Empower & Advance cofounder Dr. Ayesha Khan first came to Fort Liberte, Haiti in 2010 to treat survivors of the Port-au-Prince earthquake who had fled the devastated capital.

creditMichaelEssman

There and in subsequent travels to other countries, she grew convinced that a healthcare model based on flying doctors around the world could never adequately address the needs of developing nations. She decided to trial a program aimed at increasing regional capacity by training local residents to provide basic healthcare services.

Recognizing the potential for tech skills to strengthen the effort, she teamed with computer scientist Brad Penoff to create Empower & Advance. They decided to test the program in Fort Liberte.

Focusing on emergencies

An emergency physician, Khan decided to focus the community health worker program specifically on that branch of healthcare. Emergency medicine is relatively young field and doesn’t exist as a separate discipline outside of a few wealthy nations. However, the combined impact of emergencies—which can be thought of as anything that needs to be dealt with during a critical period of time in order to prevent death and disability—outweighs that of many individual diseases that receive far more funding.

Emergency medicine is also particularly well suited for a community health worker program because many of the problems encountered therein are relatively simple to diagnose and treat. By training laypeople to provide basic emergency care, Khan reasoned, she could help free up the town’s few doctors to focus on more difficult cases.

Creating sustainable employment

Determined to avoid creating dependency on international donors, a common problem in foreign aid, Khan and Penoff developed a business model that they believed might allow the program to be self-sustaining in the local community. They decided to ground the long-term strategy in an insurance scheme that would be affordable to Fort Liberte residents but sufficient to pay most of the program’s expenses (e.g., salaries and equipment).

Research

Khan and Penoff analyzed two years’ worth of local hospital records to determine which emergency health complaints were most common. The final list included trauma, stomach pain, diarrhea, wounds, rashes, high blood pressure, low blood, typhoid, malaria, pneumonia, coughs, and urinary tract infections.

They also surveyed every third household in Fort Liberte to learn more about residents’ needs and preferences. Topics explored included reasons for going to a doctor; issues that prevent community members from seeking care; attitudes regarding seeing a community health worker rather than a doctor; and willingness to pay for care provided by the community health workers.

Read more about the research process on our blog.

Program development

Together with colleagues at Stanford, Khan developed a seven-month curriculum based on the results of the research. The final program consisted of 42 modules, each covering one of the local priorities identified.

The team developed a technology-based learning program to would allow students to complete the coursework without the need for an instructor to be physically present. In this plan, each student would receive a tablet with preloaded videos, eliminating the need for costly repeated visits from doctors living abroad and skirting the issue of poor Internet connectivity common in developing countries.

Students would then work together to master the subject matter presented in the videos, checking in with Khan and other instructors during weekly web conferences.

After finalizing the coursework and passing a series of tests demonstrating mastery of the material, the students would spend two weeks with the US-based instructors, learning hands-on skills and seeing patients. Future classes of community health workers would be taught the hands-on procedures by program alumni, using a train-the-trainer model.

The team based the course videos around still images accompanied by a script read by a native speaker of Haitian Creole. This way, the images could remain the same if the training modules were used in other parts of the world in the future; the soundtrack could simply be re-recorded in the local language. Fort Liberte artist Doudy Charles created the images used: black-and-white drawings illustrating the medical conditions that had been identified as priorities.

 

Training and certification

Fort Liberte community leaders helped identify young people in the town who had performed very well in high school but had few prospects for further studies or employment.

After a rigorous interview and testing process, the team selected the first class of students and began implementing the program as planned, arranging for them to meet every weekday in a room above the town clinic.

Jean Tom, Wildiane Felix, Jocise Pierre, and Kerlandy Jean-Louis passed their exams in early 2014.

They were certified to practice as community health workers by the regional ministry of health.

On-the-ground implementation

After gaining additional experience working under the supervision of doctors and nurses in Fort Liberte’s clinic, the community health workers began working in Perches, a rural community in the Fort Liberte catchment area. They have since earned a reputation in the surrounding region for providing quality care.

In addition to staffing the local clinic, they conduct outreach to local schools, providing children with much-needed information about topics such as hygiene and nutrition.

Next steps

Khan and several members of the instructional staff and working board are traveling to Fort Liberte in January 2015 to evaluate the community health workers’ progress. They will also focus on further development of the nutrition training program, as well as improvements to the clinic, including installation of a solar generator.

They are continuing to build relationships with local government officials. In particular, they are coordinating with agencies in Perches and beyond to investigate options for implementing the insurance system that they hope will make the program self-sustaining long into the future.

To streamline tracking and quality control, Penoff is creating an app that will allow the American-based team to review the community health workers’ diagnoses and provide feedback as needed.