The Power of CHWs as Change Makers Within Their Own Communities
Madeleine Beebe, Institutional Partnerships Manager, visited Muso’s partner organization Hope Through Health for a learning exchange in mid-December 2017. Below, Madeleine shares her impressions and insights on the visit.
In mid-December 2017, I had the privilege of traveling to northern Togo with Muso’s Director of Training, Dr. Youssouf Keita, to visit our partner organization, Hope Through Health (HTH). It was my first time in northern Togo, and yet I felt at home. Not because Mali and Togo are identical—despite many similarities, they are not—but rather because HTH and Muso share such closely aligned ideologies. We are both employing proactive Community Health Worker (CHW) models to deliver community-based health care to vulnerable women and children in rural West Africa. We are both animated by the conviction that no woman or child should die of a preventable cause. And we are both committed to testing our strategies by embedding rigorous operational research into all of our programs.
Over the past several years, HTH has been adapting Muso’s Proactive Care model to their setting in northern Togo. Similar to Muso, the HTH model includes door-to-door CHW visits, the management of key childhood illnesses in the home, reinforcement of facility-level care, and the removal of user fees. Muso has shared its training manuals with HTH, and in 2017 we had the pleasure of hosting HTH in Mali for a learning exchange. Thanks to this collaboration, proactive CHW care is currently being tested across 13 sites in two different countries with an additional 20 sites slated for launch over the next four years. Youssouf and I were excited to travel to Togo see the model in action in a different geographic, cultural, and health systems context, and to learn from HTH’s experiences. We were also excited for the opportunity to deepen our partnership with HTH. While we have a number of similarities and shared conviction, we continue to learn an incredible amount from one another.
On our first day in the field with the HTH team, I found myself in one of my absolute favorite situations: being a fly on the wall for a CHW home visit to a pregnant woman. I was following Justine as she went proactively from home to home, dropping in to ask after the health of the family. Like Muso’s CHWs, Justine’s regular visits are not scheduled ahead of time, and yet she met a warm welcome. It was obvious in the smiles, the greetings, and the relaxed body language that Justine’s face is well known and that she carries the trust of the families she serves.
At the first home we visited, Justine took her time greeting the entire family and casually laying eyes on all the children as she asked after their health. Then she asked the wife, pregnant in her second trimester, if she had a few minutes to chat. Justine and I settled in on a large log, while the woman took her place in a plastic chair half-facing, half-alongside, Justine. The familiarity and comfort between the two women was evident. I was impressed by how thorough Justine was as she talked through danger signs, turning her binder to illustrate with photos as she explained. The woman was attentive, her eyes moving between Justine’s face and the illustrations, her head nodding up and down. After each danger sign, Justine asked the woman if she had noticed anything like that, or if she had any questions. Together they palpated the woman’s ankles and then laughed, agreeing that her ankles were very bony and not at all swollen.
There is magic in interactions like this—the magic of trust. First and foremost, CHWs are trusted members of their community. Through their work delivering care to every doorstep, they build familiarity with the families they serve, and that familiarity deepens into trust. And trust, though difficult to measure and difficult to define, saves lives. It is trust that creates the space for a young woman to confide in her CHW that she wants to attend prenatal care but has been unable to convince her husband to let her do so. It is trust that allows a CHW to approach that same husband and engage him in a difficult but crucial conversation. It is trust that enables a CHW to address a child’s malnutrition without shaming that child’s parents, to convince a family of the need to take their child to the clinic for a higher level of care.
The day after I shadowed Justine, Youssouf and I sat down with a group of HTH’s CHWs to talk about a new proactive reproductive health package that HTH was preparing to roll out. As Muso implemented this package of care in 2016, the CHWs were interested to hear Youssouf’s advice. Youssouf stressed the value of the confidence that the CHWs have already built with the women in their communities, and emphasized that confidentiality is paramount in matters of reproductive health. One CHW, responding to Youssouf’s advice, reflected,
“That is it exactly. When you approach a woman to offer a pregnancy test, there is already a certain confidence between you. You have been coming to see her, you have helped her keep her children healthy—she knows you. And these things are truly a question of trust. Now, if she accepts the pregnancy test, if you find that she is pregnant, that her test is positive, she is more likely to get what she needs: more likely to attend prenatal care, more likely to be followed at home from the beginning of her pregnancy. And then when her baby comes, the baby too will have access to these same services.”
This is the beauty of the health systems that HTH and Muso are working to build: they create trust between communities and their health systems, remove key barriers patients face in accessing care, and increase utilization of life-saving health services. Observing HTH’s CHWs in action, I was again struck by the power of CHWs as change makers within their own communities.
It was inspiring and exciting to see the work that Hope Through Health is doing in northern Togo; we are lucky to have such generous, committed partners in this important work. Our visit included a number of important conversations and opportunities for cross-team learning; we hope to continue to nurture the relationships that were built through regular exchanges and sharing of lessons learned. The visit also allowed us to reflect on how Muso can structure its technical assistance moving forward. As Muso continues to share our work to guide community health care delivery and policy around the world, we will continue to learn from our partners at HTH and their CHWs, redefining access to care in Togo.
Muso’s visit was generously made possible by the Bertha Centre for Social Innovation of the University of Capetown Graduate School of Business in the context of a Health Systems Entrepreneurship cohort funded by the Johnson & Johnson Foundation.