It has been five years since the first Millennium Village was started in Sauri, Kenya in 2005 and four years since the expansion of the Sauri village into a cluster of 11 villages. Today, there are a total of 14 village clusters in ten African countries with a more than 500,000 people involved. There have been important changes in all the Millennium Villages in terms of health — some of them are immediately tangible. There are health facilities where there were none, more health workers in these facilities, essential commodities required for delivery of basic healthcare, and an ambulance is a phone call and usually less than thirty minutes away — which may not sound like much in an urban environment in a developed country but may literally be the difference between life and death to a woman in labor whose baby just won’t come out. There are now community health workers, partially compensated volunteers from the community and taking charge of the health fortunes of their communities. You can see them bicycling and walking through villages carrying messages that promote health — written and spoken in the local languages. Their responsibilities also include a narrow but critical spectrum of life-saving case management for malaria, uncomplicated diarrhea, pneumonia for children who would possibly experience life-threatening delays. They make follow-up visits to see children due for immunization, monitor the growth and nutrition of children below the age of 5, visit pregnant women to make sure they are visiting clinics and are in good shape; and they collect community health information that is fed back to the community to allow the community to prioritize their health needs.
Preliminary results in the MVP show that fewer children are dying, fewer women are being lost or getting complications for reasons related to pregnancy and delivery, the nutritional status of children is better and the health of communities is steadily improving. Each of the village clusters has a specific runaway success story. The common thread that seems to run through these stories is that it was always easier to implement specific health interventions that governments had prioritized among the retinue of things they had stated they wanted to do. Mayange village in Rwanda has a great family planning program where contraceptive prevalence rates jumped from about 4% to 50% among all married women between the ages of 15 and 49. Sauri’s community health worker program has received a boost from the Kenya’s formal recognition and renewed focus on the community as ‘Level 1’ of healthcare provision and support, Bonsaaso village in Ghana has doubled the proportion of women who deliver in health facilities to just over 60%. Potou village in Senegal tests 55% of antenatal mothers for HIV, up from just 2.7%. In literally each of the Millennium Village clusters, these sorts of changes are happening.
The health of MV residents has greatly benefited from being part of a larger integrated project–ambulances can reach further into rural areas because of better road networks; clinics are put up quickly using in-house technical expertise; CHWs are using mobile telephones to send through SMS critical and sometimes time-bound patient information that allows for faster responses and increases the life-saving potential of interventions because of stronger cellular phone networks and availability of energy kiosks where phones can be charged from the extended power grid or solar powered units; and the health system is better engaged with the community through the reach of community committees that have good gender and age representation.
If someone asked me what is the single most important thing that has caused these positive developments in health I would say the Community Health Worker (CHW) system. There are definitely other equally important program interventions in setting up health facilities, ensuring commodity security for health-related consumables, and providing equipment and staffing to optimize the utilization of these health facilities, but the deployment of a paid cadre of trained community health workers has probably done more than any other single intervention for the health program in the Millennium Villages. CHWs have been used in health systems throughout the world for a long time — in many instances they have worked for special programs that had very specific and narrow objectives: “TB ambassadors,” for instance have worked in ensuring collection of sputum for testing, actively looking for possible TB in the community, assisting persons on TB treatment to adhere to and complete their treatment, and looking for treatment defaulters within their community. There have been many other “specialist” CHWs in maternal and child health, in HIV care and support, in distribution of condoms and family planning commodities, and other such areas. Some programs have met considerable success with purely volunteer CHWs, more where the activities these CHWs did were few and not disruptive of their normal livelihood routines.
The Millennium Villages Project has worked within local circumstances in each of the 14 villages to set up a cadre of paid CHWs each working in a specific area with a known number of households that they are therefore able to become familiar with and provide services and support effectively to. This is not a totally new approach. Ethiopia has a professionalized cadre of CHWs working throughout the country; Malawi has Health Surveillance Assistants working in communities and a national system for health data collection and supervision. The MVP model emphasizes CHWs be residents in the communities they serve; collect a well-known set of health data and provide education; case management and referral, and receiving continuous support and supervision including tools and commodities for carrying out their work. A number of innovative tools have also been placed in the hands of CHWs to further ease their work. Foremost of these has been “ChildCount”.
ChildCount is a mobile-Health (m-Health) application based on UNICEF innovation’s rapidSMS project that uses SMS to support health data collection and collation, and uses that data to support CHWs, their supervisors and the health system in general. A CHW taking a child’s mid-upper arm circumference (MUAC) to determine whether the child is malnourished can send that measurement by SMS and get a response that classifies the child’s MUAC under international nutrition cut-offs and prompts the correct treatment, counseling or referral. She can also do the same for the rapid finger-prick blood test for malaria on a feverish child and get the correct dose and duration of treatment, these support decision-making for CHWs in the field, helps standardize treatment given by relatively inexperienced CHWs and minimizes errors. Supervisors can check how active a CHW is in each of the different things they are supposed to do, compute the quantities of commodities used, and assess the health status of the children in an area or under the care of a CHW through reports and a look at the database. Supervisors also get SMS prompts for cases above certain thresholds of risk such as severely malnourished children. There is no limit as to what quantity of this critical health information can be analyzed and used for planning of and giving feedback to the health system. The mobile phones have also been of great use in summoning help in cases of emergencies.
There are many developments in the countries we work in, some of them related to the results seen in the Millennium Villages, all of them a move forward on old promises of moving towards comprehensive primary healthcare for all. The critical changes that, in my view, need prompt consideration towards this goal are going to be: moving towards effective free healthcare, having a strong community based health system that links effectively to health facility-based care and relies on a cadre of paid community health workers, strengthening the facility-based care by getting adequate numbers and mix of health professionals to provide care and incentives to retain healthcare workers in rural areas, and tightening existing gaps in commodity security, having a responsive health system that collects and relies on data for planning.
On the whole, the MVP’s health programs are in robust health and will continue to point the way forward for responsive national health systems in all settings where such approaches are relevant.