Sonia Sachs has been frustrated over several years of working in pediatrics and endocrinology as a public health specialist in Africa. But, she has been frustrated right into a solution. Sonia Ehrlich Sachs, MD, MPH is a pediatrician, an endocrinologist and public health specialist. She received a BA from Harvard University, an MD from the University of Maryland Medical School, and an MPH from Harvard School of Public Health. Sonia practiced medicine for over 20 years, 14 of which she spent at the Harvard University Health Services in Cambridge, Massachusetts.
Since 2005 Sonia has been leading efforts at the Earth Institute, Columbia University, to design and implement low-cost primary health systems in low-income rural Africa and India. Her focus is on systems delivery, primarily for maternal and child health, at local to national scales. Sonia coordinated the health sector for the Millennium Villages Project, overseeing all health-related interventions and research. The Millennium Villages Project was an integrated rural development initiative in ten sub-Saharan African countries designed to help poor rural communities accelerate reaching the Millennium Development Goals using a science-based, community-led approach of integrated interventions that increase food production, access to health care, education, water, infrastructure, and business development.
As deeply entrenched as she’s been in the health sector in the neediest parts of Africa, Sonia has been able to pinpoint a gap where need could easily meet solution and she has been working to close that gap. Her frustration in so doing comes from knowing that there is a simple and cost-effective solution to creating a universal health system in Sub-Saharan Africa to give all access to basic health care that could prevent people from dying of common problems, like diarrhea, pneumonia, malaria, malnutrition, and childbirth events. And yet, says Sonia, “the international community pays no attention. There have been promises of funding that have never materialized.”
Six years ago, Sonia turned her attention from the broad-scale approach to one singular intervention that she knew would make a huge difference…pay the community health workers (CHW) and give them cell phones. Most CHWs are volunteers who have graduated from secondary school and receive three months of training (on 10 diseases) before working. They are despondently poor. Just them knowing how to use a cell phone would make them more valuable. Many of those who get trained as a CHW get “poached” to other areas, and while it is good for them to advance their living conditions, it isn’t good for the villages they leave behind. This is something of a conundrum but, regardless, Sonia believes that paying CHWs and giving them phones will advance health care in this regional rapidly.
Sonia’s experience and expertise allow us the opportunity to learn more about university-founded impact efforts, how they are organized, and what is and isn’t working. What follows is a Q & A with Sonia.
Q: What is the “Millenium Village Project?” and how did it launch your work in Africa working on the health system there?
A: My husband, Jeffrey Sachs, and some of our colleagues at the Earth Institute at Columbia University launched the Millennium Villages Project in 2005 -2015 as a proof-of-concept of showing the feasibility of alleviating extreme rural poverty in sub-Saharan Africa. The idea was to use a holistic, integrated approach addressing food security, access to health, education, infrastructure, gender equity, and business development. For over three decades the rich countries have made promises of devoting 0.7% of the rich world’s GDP to help very low-income countries so that the poor could reach the Millennium Development Goals (MDGs). Of course, here we are, many years later and the promises are still just promises. But, in the meantime, through the project of the Millennium Villages in 10 sub-Saharan countries, we have learned that with just a very small amount of external funding, well within and below the 0.7% promised, these remote poor rural communities could make progress towards the MDGs. In the health sector, we learned and demonstrated that for what now would be about $80 per person per year, one can have a functioning basic health system that improves villagers’ health and decreases maternal and child mortality. The system consists of a basic, equipped, functioning clinic, with 24/7 presence of a skilled birth attendant, emergency transportation and an outreach Community Health Worker. The CHW has to be formal part of the health system, meaning she/he is full time, trained, paid, managed and empowered by a backpack with life-saving commodities and a smartphone with an application that supports his/her decisions at the household while simultaneously providing real-time data to the manager who can make performance decisions, retraining, and other adaptive interventions. Once you train, supervise, pay and empower the CHW, they become impactful and can be accountable for the wellbeing of their 100-150 households.
Q: Why do you think that the international community isn’t seeing the solution you and your team have designed to address the Community Health Worker (CHW) issue?
A: We have done a costing study of a professionalized CHW cadre (one who works full time, is paid, trained, managed and uses a smartphone) and it is around $7 out of the government’s health budget. As small as that amount is, considering its life-saving function, most countries in sub-Saharan Africa can’t afford it at the moment and so, about half of that amount would have to come from international donors for a few years until such time that the countries can afford it on their own. It is for this albeit tiny additional needed foreign aid, that the international donor community is not interested in this solution, because it implies a small additional cost.
My husband, few of my colleagues and I have started a CHW Campaign six years ago to advocate for the $3 billion dollar increase in foreign aid so as to include a CHW professional cadre. We have also advocated that the “Global Fund for AIDS TB and Malaria” include a health systems window, one where countries could apply not just for vertical diseases and just for commodities but also for health systems, including human resources such as CHWs. So far there is no global fund for health systems
Q: You mentioned the “poaching” of trained healthcare workers and the movement from more desolate communities doctors and nurses – even if it is helpful for those who need that elevation of quality of life, what can be done to secure and maintain continuity of good healthcare?
A: We found that professionalizing CHWs is actually a good job creation for young people, especially women, living in rural communities. To become a CHW, the young person gets a 3 months training and then gets continuous supportive supervision with continued on-the-job training, including on the use of the smartphone. We found that after about two years or so these young CHWs become eligible for better jobs with NGOs or in government clinics. I jokingly said that the CHWs that we trained in all the Millennium Villages in ten countries were ‘poached’ for other jobs and yet how great that is because it proves that becoming a CHW is a great first step out of rural poverty as the young person then is eligible for more remunerative and satisfying careers.
Q: You mentioned that smartphones have been a “game changer” for healthcare in marginalized communities in Africa. Are there other technologies that could be cost-efficient and helpful to improve care?
A: Given the use of smartphone has changed what used to be a set of individual health interventions into the possibility of a health system because with the phone and the data that the use of the phone provides, one can have a health system which has real-time data about births, deaths, diseases, etc., which then can inform real-time decision making and adaptation for continuous quality improvement. Instead of finding out through some survey done every few years about how many cases of diarrhea or malaria or child deaths there are, thanks to the CHW with the use of the phone, these indicators can be obtained in real time and solutions applied in near real time.
Other technology that we have piloted in the Millennium Village in Ghana is Telemedicine which has two years ago been adopted by the government as a national program. Since there not enough doctors and nurses in rural areas in most low-income countries, there is not a way to quickly and accurately identify an emergency and transport the patient to a referral hospital. If CHWs and community nurses are given a cell phone and a connection to a Teleconsultation Center in a referral hospital, they can present the case and get the advice they need to properly handle the emergency situation, including the Teleconsultant dispatching an ambulance to bring the case to a hospital.
Q: What are the primary diseases you see are being impacted by a lack of quality healthcare? How is specifically HIV being impacted?
A: That is the sad fact of life in very low-income communities. Women and mainly children die of the most easily preventable and treatable diseases. Many children and mothers die during childbirth because of not having access to institutional delivery and many children die of diarrhea, malaria, pneumonia, and malnutrition.
CHW could be very helpful in the HIV care in that the first step of HIV treatment is to know that you are infected which requires testing. Most people in a very low-income setting don’t get tested until they are ill by which time they may have infected others. So, relying on going to clinics or hospitals to get tested misses out on the large portion of infected people who don’t go to get tested. CHWs who are in charge of the wellbeing of their panel of households, can, in a culturally sensitive way, encourage the young people they deal with in the privacy of their home to go get tested and if positive, the CHW can help encourage compliance with the treatment and support the family in a holistic way.
Q: Can you paint a picture of the impact it would have on healthcare in desolate areas of Africa to have the money to pay CHWs and give them smartphones?
A: A robust health system consists of multiple components. There needs to be a clinic within walking distance and the clinic has to provide services free-at-point-of-service. The clinic needs to be a functional clinic with electricity, water, equipment, laboratory, pharmacy, skilled birth attendant, nurse, lab technician, sanitation facilities, maintenance person, telephony, and emergency transport. But, even if that is in place many families or individuals still do not go to the clinic when needed either because of social, religious, or other reason of stigma including old age, infirmity, mental disease, domestic abuse, etc. Therefore, adding a component of outreach, a community health worker, whose job it is to go to the family’s home on a regular and as-needed basis, and to keep his/her panel of 100 households healthy, improves the chances that those who needed it, do get health care or other social services.
We thank Sonia for her contributions as she was traveling during correspondence and was able to finally situate in Astana (as of March, renamed Nursultan) to be able to jot up these responses. If you have any connections you feel meaningful to Sonia’s work, feel free to share in comments below.