Hi Nick, your work sounds really great. I do want to get your view on whether it is potentially more cost-effective to (a) run centres which people come to, vs (b) send community health workers out into villages, rotating through on a regular basis. For (a) the benefit is you don’t have to expend resources and time on identifying who is sick; for (b) the benefit is you get to reach out to people who are sick but who are too ill/poor to travel long distances to get treatment & medication; this is especially true for chronic issues which can be detectable any time and whose management can be fairly light touch. The latter is an issue that experts I’ve been talking to seem fairly worried about, and I would value your opinion on how.
TLDR even for villages which may not warrant a centre per OneDay’s metrics, would it be potentially be valuable to rotate nurses through on a semi-regular basis?
Thanks Joel! Your community health worker question is a common one! I’m a big community health worker fan, and the movement is even part of the inspiration for ODH. But there are a number of common misconceptions about what they actually do
1) Community health workers might serve an area of 500 households (or more). Even the most active community health worker can’t get around more than 50 housholds in a day (and the data shows the norm is more like 5-20 households). When you have malaria or pneumonia, you need help in the first 24 hours of illness and the illness can often get very bad within 1-2 days. So in reality most people visit a VHT for treatment—the VHT doesn’t visit them, it’s just not possible. This myth of the VHT actively case finding most of their work is persistant though...
2) Community health workers are not usually very cost effective. Monitoring them, supplying them and paying them to do a part time job works out as being surprisingly expensive. The orgs I’ve look at (Lastmile health and living goods) including all project costs seem to treat patients at between 4 and 10 dollars per patient (we are between $1-$2 depending on how you calculate), but it’s hard to tell as I haven’t seen these orgs release these numbers.
3) Community health workers only usually treat kids under 5 for malaria, pneumonia and diarrhoea—it would be medically irresponsible to get them treating others as they have minimal training. They don’t treate adults for malaria. Yes these childhood illnesses are the highest DALY burden conditions, but they still can’t treat the majority of patients.
I’m not sure you mean by chronic issues? Community health workers rarely treat chronic conditions, they treat malaria, pneumonia and diarrhoea in under 5s and sometimes (rarely) provide antenatal care. Maybe in urban places they are involved in NCD care, but certainly not in remote rural placee
There are a lot of good reasons for community health workers t be doing part of this job. Filling the gap of lack of trained personal (like Uganda), health education and getting as much malaria treatment out there as possible. There are many RCTs proving their worth But we still need more cost effective solutions, and high quality universal helathcare in remote places.
I think Joel’s question and your response raise interesting issues about the most cost-effective ways to meet (at least more of) the health-care needs of people in places too small/remote to support a ODH health center. I can think of three general possibilities:
One, improve transit for bringing sick people to a center, such as by providing a bike (with small pedicab trailer) for a trusted community member to lend out to those needing to transport friends or family members to an ODH or other health center. The obvious problem there is that the bike might disappear or be diverted to other uses.
Two, create some sort of lightweight stationary version of ODH health centers for communities that cant support a full one—employing a part-time, non-nurse community health worker with a sharply limited scope of practice (e.g., malaria, pneumonia and diarrhoea in under 5s).
Three, put a nurse on a motorbike with a small trailer to create a mobile, semi-lightweight version of an ODH health center (e.g., two hours a day in each of three locations, with two hours of transit time). The cost per patient would obviously be higher than ODH’s model due to lower patient volume per nurse, travel expenses, and likely higher facility costs per patient.
I suspect all of those require more donor subsidy per patient than ODH’s current model. The potential advantage would be that the treatment provided may be even more counterfactual than what ODH currently provides.
I’m not Nick, but it might be helpful to clarify what you mean by “community health workers”—your TL;DR suggests you may be referring to nurses. (ETA: Nick’s comment above explains the difference in scope of practice.)
Wikipedia (usual disclaimers apply) describes Uganda’s levels of public non-hospital care as follows:[1]
The lowest rung of the district-based health system consists of Village Health Teams (VHTs). These are volunteer community health workers who deliver predominantly health education, preventive services, and simple curative services in communities. They constitute level 1 health services. The next level is Health Center II, which is an out patient service run by a nurse. It is intended to serve 5000 people. Next in level is Health Center III (HCIII) which serves 10,000 people and provides in addition to HC II services, in patient, simple diagnostic, and maternal health services. It is managed by a clinical officer. Above HC III is the Health Center IV, run by a medical doctor and providing surgical services in addition to all the services provided at HC III. HC IV is also intended to provide blood transfusion services and comprehensive emergency obstetric care.
Hi Nick, your work sounds really great. I do want to get your view on whether it is potentially more cost-effective to (a) run centres which people come to, vs (b) send community health workers out into villages, rotating through on a regular basis. For (a) the benefit is you don’t have to expend resources and time on identifying who is sick; for (b) the benefit is you get to reach out to people who are sick but who are too ill/poor to travel long distances to get treatment & medication; this is especially true for chronic issues which can be detectable any time and whose management can be fairly light touch. The latter is an issue that experts I’ve been talking to seem fairly worried about, and I would value your opinion on how.
TLDR even for villages which may not warrant a centre per OneDay’s metrics, would it be potentially be valuable to rotate nurses through on a semi-regular basis?
Thanks Joel! Your community health worker question is a common one! I’m a big community health worker fan, and the movement is even part of the inspiration for ODH. But there are a number of common misconceptions about what they actually do
1) Community health workers might serve an area of 500 households (or more). Even the most active community health worker can’t get around more than 50 housholds in a day (and the data shows the norm is more like 5-20 households). When you have malaria or pneumonia, you need help in the first 24 hours of illness and the illness can often get very bad within 1-2 days. So in reality most people visit a VHT for treatment—the VHT doesn’t visit them, it’s just not possible. This myth of the VHT actively case finding most of their work is persistant though...
2) Community health workers are not usually very cost effective. Monitoring them, supplying them and paying them to do a part time job works out as being surprisingly expensive. The orgs I’ve look at (Lastmile health and living goods) including all project costs seem to treat patients at between 4 and 10 dollars per patient (we are between $1-$2 depending on how you calculate), but it’s hard to tell as I haven’t seen these orgs release these numbers.
3) Community health workers only usually treat kids under 5 for malaria, pneumonia and diarrhoea—it would be medically irresponsible to get them treating others as they have minimal training. They don’t treate adults for malaria. Yes these childhood illnesses are the highest DALY burden conditions, but they still can’t treat the majority of patients.
I’m not sure you mean by chronic issues? Community health workers rarely treat chronic conditions, they treat malaria, pneumonia and diarrhoea in under 5s and sometimes (rarely) provide antenatal care. Maybe in urban places they are involved in NCD care, but certainly not in remote rural placee
There are a lot of good reasons for community health workers t be doing part of this job. Filling the gap of lack of trained personal (like Uganda), health education and getting as much malaria treatment out there as possible. There are many RCTs proving their worth But we still need more cost effective solutions, and high quality universal helathcare in remote places.
I think Joel’s question and your response raise interesting issues about the most cost-effective ways to meet (at least more of) the health-care needs of people in places too small/remote to support a ODH health center. I can think of three general possibilities:
One, improve transit for bringing sick people to a center, such as by providing a bike (with small pedicab trailer) for a trusted community member to lend out to those needing to transport friends or family members to an ODH or other health center. The obvious problem there is that the bike might disappear or be diverted to other uses.
Two, create some sort of lightweight stationary version of ODH health centers for communities that cant support a full one—employing a part-time, non-nurse community health worker with a sharply limited scope of practice (e.g., malaria, pneumonia and diarrhoea in under 5s).
Three, put a nurse on a motorbike with a small trailer to create a mobile, semi-lightweight version of an ODH health center (e.g., two hours a day in each of three locations, with two hours of transit time). The cost per patient would obviously be higher than ODH’s model due to lower patient volume per nurse, travel expenses, and likely higher facility costs per patient.
I suspect all of those require more donor subsidy per patient than ODH’s current model. The potential advantage would be that the treatment provided may be even more counterfactual than what ODH currently provides.
I’m not Nick, but it might be helpful to clarify what you mean by “community health workers”—your TL;DR suggests you may be referring to nurses. (ETA: Nick’s comment above explains the difference in scope of practice.)
Wikipedia (usual disclaimers apply) describes Uganda’s levels of public non-hospital care as follows:[1]
The lowest rung of the district-based health system consists of Village Health Teams (VHTs). These are volunteer community health workers who deliver predominantly health education, preventive services, and simple curative services in communities. They constitute level 1 health services. The next level is Health Center II, which is an out patient service run by a nurse. It is intended to serve 5000 people. Next in level is Health Center III (HCIII) which serves 10,000 people and provides in addition to HC II services, in patient, simple diagnostic, and maternal health services. It is managed by a clinical officer. Above HC III is the Health Center IV, run by a medical doctor and providing surgical services in addition to all the services provided at HC III. HC IV is also intended to provide blood transfusion services and comprehensive emergency obstetric care.
Cf. The Guardian here, but dated.