Going the Last Mile: Redefining Healthcare in Remote Settings
In 2013, Last Mile Health committed to scale their innovative, high-impact Frontline Health Worker (FHW) model to bring high quality health care – for the first time – to 150,000 rural Liberians. There are 400 million rural Africans that go their entire lives without seeing a health worker, and it is becoming increasingly clear that villages that are remote and hard-to-reach are the final frontier of global health. In Liberia’s ‘last mile’ communities, there are 1.5 million people who currently lack access to care because they live too far from a doctor and/or healthcare. By training, monitoring, and supporting a new corps of 270 FHWs over 4 years, Last Mile Health aims to reduce under five child mortality by at least 33 percent, increase access to prenatal and skilled maternal care by 50 percent, and increase access to HIV, TB, malaria and NCD diagnosis and treatment by 50 percent in these communities.
In conjunction with the Government of Liberia, Last Mile Health (LMH) will bring high quality health care – for the first time – to 150,000 rural Liberians, with the goal of accelerating national progress toward MDGs 4, 5 and 6. Last Mile Heath will do this by scaling its innovative, high-impact Frontline Health Worker (FHW) model, that was developed and deployed as part of its 2011 CGI commitment, to an additional ten Liberian health districts by June 2017. Additionally, LMH will work in conjunction with the Government of Liberia to leverage lessons learned from the LMH FHW model, and build a partnership mechanism with government centers and affiliate organizations throughout the country to ensure access to care for an additional 1.35 million Liberians in the future.
In collaboration with the Government of Liberia, LMH will serve as the primary implementing partner for this commitment. With primary goals of reducing under five child mortality by at least 33%, increasing access to prenatal and skilled maternal care by 50%, and secondary goals of increasing access to HIV, TB, malaria and NCD diagnosis and treatment by 50%, LMH will provide the following resources:
Training and Curriculum: An evidence-based curricula has been systematically developed based on local quantitative and qualitative data, to permit LMH FHWs to bring life-saving treatment, prevention and care to fight the five leading causes of child, maternal and adult mortality and morbidity, including childbirth complications, pneumonia, malaria, HIV, and mental illness, in remote villages lacking doctors.
Support and Supervision: By applying recent advances in telemedicine and mobile health, FHWs will be supervised and supported by a network of mid-level clinicians based in public health centers. (Note: Communications between FHWs and clinicians are enabled by key advances in access to telemedicine in Konobo – a direct result of the 2012 LMH/Medic Mobile CGI commitment.) With training, support and supervision, LMH will recruit, train and manage FHWs to respond to 85% of health problems typically handled by a primary care doctor, delivering access to a quality primary health care system for all villages, including those without doctors, for the first time.
Monitoring, Evaluation and Dissemination: LMH and its partners will demonstrate not only the health impact but also the economic value of the model. These outcome, systems, and economic data will be shared via scientific literature and through an open-access portal, allowing this work to be shared with and receive critique from others working in rural settings. Having demonstrated the heath and economic value of the frontline health corps, LMH will build, in collaboration with the Liberian Ministry of Health, an adaptable mechanism to certify, hire, and sustain this new village-grown workforce within the African public health sector.
Phase I (October 2013 – June 2014): LMH will expand the Konobo FHW model to a second district in Konobo. LMH will recruit, train and deploy a second cohort of 30 FHWs (thereby doubling the number of FHWs currently operating in Konobo district) to bring primary health services to an additional 15,000 people that currently lack access to care. Through this expansion, LMH will demonstrate that the outcomes of its FHW pilot model (i.e. reduction in child mortality and improved access to maternal health services) are replicable and will strengthen systems to support role out of additional cross-site programming.
Phase II (July 2014-June 2017): LMH will hire a total of 300 FHWs to bring primary health services to 150,000 people currently without access to care across 10 health districts. In Phase II, LMH will also create a partnership mechanism to replicate our FHW model through alliances with government centers and affiliate organizations throughout the country.
LMH currently partners with two health districts and by July of 2015 it will partner with four, by July 2016 six, and by July 2017 ten. Given LMH’s existing base of operations in Grand Gedeh, and given that the majority of districts that are >10km from a health facility are in the Southeast, LMH will conduct a district health assessment in the five Southeastern counties (Grand Gedeh, Sinoe, Grand Kru, Maryland, and River Gee) in the summer of 2014. Similar to the health district assessment conducted by LMH in Grand-Gedeh in winter of 2012, the summer 2014 assessment will gather necessary information about each district in order for LMH to make an informed decision about where to best devote resources and in what sequence.
According to the World Health Organization, one billion rural people around the world, including 400 million rural Africans, go their whole lives without seeing a health worker. It is becoming increasingly clear that villages that are remote and hard-to-reach are the final frontier of global health; these so-called ‘last mile’ villages are precisely where the fight to improve child and maternal health, and control HIV/AIDS, tuberculosis, malaria and malnutrition, is most likely to fail. This crisis is accentuated in Liberia’s last mile communities where, according to the Liberian Demographic and Health Survey, 1.5 million people currently lack access to care because they live too far from a doctor and/or healthcare facility.
It has never been clearer that new solutions to village health delivery are desperately needed. Village health workers – community health workers and primary care providers in rural clinics – are the first and often the only point of contact to the health care system for millions of people in remote villages.
Unfortunately, while village health workers have been recognized as potential high-impact solutions, they remain undervalued by most health systems. A combination of insufficient investment and reliance on an outdated model has prevented community health workers and rural primary care providers from reaching their full potential to save lives in remote villages. There is a critical need for a new 21st century model that reinvests in and leverages innovation to bring modern primary care to last mile villages.
Last Mile Health currently supports 283 CHWs and a total of 44 peer and clinical supervisors who provide CHWs with one on one supervision and coaching to ensure that they are able to provide the highest possible quality of health services to the patients they serve. Having completed the recruitment of 103 community health workers (CHWs; formerly known as Frontline Health Workers) in March 2016 to serve the remaining three health districts in Rivercess County, Last Mile Health now serves a total of more than 300 communities and 33,664 people across every one of the six health districts in Rivercess County as well as Konobo, Gboe, and Ploe Districts in Grand Gedeh County. This exceeds the target of 270 CHWs set in 2013.
When fully trained in all four of Last Mile Health’s modules, CHWs are able to conduct household registration and mapping, health promotion, birth and death tracking, and vaccination tracking (all Module One skills) in addition to community based outpatient care and referral services for the top killers of children under five (Module 2), mothers and neonates (Module 3), and adults (Module 4).
While Last Mile Health still aims to achieve its ultimate mission of saving lives in the world’s most remote villages through the provision of health services to Liberia’s extremely remote populations, they recognize that improvements in maternal, neonatal, child, and adult health such as reductions in child mortality can only be measured over extended periods of many years. With this in mind, Last Mile Health has recalibrated its impact targets to reflect key indicators in each of these areas that can be measured accurately and reliably on an annual basis and which help the organization to better understand its impact in the last mile. Last Mile Health is currently in the process of conducting its annual “Last Mile Survey” to evaluate the organization’s progress towards numerous impact indicators including the percentage of expectant mothers receiving all four WHO recommended antenatal care visits, the percentage of children receiving a full course of the pentavalent vaccine, and percentage of deliveries occurring in a health facility.
Leveraging work at the community level for maximum impact, Last Mile Health is also supporting the Liberia Ministry of Health’s Community Health Services Division’s implementation of a nationwide CHW program. The national program, called the National Community Health Assistant (CHA) Program, will ensure that by 2021, all 1.2 million Liberians – including approximately 570,000 children and living more than five kilometers from the nearest health facility have access to lifesaving health services provided by a professional CHA.
Yes, Last Mile Health continues to seek investment and programming partners with focus in the following areas: supply chain management, human resources, and cross-site communications and systems building.