New Evidence from Bangladesh

(Photo: The Woodrow Wilson School at Princeton University)

Researchers at Princeton, Columbia, Cambridge and BRAC — working in communities mobilized by The Hunger Project — have demonstrated the value of building strong communities.

As announced here by Princeton University’s Woodrow Wilson School: “Published in the Proceedings of the National Academy of Sciences, the study finds that low-income individuals who trust their communities make better long-term financial decisions. This is likely because citizens rely on friends and neighbors for financial support rather than quick fixes like payday loans, which further indebt them.”

“In terms of policy, the findings show the importance of building strong communities, especially for low-income individuals. The researchers suggest moving away from a focus on low-income individuals, instead focusing on low-income communities through targeted policies.”

Movement Grows in West Africa

In late February and March 2017, the Movement for Community Led Development announced the formation of three new national chapters — Benin, Burkina Faso and Senegal. Two member organizations — Corps Africa and The Hunger Project (THP) — seized high profile media opportunities to announce these  chapters. Corps Africa celebrated the completion of its first cohort of volunteers in Senegal, and THP-Benin and THP-Burkina Faso both celebrated the 20th Anniversary of their programs.

Photo above: government, intergovernmental and civil society representatives at the conference on Community-led Development in Benin on March 24, 2017.

I had the pleasure of visiting my Hunger Project colleagues in Benin and Burkina Faso for meetings with senior officials, strategy meetings on Community-led Development and field visits to Hunger Project epicenters that have recently “graduated” — having achieved 52 specific indicators of self-reliance.

boulkon epicenter

The Boulkon Epicenter (above), serving 25,979 citizens as one of 125 epicenters mobilized by The Hunger Project in 8 countries, has achieved the highest “self-reliance” score of any epicenter to date.

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Press conference after meeting with the President of Burkina Faso on March 31, 2017: Regional program officer Judith, Chair of THP-Burkina National Advisory Council Mme Ouattara, THP Executive VP John Coonrod, Country Director Evariste Yaogho and Vice President for Africa Idrissa Dicko. Courtesy RTL.


Strengthening the global health workforce

By Hunter Isgrig, Digital Campaign Producer, Crowd 360, FHI 360

The World Health Organization estimates that the current shortage of global health care workers is 7.2 million. Without intervention, this number will soar to 18 million by 2030. Rachel Deussom, an FHI 360 expert on the health workforce and Senior Technical Officer, Human Resources for Health, Health Systems Strengthening, hosted a conversation with other FHI 360 colleagues to examine the shortage, its underlying causes and potential solutions.

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She opened the conversation with a personal experience she had while visiting an FHI 360 health project in rural Sierra Leone. When health workers saw that she was pregnant, several said they hoped that her child would study hard, become a doctor and return to Sierra Leone to save lives. Clearly, those on the front lines recognize the struggle to develop a well-trained, well-distributed health workforce.


How do we respond to this growing crisis? Dr. Nadra Franklin, Director of Social and Economic Development, and Dr. Otto Chabikuli, Director of Global Health, Population and Nutrition, discussed the need for an integrated approach to solutions that will achieve health for all. One component of this approach is to address the root causes of the worker shortage, pinpointing where the jobs are now, where the jobs will be in the future, and the education and skills that are supplied by training institutes. Identifying and understanding the gaps between the education and training health workers currently receive and the skills that are in demand will help address this shortage.

Another component is examining all jobs along the workforce “value chain” — not just doctors and nurses providing direct services, but all workers performing jobs within a health care system. It is also important to acknowledge how technology has changed the way people work and the nature of the skills that employers seek. In addition, we must address local market forces — the distribution of health workers among rural and urban areas and among public and private sectors. Policymakers may need to step in and equalize the incentives in health care so that workers are attracted to underserved areas. Through an integrated approach, we can ensure that we are addressing the health worker shortage of today and planning for the demands of tomorrow.


Groups like the Frontline Health Workers Coalition, of which FHI 360 is a member, have taken advocacy roles with U.S. policymakers to encourage prioritization of and investment in the global health workforce. Placing a high value on trained health workers will not only address the immediate needs of the communities they serve, but it will also contribute to global health security. World Health Workers Week (#WHWWeek) is a prime opportunity to intensify our support of health workers and the need for more integrated solutions to address the crisis of the health worker shortage. We must show that health workers count (#HealthWorkersCount) because, without them, millions of children and families around the world will never have access to proper health care.

Please help us continue this conversation in the forum:

Most will agree that health workers play an important role in health systems, eradicating diseases, empowering communities, and strengthening local economies. Yet few donor-funded projects focus exclusively on the health workforce.
• How can we do more to strengthen the national health workforce in global health projects?
• How can projects focusing on gender, youth, workforce development and education better develop the health workforce, including job creation?

The role of Community Health Workers in the heart of crisis

By Iffat Nawaz, FHI360

Community volunteers conduct hygiene promotion in Dikwa, Borno State, Nigeria. Credit: Henry Omara, IHANN project

2017 began with a new momentum for FHI 360’s Crisis Response Initiative as we launched the Integrated Humanitarian Assistance to Northeast Nigeria (IHANN) program funded by the Office of U.S. Foreign Disaster assistance (OFDA). IHANN is delivering integrated services in health, water sanitation and hygiene (WASH) and protection to victims of gender-based-violence in Borno State, where 1.3 million people are internally displaced due to the Boko Haram insurgencies.

The average length of conflict-induced displacement is 17 years, which means communities in displaced situations require support that are not just effective in the short-term but will pave a path towards resiliency for the long-term. Entering the humanitarian space, as FHI 360 does, with a robust development background can offer new insights for how to approach humanitarian problems. We are combining methods which hold the possibility of bringing sustainable solutions to traditional humanitarian delivery models that usually tackle problems with emergency in mind.

IHANN is working in Internally Displaced Persons (IDP) camps and communities in Dikwa and Ngala in Borno state. For the last few weeks there has been a constant daily influx of displaced persons in Dikwa, who are arriving with dire needs. This increase in total population of IDPs has overstretched health and other services. Many are living in congested environment in camps and host communities which hold public health risks- especially of disease outbreak. Currently disease surveillance and monitoring of the health situation as well as, expanding the delivery of health services are high priorities.  For the IHANN program health workers, specifically Community Health Extension Workers (CHWs) and Environmental Health Assistant Volunteers (EHWs) from the IDP population are engaged with just that in mind

For many decades, CHWs have been playing key roles in improving the health status of people especially women and children in rural and remote areas, where skilled Doctors, pharmacists, and midwives are absent. CHWs in the IDP camps in Dikwa and Ngala are contributing to the health sector response by providing health outreach services; treating minor ailments in the communities and IDP camps, making referrals for patients who require facility-based services like antenatal care, labor and delivery or family planning services. The CHWs, who speak the local languages, are also providing health education to change behaviors on risky practices. As many of the CHWs are part of cultural and religious groups they can encourage men and women to accept family planning and immunization in a culturally acceptable manner.

On to EHWs, the IHANN WASH sector Environmental Health Officers are working with community volunteers in the host communities and IDP camps to ensure adequate sanitation and promote hygiene. The EHWs are carrying out hygiene promotion, social behaviour change and camp clean-up campaigns to decrease the chances of a cholera outbreak, minimize environmental conditions that promote disease:  like standing water, for mosquito breeding, and unmanaged garbage which attracts rats that can carry Lassa Fever- a hemorrhagic disease like Ebola.

Since EHWs and CHWs receive trainings in same institutions and often work together in parallel settings in Nigeria, integrating health and WASH services show a direct enhancement in delivery. In the IHANN program, the CHWs and EHW work in the same communities and IDP camps. One of the roles of CHWs is to work as community health monitors. If there are a surge of diarrhea and vomiting cases it may be an early warning of fecal oral disease that could be cholera. Because diseases can spread fast in a close packed IDP camp it is important to identify these outbreaks quickly before they become severe. CHWs and EHWs work together in providing health education on communicable (air, water- or food -borne) diseases, skin diseases, and general infections prevention and control within the camps and the communities.

Similarly, as the WASH sector advices on building new tents on higher surfaces/areas, away from drainage systems or potential water-logged areas, EHWs are working with camp members to clear water paths and drainages to prevent flooding of the IDP camps during the rainy season. The health sector of the project, on the other hand, is working with health partners on cholera outbreak preparedness, and is also collaborating with Malaria programs to provide Insecticide-Treated Nets (ITN) for distribution to the IDPs by CHWs and EHWs.

In these situations, keeping close coordination is a high priority and the health and WASH sectors are working to have a forum where CHWs and EHWs share information, work together and engage camp leaders in health promotion campaigns and activities.

While IHANN’s doctors, pharmacists and midwives are working together with the Ministry of Health, WHO and UNICEF in delivering lifesaving health services at the facilities, the CHWs and EHWs are building capacity by taking leadings roles in health and WASH activities in their communities. The IHANN program is funded by OFDA for one year, but our hope is the knowledge, capacity building and awareness that are being woven into the communities through the CHWs and EHWs will increase the chances of saving more lives in the future and what could be a better ask than this, as a community volunteer, a humanitarian aid worker and most of all as a human.

Please help us continue this conversation in the forum:

Have you seen other projects where development expertise was applied to humanitarian response?  What we were the advantages?  What were the drawbacks?

Putting Vision into Focus: Lessons on scaling up a social enterprise

By Sarah King, BRAC

A community health worker leads an educational health forum on vision. Photo © BRAC

Helena Begum had a problem. Her job at a garment factory in Bangladesh paid good wages. But her eyesight was fading.

“I used to earn 6-8 thousand taka [about $100] a month working at the garment factor,” said Begum. “But when my vision deteriorated a year ago, I couldn’t thread my needle anymore and had to leave my job. Now I work as a maid earning 2,000 [$25] per month.”

Approximately 12.7 million people in Bangladesh suffer from near vision loss, a consequence of the eye’s natural aging process. Without correction, it can significantly impact a person’s productivity, with serious financial, health and social implications. Uncorrected, vision costs the global economy an estimated $227 billion in lost income-earning potential. However, there is a seemingly simple fix. Of those experiencing vision losses, 2.5 billion individuals globally can have their vision restored with just a pair of eyeglasses – and 77% of those individuals can be helped with a pair of reading glasses.

Low-cost eyeglasses provided through VisionSpring and BRAC’s partnership. Photo © BRAC

The challenge is that many Bangladeshis still do not have access to health care that can help them diagnose their vision loss, nor do they understand that it can be treated simply with eyeglasses. Many people also lack confidence in their ability to use reading glasses, making them hesitant to make the investment. In addition, a gender divide means that while many men purchases eyeglasses after receiving a diagnosis, women often do not, either because they do not have the funds available, or do not receive approval from their husbands to make the purchase.

To address this large unmet need, BRAC and VisionSpring partnered to develop an eye-care delivery system with an innovative social entrepreneurship model: selling low-cost reading glasses to low-wage earners through BRAC’s network of community health workers in Bangladesh. How does it work? VisionSpring supplies BRAC with high-quality eyeglasses and provides assistance with program design, product development and demand forecasting. The eyeglasses are affordable for the average low-income customer and are manufactured in Bangladesh to keep costs down. BRAC’s health workers are trained to offer free eye screenings, referrals for specialized eye care and sell low-cost eyeglasses for a small profit. These services are accompanied with activities to educate the community, including informational posters, handouts and health forums. Revenue from the eyeglasses provides health workers a supplemental income and also covers some of the program’s expenses.

The vision initiative began in 2006 as a two-year pilot with nearly 560 community health workers in 27 sub-districts of Bangladesh. More than a decade later, the program now reaches 61 out of 64 districts in Bangladesh with 33,000 community health workers providing vision care. To date, BRAC’s health workers have screened 4.5 million people, sold more than one million pairs of eyeglasses and referred nearly 610,000 individuals for higher level care. According to VisionSpring, the program is estimated to have created the potential for $110 million in increased income at the household level, based on a study conducted by the University of Michigan. Additionally, BRAC’s health workers have earned a total of $450,000 in supplemental income and now hold unique skillsets that create opportunities for career advancement and improved workforce retention. Due to the program’s considerable successes in Bangladesh, BRAC and VisionSpring will begin piloting a similar initiative in Uganda in June 2017.

At the conclusion of the initial pilot, BRAC’s Research and Evaluation Division conducted an independent review of the program to ensure its effective scale-up. The review revealed that the program provided sustained and increased productivity and earning power to the users of reading glasses. But the research team also identified many of the obstacles noted above: specifically that alongside access to eyeglasses, people with vision problems also need support from health workers and their community.

It was determined that to effectively scale up the initiative, the education campaigns would need to be strengthened to provide in-depth knowledge on vision loss and its treatments. Past clients would be used as role models within campaigns to provide insights into their personal experiences, the worth of eyeglasses and normalize eyeglass wearing. The program would also take gender biases into consideration and would aim to provide an equitable expansion of the program. The skills of the community health workers would also be improved through hands-on intensive training with frequent refreshers and close supervision.

BRAC community health workers engage in vision care training. Photo © BRAC

BRAC’s health workers are at the center of not just creating access to affordable eyeglasses across Bangladesh, but to generating demand. They have helped their communities to understand vision loss, the benefits of eyeglasses and how income can increase with improved vision; and also confront residual social stigma associated with wearing glasses. Over the course of ten years, BRAC and VisionSpring have iterated the program design, adjusting to take into consideration social and economic constraints that inhibit the uptake of eyeglasses. Health workers are valued, respected and trusted members of their communities. They have a deep understanding of the contexts and constraints, permitting them to respectfully address and mitigate concerns. The program continues to expand its reach because of the dedication and effectiveness of the health workers. As a result, community health workers now screen more than 1.2 million people annually, with women making up 63% of the client base.

Helen Begum, a BRAC vision customer. Photo © BRAC

Helena Begum is one of them. Her new eyeglasses are allowing her to increase both her income and her confidence. “With these glasses,” she says, “I can see clearly once again and I will soon be returning to the garment factory.”
For World Health Workers Week, it’s important to acknowledge the integral role community health workers play not only in delivering basic services, but also the extraordinary impact they have as leaders and validators in their communities.

Please help us continue this conversation in the forum:

1. how might this program have benefited from giving community health workers a greater role in design at the beginning?
2. What other community leaders (schoolteachers? Civil society leaders?) could have served as role models to encourage wider adoption of eyeglasses by community members?

Investing in the next generation of health workers

By Rachel Deussom

Mabinteh Koroma, nurse at Makump Bana health post in Sierra Leone, says healthy mothers and babies make her smile. © Rachel Deussom/FHI 360.

In Krio, I was called “belly woman.” Rural Sierra Leonean communities had not seen many foreign pregnant “belly women.” Sierra Leone had been recovering from years of conflict that had broken its health system and forced health workers to flee. The 2014-2015 Ebola epidemic only served to demonstrate how this weak health system and inadequate health workforce had prevented an effective response to the epidemic, and left communities without any other basic health services.

I had been working with Advancing Partners & Communities in Sierra Leone since early 2016, with the post-Ebola project goal of improving reproductive, maternal and child health services. During last month’s trip, we traveled to remote villages to talk with stakeholders in community health. I was in my second trimester, but despite bumpy roads I was feeling good. We met with district health managers, nurses, midwives, traditional birth attendants, community health workers, youth, pregnant mothers, and Ebola survivors. At the sight of my pregnant figure, many would congratulate me or call out “belly woman, very nice!”

But many went further, enthusiastically encouraging my unborn child to study very hard in school, so that he or she could become a health worker, and return to Sierra Leone to save lives.

I was heartened by their sense to recruit future generations to the health workforce. Sierra Leoneans know well the value of such an investment. The country has among the fewest doctors, nurses and midwives per capita: only 3 doctors per 100,000 people, and fewer than 4 nurses and midwives per 10,000 people, respectively. Globally, it’s estimated we’ll have a shortage of 18 million health workers by 2030. The world needs more health workers.

However, in the global development community, this health workforce investment logic can somehow seem complex, maybe because the solutions are intersectoral. Producing and sustaining a successful health worker requires an integrated approach, as I discussed with FHI 360’s Nadra Franklin and Otto Chabikuli earlier this month.

First, a child must grow up strong and healthy to excel through primary and secondary school. Then her family must be able to afford tuition for nursing school. She must be well-supported during her studies by a competent faculty who teach relevant curricula in well-equipped classrooms, with hands-on practice to prepare her for a job.

When she graduates, her future employers attract her to a well-paid position, ideally one where she helps underserved populations. She will be more likely to succeed and stay on the job if she can apply her skills: this requires running water, electricity, adequate equipment and drugs, and sleeping quarters so she can be available to the community she serves, especially if a mother in labor knocks on her door in the middle of the night.

She needs supportive mentors, supervisors and career opportunities to help her grow. She needs to feel safe in her working environment from hazard, harassment, and violence. When she starts a family, this nurse needs the flexibility to return after her maternity leave. She needs these elements and continued support over the course of several decades, so that she can join the nursing school faculty and mentor new health workers before she retires.

Many governments, employers, and partners in developing and developed contexts alike are challenged to promote this successful health worker life cycle illustrated above. Here are a few of the issues:
• How do we know if health professional education institutions are training health workers in the right skills?
• If it takes almost a decade to train a doctor, and nearly half as long to train a nurse, how can we scale up the health workforce to get results sooner than later?
• If country governments cannot sustain the existing health worker payroll, how can they expand it? What can other actors do?

What can be done?

Broadly, health, education, youth, gender, and workforce experts need to come together to transform the health workforce.

Pre-service training programs should prepare graduates to address the health issues faced in their country. Training programs should produce graduates to be competitive for jobs now and in the future. Programs also should attract and support youth from the rural and marginalized communities that need most to be served. They must integrate team-based approaches, management skills, public health values, and new technologies.

Policymakers need to recognize innovative ways to distribute health worker more equitably. First, they need to know their existing workforce with greater precision: How many? Who are they? Where are they? What skills do they have? Efforts to build health worker capacity should be better coordinated and better tracked. Too often, health workers are trained and re-trained on the same topics, which pulls them unnecessarily away from serving patients. For example, establishing nationally standardizing reporting approaches and building a national health workforce database (or human resources for health information system) and is a first step.

Professionalizing the community health workforce is also important. These lower-level health workers can be trained under a year to promote health, prevent and treat diseases at the community level, and drive demand for services. When appropriate, they can take up some of the tasks that doctors and nurses perform under their supervision; this is referred to as “task shifting” or “task sharing”. Community health workers can promote health system resilience by being rapidly trained to address emerging problems, whether it is Ebola, gender-based violence, opioid addiction, or diabetes.

Health is the largest growing sector for jobs. The public sector cannot support it alone. Private sector investors should recognize this emerging market, and consider how social impact investments, or partnerships for public purpose, align with their values. They can also help the efficiency of the existing health workforce by providing innovative technologies and services, such as helping a pharmacist manage stocks or provide clinical decision support on a tablet, or help a patient manager hypertension through a smartphone app.

I don’t know what my children will grow up to become, but my hope is that by they will have high-quality education, good health, and ample job opportunities. Our efforts now to invest in the health workforce should reap such dividends into the future. In the meantime, I shall be grateful for my midwives’ support at each prenatal appointment, that they may help deliver more prosperous futures.

How can we sustainably strengthen the global health workforce? Please help us continue this conversation in the forum:

Many governments, employers, and partners in developing and developed contexts alike are challenged to promote this successful health worker life cycle illustrated above. Here are a few of the issues:
• How do we know if health professional education institutions are training health workers in the right skills?
• If it takes almost a decade to train a doctor, and nearly half as long to train a nurse, how can we scale up the health workforce to get results sooner than later?
• If country governments cannot sustain the existing health worker payroll, how can they expand it? What can other actors do?