Subarna Mukherjee

Health Workers Go the Last Mile: Organization is training staff to deliver care in the world’s most remote regions

Working in remote subsistence communities in the rainforests of Liberia has led me to understand and appreciate the power of consumer demand like never before.

I work at Last Mile Health (LMH) where we’re creating an innovative model for delivering primary care in the world’s most remote villages. While “remote” may conjure varied images, Liberia is remote in many contexts. A country that had some semblance of development in very recent history was destroyed by 14 consecutive years of civil war. Today, the rutted and muddy roads are so bad that a trip that would usually take four hours on a paved road takes 10 hours instead. Transport options within the country are limited and very expensive – not to mention unsafe and uncomfortable. Cell network signals are sparse. Many of LMH’s patients must walk six to 15 hours to reach the nearest health facility – an impossible distance that leaves them without access to often life-saving basic primary care.

Yet, the desire for a service or good that does not exist often leads to the creation of an enterprise to meet demand. In the absence of entertainment centers, candle-lit huts with portable radios and speakers become nightclubs. In the absence of a market, bush transporters are willing to push overloaded motorbikes, tipping with all sorts of goods, across narrow log bridges to make sure eager consumers have their needs met. In the absence of a formal health care system, an elaborate system of traditional health attendants, country doctors and tablet men hawking fake medications have been serving the people of rural Liberia.

Without disparaging the valuable services rendered through this informal system, it is clear that, with the lowest life expectancies in the world, sub-Saharan Africa will require a new way forward.

The need and desire for health care is palpable. More than 50 percent of the mothers in Konobo – Liberia’s most remote district – have watched one of their children die. People are almost unfazed by a young death. They know grief in a way I will never understand; amidst joking, working, clearing the forest and farming, people somehow carry on.

This is the backdrop to LMH’s work in Liberia and, I suspect, in all so-called “last mile” communities of the world.

It is here in the remote villages of Konobo in southeastern Liberia, in the middle of rainforests and connected mostly by roads only passable on motorbike or by foot, that Last Mile Health has been working in partnership with the government of Liberia to pilot a new model for health care delivery.

(In the rainforests of Liberia, many roads are passable only on motorbikes, left. And even then, just barely.)

LMH works in these villages to address the top 10 killers of women, children and men through our frontline health worker (FHW) model. The model recruits, trains, equips, manages and incentivizes frontline health workers, who deliver care door-to-door in the villages and tackle 75 percent of the burden of the disease in these villages. However, for emergency and/or severe cases, FHWs refer cases to local health facilities, which creates linkages between community services and clinic services.

Currently, Last Mile Health has recruited and trained 46 FHWs who have now ensured that every villager in Konobo has access to a health care worker. Since LMH started working in Konobo in 2012, we have learned much about what it will take to deliver and scale health care to last mile villages throughout the nation.

Two lessons in particular stand out.

First, you can’t set a low bar for any part of the recipe to create a successful community health worker. They need exactly what you and I need to be successful: a minimum standard for recruitment to do the job successfully; training; routine and structured performance management; tools and resources; and a living wage. In addition, FHWs need to be linked to a health facility equipped to handle severe presentations outside the scope of the clinical training provided to FHWs.

The second lesson is that while riddled with operational challenges, the vision of delivering care in remote areas is never impossible.

Aaron, a 17-year-old FHW, graduated from high school and was working in his community as a subsistence farmer when we invited him to the initial FHW recruitment process. We were lucky to find him. After a three-step recruitment process, Aaron stood out as a shining star. He now serves a catchment of more than 200 people and is currently able to provide a range of services.

(Aaron, 17, is a “shining star” with Last Mile Health, left.)

Prepared with medications, decision-making tools and weekly supervision, he is able to conduct diagnosis and treatment of pneumonia, malaria and diarrhea. Pregnant women and their partners in his community receive a monthly home visit, where Aaron screens the women for danger signs, provides prenatal education and facilitates a process of birth planning. Since Aaron lives in the same village as the expectant mother, he will make sure she is able to get to the facility to deliver her baby in an environment equipped to handle any obstetric complications. He will also be able to provide her and her child follow-up care after the birth.

When he is fully trained, he will be able to implement more than 40 clinical skills in his community. He will be able to do this and do it well because he has a supervisor who visits him every Monday, checks his work, coaches him through problems and successes and, most importantly, treats him like the life-saving health care provider that he is.

While our model is effective, operational challenges still abound. LMH must constantly navigate the uncertainty of when and how many medical supplies will arrive. We must also build systems against theft and fraud. We must decide when and how to use mobile technologies to make our work more efficient within the constraints of limited cell network coverage. Finally, it has become clear that as we scale our model we must learn how to modify and make all aspects of delivery systematic.

Systems have to be simple, not only to be executed by staff with varying degrees of literacy, but also in accordance with the limited resources available in these areas. Given the scarcity of health resources, we must create a cost-effective model that shows that lives can be saved. FHWs are not a Band-Aid solution to the shortage of health facilities and health workers; they are an essential and sustainable solution. With the proper investment, FHWs can be trained to provide simple interventions that are low cost and high impact.

Recently, Last Mile Health partnered with Prophet to create a new brand identity to highlight our story and goal to save lives in the world’s most remote villages. In addition to innovative partnerships with companies like Prophet, Last Mile Health has a variety of philanthropic and corporate partners.

We have a long way to go, but as long as our organization grows with the right people on our team, we are well positioned to strengthen our model and meet the demand and right for health care for the 400 million rural Africans and 1 billion people globally who currently lack access due to distance.

Subarna Mukherjee is the frontline health systems director at Last Mile Health.

Education, Environment, Health Care
scale, skill development