SAN FRANCISCO — Jacques Sebisaho, founder and executive director of Amani Global Works, manages a network of 68 community health workers, nine clinics, and one hospital on an island where the average life expectancy is 25 years.
As a fellow at the Mulago Foundation, a San Francisco-based funder of early stage social entrepreneurs, he met other leaders providing frontline services to improve primary health care in challenging settings.
When he returned to Idjwi, an island in Lake Kivu between the Democratic Republic of the Congo and Rwanda, he applied what he learned from social entrepreneurs working in Mali, Togo, and Nepal.
“We are a summary of all of you,” he said at an event on primary health care hosted by the Mulago Foundation last week.
While randomized control trials have proven the efficacy of community health programs, these results from research settings are not being replicated at a national scale. In fact, the three most recent evaluations of large scale national community health worker programs in Malawi, Burkina Faso, and Ethiopia demonstrated no impact on mortality.
As countries work to make community health workers frontline in their health systems, a new effort is underway to standardize best practices, and ensure that what has been proven to work is put into policy.
The Community Health Impact Coalition, or CHIC, which officially launched in January, is a five-year initiative bringing community health programs such as Amani Global Works and its peers Muso, Integrate Health, and Possible together to pursue what its members describe as “radical collaboration” for better design of community health systems.
The idea for the effort originated from philanthropist English Sall, who gathered some of the community health organizations she funds at the offices of the Sall Family Foundation in North Carolina two years ago.
“[CHIC] flies in the face of the traditional aid model.”— Josh Nesbit, CEO, Medic Mobile
CHIC is currently comprised of 10 members and will soon welcome two more. Others are welcome to join if they meet identified criteria, such as endorsement of design principles and a willingness to put in “sweat equity.”
“There’s something about how each of the organizations in this room operates which is often absent from these struggling, large-scale efforts,” said Madeleine Ballard, who now leads the effort, at the Mulago Foundation-hosted event.
While it is still in its early days, CHIC has already seen some success, with its eight design principles being championed by the World Health Organization, UNICEF, and U.S. Agency for International Development.
“This is a huge step in our goal to embed these quality practices in the standard operating procedures of these large technical assistance and funding bodies,” Ballard said.
Representatives of each of CHIC’s 10 member organizations have had biweekly calls leading up to the formal launch in January. But they spent last week together in person, without donors in the room, refining their strategies around two key areas: targeted advocacy to create an enabling environment for quality, and joint knowledge production and sharing. On Thursday, they shared their plans for how to ensure the design principles that have worked for them are part of the plans for national scale implementation.
One of their goals for 2019 is to support the development of the section on optimizing community health systems in the upcoming Global Financing Facility toolkit: “We need to work with the doers with the local and technical know-how, and make those connections at the country level,” Mariam Claeson, director of the Global Financing Facility at the World Bank, said at the event.
Top down, bottom up
On Tuesday, Kevin Starr, who directs the Mulago Foundation, gave a presentation on the path of “the doer” — his preferred term for implementers — from research and development to replication to scale, where taxes and big aid become the payers and governments become “the doers.”
“In the journey all these guys are on, the bottom up never succeeds without the top down,” he said. “They’ve come together to create that outside momentum to bring the top down and the bottom up together.”
Starr, who sees the role of philanthropy as supporting promising new models until they can access big aid and scale through governments, convened this group of primary health care “doers and funders” in part so CHIC could have the unstructured time they needed to discuss next steps.
“[CHIC] flies in the face of the traditional aid model,” said Josh Nesbit, CEO of Medic Mobile, a nonprofit organization that builds software for community health workers, and a member of CHIC.
Rather than protecting their intellectual property, these organizations are unpacking it and making it public, he said.
That is just one way these community health programs are going against the norms in a sector where NGOs are often incentivized to treat each other as competitors in pursuit of scarce resources. Instead, CHIC aims to be a “field catalyst for quality,” said Ballard, who was the founding program manager of Last Mile Health, a member of the coalition.
A shared vision of health
There are a few key challenges these programs will face as they try to scale, said Dr. Prabhjot Singh, director of the Arnhold Institute for Global Health.
First, some aspects of the programs are harder to scale than others. For example, it is easier to scale mobile phone usage than the quality of supervision of community health workers. Second, different things break at different rates as they go to different scales. Third, the more a program scales, the harder it is to keep the focus on the frontline.
As organizations scale impact, they risk losing equity, because the most efficient way to reach more people more cheaply is to avoid the places and people that are hardest to help, Singh said.
Plus, while community health workers are valuable as extensions of facility based care, the care in those facilities can be inadequate or even negative, and there are still causes of morbidity and mortality that require highly skilled clinicians.
Kiribakka Tendo, who works with the ministry of health in Sierra Leone as part of the Aspen Management Partnership for Health, said community health program funders and practitioners need to involve the governments that will enable them to scale from the outset.
As the U.K. development finance institution ramps up investments in private health care, it wants to understand the impact it has on the broader health ecosystem in lower-income countries.
Noting the absence of governments from the beginning stages of CHIC, he pointed to the importance of “radical involvement” of governments in addition to “radical collaboration” among community health programs.
All too often, governments are considered a single entity, but community health programs seeking national scale need to know which government ministries to engage, said Nelly Wakaba, country engagement and support director at the Financing Alliance for Health.
While the ministry of health might seem like the natural partner for community health work, the ministry of finance is where the money sits, and they speak a different language than its counterpart working in health.
“This is hardcore math and economics and we have to make the case for it in terms of cost savings and return on investment,” she said.
James Nardella, principal at the Skoll Foundation, said he hopes CHIC can succeed in creating the exemplars for community health at national scale. More recently, the David Weekley Family Foundation has supported the effort, and Children’s Emergency Relief International will be the next donor to come on board, with the ultimate goal of six funders coming in at equal levels.
Ballard said the Mulago Foundation gave her the “gift of time” last week as CHIC members asked donors to stay outside the room so they could work through their priorities. Building this coalition has not come without its “false starts,” she said. But the key has been to keep focused on “a shared vision of health for all without caring who gets the credit.’’
Update, Feb 18, 2019: This story was updated to clarify details on Ballard’s work before joining the Community Health Impact Coalition.