged in the process, against a background of considerable noise. There is a lot of debate about RCTs etc… and the project has identified comparison villages (different from formal “controls”). My background is in information theory/neural systems (and medicine) and would posit that there are a number of dynamic approaches to dealing with sort of setup that doesn’t require the clunky apparatus of RCTs, not to mention the practical/financial problems it presents. But no broad strokes here, we’ll continue to look at opportunities to build a multiplicity of analysis approaches to facilitate as many perspectives as possible.
MV Health and CHWs
The health budget is ~$40/person per year. This is put into a pooled fund that is managed locally by a health coordinator who is from the region in coordination with village health committees. The coordinators are technically skilled and may be doctors, pharmacists, clinical officers of other rank — but they share a common characteristic of paying attention to information and political processes simultaneously. They live very close to the village and spend a lot of time there. Their salary is costed for in the MV budget and often times they are seconded from government to ensure that their position is sustainable and scalable (after adequate training). The site management team forms a functional network of experienced individuals who work within countries at multiple levels; their presence is crucial and scale-up plans include the identification of these sort of people.
The MV Primary Health Case System is predicated upon meeting a localized but uniformly available package of primary care services in the community. The household is the foci of our efforts, even if simply to facilitate demand at clinics. This makes CHWs the basic building block of health system development, as much as the building/upgrading of clinics if there were none (usually something there but not always) and the installation of an emergency response system (ERS). The latter consists of ICT investments to provide cellular coverage to these rural areas, an investment that has being matched and overtaken by market driven investments since the beginning of the project in 2006. Nevertheless, in all locations there is considerable udnerstaffing of clinics from aspirational national standards and there have been an array of efforts to supplement the clinics. Even though there is national support for the MVs, there is a limited ability to simply get the MV clinics staffed by fiat (in fact, in some places, people are taken away because of the perception that “millennium has money”[4]).
Variation in CHW programs across countries has been a challenge. Not only does it require really knowing the existing policies etc… but you have to understand the historical view to village health workers and the reasons for various constraints (volunteer vs paid, certified vs informal etc…). Most of the time you’ll find that the rationale for various policy constraints are historical-circumstantial rather than evidence based or principled. Show a better way (either from other countries or tested ideas from other areas) and ministries are interested. But people ain’t fools and an idea is only worth its weight in implementation fidelity.
Anyway, our approach has really morphed to tightly defining a standard core of practices across the MVs that CHWs can do and must to really demonstrate their competitive advantage. They go to households use clinical algorithms to assess fever with RDT’s and give anti-malarials, use ORS/zinc for diarrhea, MUAC+referral for malnutrition, close monitoring of pregnant women (pushing facility births) and newborns (various). That’s the core. Depending on country, CHWs do other stuff too — family planning, sanitation/hygeine etc… We support and strongly advocate for a number of other things, but nailing down a standardly acceptable core for 10 countries has taken some effort.
In all sites, CHWs use paper forms to report their information and the MV standard forms protocol includes localization to language, ministry requirements, and site specific health needs. If you can imagine, this requires a lot of management and support and this is what I want to underscore. If management and supervision are not considered with as much interest as the technology, including a budget to support it, you’ll hurt an effort. I say this in stark terms because the cost is “system load” on the human resources and people will pay attention to the technology because it’s just more specified in terms of actions etc… It becomes sorta like those tamagotchi toys [http://en.wikipedia.org/wiki/Tamagotchi] where people will pay attention to feeding their digital pet to the detriment of their other responsibilities. Happens. But the bottom line is that phones and technology are fundamentally changing the spatial and communication landscapes of rural areas. If the development community doesn’t figure out how to do this work, commercial, for-profit, social venture etc… groups will do so. “No market, people are poor, that’s why we’re doing this!” Agreed, and this community is critically important to set the standards of interaction and really hone in on the true priorities. Not just for the effort we’re involved in, but for where it sits in a broader landscape that extends beyond traditional development boundaries.
Recently we’ve introduced the ChildCount+/RapidSMS system that Matt Berg introduced on another thread here. Earlier, Zoravar Dhaliwal of Community Lab may have spoken about their management systems. We use both. Togther, they are the technology enabler for the information management and process improvement methodologies that we’d like to see “installed” to really get higher “implementation fidelity” from CHWs. This has been very important because in every program I’ve seen (africa, india, latin america), the CHW roles and responsibilities are underspecified while simultaneously being content overloaded. Even if the content has been whittled down (i.e. a vertical malaria or DOTS programs) enough to minimize the poor technical/operational specification of the CHW program in general, you’re simply lowering expectations to match the fuzzy structure rather than sharpening the latter to experience efficiency gains that create space for an enriched activity set. This isn’t just a question of style or where to place program emphasis, if there is any interest in having valued, full-time, paid CHWs that are truly an integral part of the health system (either public or private), addressing content and technical/operational specification is a must.
I’m sanguine about ChildCount+/RapidSMS in the MVs but I’ve been far more interested in the process we’ve had to follow in order to create an appropriate interface for the technology and the broader CHW/Health System/MV goals. The work that has gone into really understanding the constraints on management, data flow, coordination with other health sector activities as well as the critical element of sequencing/phasing deployment has been critical. It is precisely the constraints of a technology system that allow for a focus on priorities, but this is a double-edged sword because it’s easy to forget that not everything should be channeled through this constraint. Health can’t be viewed through the screen of a mobile phone as much as it is a crucial interface to be incorporated. We have a superb team on the technology front — Matt Berg, Andy Kanter, Patricia Mechael — but they work in coordination with regional CHW coordinators — Jackline Oluoch and Yombo Tankoano — who in turn work with CHW managers at every MV site. The CHW managers communicate with senior CHWs who manage 6 CHWs (when this arrangement is possible, often modified). This entire team is supplemented by a M&E team that looks at quarterly data while aligning real-time monitoring information. Finally there is the critical eye on the shifting politics and emerging opportunities to scale-up to national levels.
Finally, much of this work has been shaped by interactions I’ve had with Jonathan Jackson and Neal Lesh as CommCare has developed. The concept of a protocol driven health worker support that provides real time monitoring via a management dashboard has been formative. At this point we’re holding on the CommCare work but I think we’ll really see a reprise of the type of approach this represents as quality of care really becomes a focus above and beyond setting up these basic primary care systems. But until then, we’re really looking out to this community for ideas, direct support and partnerships that add value to health delivery and systems strengthening. We’re serious about the economic costing and financial impact of this work and I can explain what we’re doing in this regard even as we speak. Even though we’re working with certain groups, none of our relationships are exclusive. We work across too many countries closely with enough governments to preclude this, although there is a degree of coherence that we aspire towards.
But I’ll stop here because, well, many of you might have stopped reading some time ago. I imagine there would be more granular, interesting questions that I can use to provide more information. If this is too long to digest I’ll repost something punchy and short.
Best Regards,
Prabhjot Singh
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[1] the original plan called for 1 site and as the blueprint was released, a dozen countries requested MVs immediately
[2] notable exceptions are in the nomadic “village” of Dertu, Kenya, on the border of Somalia/Kenya
[3] this isn’t a fertilizer dump; it’s based upon soil analysis, titering the amounts required through working to educate farmers in villages while culling best practices from other parts of africa/world or successful farmers within a community
[4] This is worth addressing. Yes, MV has money. It sounds like a lot because it simply can be accounted for and distributed in a prioritized manner. But we’re still talking about a budget of $40/person/year for health, and $110 total, which includes building infra- structures like roads, ICT, corporate donations like phones (all inputs are accounted) etc… This is up from ~15/per/year in most Sub-Saharan africa countries for health, in comparison to ~$8,500/person/year in the US. So is it gold-plated? If you call being able to get ORS/zinc semi-reliably gold-plated up from not at all… Finally, there are some things money can’t simply transact although it can facilitate if you know what you’re doing (”if you throw enough money at a problem of course you’ll solve it”), including appropriate management, attitudes about the unacceptability of routine deaths, broader vistas of what is possible for your family.
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