Trade and Globalization

Hatching New Ideas to Deliver Health Care to the Last Mile

July 22, 2015  • Nikki Tyler & Daniel Brown

On June 24, The Aspen Institute held the inaugural Ideas to Action Incubator, a convening of health experts to create collaborative approaches to bring healthcare to the hardest to reach. In this first session, Aspen welcomed government health officials, leaders from NGOs, funders, academics, and financiers to discuss challenges and opportunities for community health systems. By the end of the day, the group had developed and committed to action on three solutions that strengthen and increase equity in community health systems.

As we have seen in the West African Ebola outbreak, health crises carry devastating costs for individuals, governments and economies. The world needs stronger health systems to prepare for future epidemics, to continue the fight against the top killers of children and mothers around the world, and to address the growing burden of chronic, non-communicable diseases in low- and high-income countries alike. In particular, an emerging consensus among health leaders is that cadres of professionalized Community Health Workers (CHWs) — together with community-based primary health care systems — are essential to responding to health crises, providing routine care and linking hundreds of millions of individuals to health facilities. 

Despite this growing recognition, few countries have developed strong community health systems, even when health has been a government priority. For example: in Liberia, government health spending per capita increased from approximately $5 to $44 between 2003 and 2013 — an astonishing increase of nearly 1,000%. However, this impressive gain masked a somber reality: at the end of that period, government health spending per capita in some remote districts was still only $0.76 per capita. Government records maintained long rosters of community health workers in these districts, but on the ground, most of these CHWs did not exist. Those that were practicing were isolated, with no training, supervision, supplies or salary. These underfunded, underserved rural districts were highly vulnerable as the Ebola outbreak began to spread, ultimately leading to over 27,000 cases, 11,000 deaths, and billions of dollars of lost economic growth and international aid spending.

Deborah, a CHW in the Millennium Village in Bonsasso, Ghana, measures the mid-upper arm circumference (MUAC) of 7-month-old Abena on a home visit. Photo courtesy of Direct Relief

The impact of the Ebola outbreak on lives and communities has been disastrous, and it put a spotlight on the state of health systems worldwide. As devastating as the Ebola outbreak has been, the next outbreak could be far worse. Bill Gates has stated that the event most likely to kill over 10 million human beings in the next 20 years is a pandemic disease, and the World Bank has estimated that a global pandemic could cost the global economy up to $3 trillion. The Ebola outbreak called attention to the fact that hundreds of millions of people are unable to access high-quality healthcare, and reminded us that everyone is at risk if even one health system is not functioning.

Against this backdrop, the inaugural Ideas to Action Incubator looked to develop breakthrough approaches and solutions to strengthen community health systems. The Incubator focused on three tracks: Public Sector Leadership, Community Health Delivery and Innovative Financing. In each track, participants presented and discussed innovative ideas to “push the pace” of progress in community health.

Building from this discussion, the Incubator “hatched” three ideas:

  • Public Sector Leadership:  Leadership for the Last Mile (LLM) is a collaboration between multi-sector partners including the private sector, NGOs, donors, and Ministries of Health (MoHs). LLM aims to address health systems challenges in high-burden countries by providing in-country managerial, financial and strategic expertise to MoHs while creating a platform for collaboration and knowledge-sharing across sectors. The partnership will provide a menu of support opportunities to strengthen management and leadership capacity in MoHs. Key MoH staff will have access to training, mentoring and joint-problem solving through a local mentor network and cross-country convenings. LLM will also provide on-demand support to MoH teams during the partnership, including planning/strategy tools and relevant analytics. LLM will also add capacity to take on pre-identified high-priority community health projects by placing top-tier professionals with complementary skills directly in MoHs.
  • Community Health Delivery:  In community health delivery, tracking progress towards health outcomes is easier. There are no systems or scorecards to track the progress of an equity agenda in health programming. As a result, a Last Mile Toolkit was proposed with two pieces: (a) an equity scorecard that allows programs to target the last mile based on geography, socioeconomics, marginalization, and hotspots, and (b) a better set of metrics for understanding success from the perspective of those most in need.
  • Innovative Financing:  For these nations to one day fund their health interventions sustainably, it’s critical to understand the return on investment from building capacity and retaining human capital. To that end, specialized teams should be created to: (a) develop investment cases for health programs, (b) build diverse financing pathways for these health investments, and (c) actually implement the financing program. To be successful, three types of human capital resources must be present in these teams: (a) in-country leadership (such as financing professionals in Ministries of Health or professionals from programs like Leadership for the Last Mile), (b) teams of global experts to support countries in assembling innovative financing packages, and (c) global political leadership to broker the deals between donors and country governments.

The group then made commitments to bring these proposals to action. For example, Partners in Health, the GE Foundation, the IBM Foundation, and others pledged support for Leadership for the Last Mile, recognizing its power to reach universal health coverage and build capacity. Representatives from the Ministries of Health in Sierra Leone and Malawi also expressed excitement regarding Leadership for the Last Mile, asking to be considered as potential countries of operation.

The Ideas to Action Incubator concluded with a final commitment to form a “community of practice” for last mile health delivery. To build this and ultimately strengthen health systems and save lives, we need the help of the wider health innovator community. We need to shift the discussion in global health so all countries are equipped with the tools to design and deliver effective, quality healthcare programs that all people can access.