REPURPOSE WHAT WORKS

In 2012, Timor-Leste’s Ministry of Health (MOH) asked a straight-forward question: What if living far from a health facility wasn’t a barrier to healthy birth outcomes? A 2010 survey indicated that for every 1,000 births, >5 mothers lost their lives. The urgency of the question was heightened by Timor-Leste’s high fertility rate (top 10 globally) and low skilled birth attendance (79% of rural mothers delivered without a skilled birth attendant). What if Timor-Leste’s health system could better reach women with critical prenatal care information?

To the Ministry’s surprise, an HAI-led study identified that cell phone use in rural areas was far more common than anticipated, indicating a potential opportunity for linking remote communities to care. What if cell phones could be repurposed to play a role in connecting Timorese women with government midwives?

In 2013, HAI and Catalpa International developed and piloted Liga Inan—a mobile phone-based service that allows midwives to share critical pregnancy and child health information with Timorese mothers, regardless of whether they can travel to the nearest health post. The program worked. The seed began to grow. And soon the MOH posed another question: What if all women in Timor-Leste had access to this service? By 2019, HAI and the MOH had worked together to expand Liga Inan to all 13 municipalities of Timor-Leste through the national health system.

In 2020, HAI and the MOH asked a new question: What if this nationally scaled, trusted system could help disperse information about COVID-19 to families across the country? With over 65,000 mothers just one text message away, it didn’t take long to repurpose Liga Inan and get the message out to families across Timor.

LEAD WITH SCIENCE

Evidence-based decision making is a critical health systems strengthening skill. More often than not, health care workers have a good sense of how to better organize care delivery to best serve their patients. However, providers don’t always have the data and analysis tools, skills, and authority to help grow those ideas into active strategies.

HAI’s SAIA projects are an example of focusing on individual, team, and system-wide data-driven decision-making to improve patient health. In Nhaconjo, Mozambique, one team of providers led an effort to reduce patient wait times (and missed connections) by setting up a “one-stop-shop” for integrated mental health care. A first in the region. Alberto Muanido, HAI Study Coordinator for the SAIA-Mental Health project, was struck by the initiative taken by the Nhaconjo team, when equipped with the SAIA toolkit to help justify the intervention and track its effectiveness:

“It was the team from the health center who put it into practice, spoke with hospital leadership, outlined how they would like the model to work, and started to implement it.”

With the help of the SAIA toolkit, the Nhaconjo facility team was able to collect data and track the impact of the one-stop-shop on patient outcomes. Results from the project, published last month in Health Policy & Planning, showed that provider-initiated, data-driven changes like the “one-stop shop” led to improved patient adherence (↑53%) and mental health function improvement (3.7 fold increase!).

BUILD ON TRUST

Extending health systems beyond clinic walls is an important aspect of public health prevention and response.  Community health workers play a critical role breaking down misinformation, modeling best practices, providing linkages to care, and perhaps most importantly: planting a seed of trust in public health.

In 2020, community counselors supported by HAI’s Project LINKS to provide community-based outreach to people living with HIV, multiplied their impact by including COVID-19 information in their messaging. Dr. Yacouba Doumbia, HAI-Côte d’Ivoire Program Director, noted: “By becoming messengers of COVID-19 information, [community counselors] are able to respond to concerns that affect the whole household.”

In Mozambique, HAI worked with the Ministry of Health to build COVID-19 expertise among shopkeepers and transport workers in 16 of the busiest markets and transit centers in the country. This community-based Activista approach, combined with a multi-media campaign, is estimated to have reached over 400,000 Mozambicans with COVID-19 prevention information in under 3 months.

ADAPT, ADAPT, ADAPT

Small tweaks or major shifts, the time for action is now.  Across the globe, COVID-19 has tested the responsiveness and resilience of systems of public health.  At HAI, we are acting from the micro- to the macro-level, making sure that even as we plant new seeds, we don’t neglect the growth that has already occurred.

Small, timely adjustments to existing programs are helping sustain continuity of care, even as COVID-19 threatens to roll back progress on decades of advances in public health. In Timor-Leste and Côte d’Ivoire, support groups and community outreach activities look a little…roomier.  Research protocols and project implementation strategies are getting extra attention to keep participants, providers, and our own staff & collaborators safe.

But our response isn’t just reactive, we are looking forward as well. As families spend more time at home, our Timor-Leste team is rolling out new programming focused on gender-based violence prevention and response. On a global front, we’ve joined with like-minded activists and institutions around the world to put pressure on major powers to relieve the constraints of austerity on the Global South, which lead to under-resourced health systems and emergency public health response.

REFLECT & RECOMMIT

For too long, global health has focused outward.  Global health strategies and methodologies are, nevertheless, well suited to improve the health of underserved communities in the United States.

At HAI, we are taking the “glocal” transition seriously and critically.  In 2020, we recommitted to a more equitable, inclusive, and anti-racist glocal health. Working with Global to Local, we are defining a glocal that identifies the components necessary for this work to thrive and avoid the pitfalls of one-size-fits-all interventions, assumed expertise, check-a-box collaboration, and more.

A starting place is making sure community leaders are leading the charge.  A practice that HAI has embraced while providing technical assistance to Somali-American Researchers from the Seattle-based Somali Health Board and UW as part of the Mama Amman and Healing Heart and Soul projects.  This community-based and community-driven participatory research is building networks of pregnancy and motherhood support that respond specifically to the experience of pregnant Somali women in South King County.

“The population coming together. Mingling. And that is what you benefit from. And that is what we got. And we benefitted.”

– Participant, Mama Amman/Safe Motherhood community group

We see a strong future for a truly global global health.