Designed to Fail? Why CHW Program Design Matters
In 2013, a Harvard/UCSF study documented a 10x increase in patient access to health care and a 90% difference in child mortality in the communities where Muso rolled out Proactive Care in Mali(1). This year in partnership with the Malian Ministry of Health, Muso is expanding the program and opening eight new sites to test it in a rural context. Proactive Care is designed to save lives by finding patients and caring for them early, within hours of when they first become sick.
At the United Nations in 2015, the global community committed huge efforts to improve child survival and connect hundreds of millions of people to care. In Sub-Saharan Africa alone, there are 28 countries scaling up CHWs to improve child mortality rates. At this moment, there is an unprecedented level of government engagement around CHWs globally. Recently, three separate evaluations of healthcare delivery models in Burkina Faso(2), Ethiopia(3), and Malawi(4) documented distressingly low impact on access to care and child mortality. If these initiatives, like Muso’s, were intended to increase access to care and lower child mortality, why didn’t they succeed, and what can Muso learn to avoid the same pitfalls as we expand our service delivery footprint?
Here, we identify three interdependent components that distinguish Muso’s design:
1) Community Health Workers—reactive vs. proactive: In the studies in Burkina Faso, Ethiopia, and Malawi, CHWs were stationed passively, waiting in rural health posts for patients to find them in cases of illness. Travel costs and social and geographic barriers are just a few obstacles that commonly discourage people from seeking health care; thus, merely having a CHW in each community is not enough. By contrast, the Muso model delivers an integrated package of care proactively, through door-to-door CHW case finding visits, to connect patients to care faster. In the first three months of 2016 alone, Muso CHWs were able to reach 82% of sick children within 24 hours of symptom onset, and 95% within 72 hours. Muso and its partners will evaluate how proactive care impacts child mortality and access to care in a randomized controlled trial launching later this year.
2) CHW Supervision: Community Health Workers in Burkina, Ethiopia, and Malawi did not get frequent, rigorous supervision, which may have contributed to poor outcomes and quality of care at the end of their studies. Only a third of sick children in Burkina Faso were correctly treated by CHWs; only half of patients needing referral in Ethiopia were actually referred; and only half of providers in Malawi received the supervision and supplies necessary to be deemed “ready” to provide appropriate care.
In Mali, Muso uses a 360˚ Supervision system to actively and regularly mentor CHWs for improved performance, including efficiency and quality of care. During weekly meetings, supervisors and CHWs exchange and discuss data, address protocol updates, and restock supplies, like rapid malaria tests and contraceptives. In monthly sessions, supervisors use dashboard analytics, patient satisfaction surveys and direct observation during CHW home visits to provide individual performance analysis. In one-on-one meetings, supervisors set milestones for each CHW to achieve, weighed against the highest performing CHW.
3) User Fees: A large body of evidence demonstrates how user fees reduce service usage and increases the time before seeking care in low-income countries, thus driving up preventable deaths. The Burkina and Ethiopia studies charged user fees to access care, yet neither study saw any significant increase in service usage. Several studies have demonstrated that removing user fees significantly increases access to care for the poor. When Muso eliminated user fees in our partner clinic in Yirimadjo, the number of clinic visits doubled.
Muso believes that the failure of these studies to significantly impact community health is due to failures of program design: each component described above are interdependent and cannot have a meaningful impact on health outcomes if one piece is missing. For example, the Malawi study eliminated user fees but didn’t see any increase in health care service usage. Free health care is only one component of a comprehensive health system, and the rest of the system in Malawi was not in place to drive or support demand—CHWs were passive and supervision was inadequate.
At Muso we are testing our proactive care strategy with the Malian Ministry of Health to provide not only Mali, but also governments and non-profits around the world with a healthcare package that better serves their vulnerable populations. Successful programs depend on evidence-based, comprehensive design.