1. What do you feel was accomplished at Recife? Pape Gaye: The meeting was a milestone, especially for someone like me, who is interested and passionate about advancing HRH. I thought three main points came out clearly. First, gaining commitment to Universal Health Care (UHC) is an important step. Building on past forums in Uganda (2008) and Bangkok (2011), this conference provided a mechanism for country leadership, engagement and platforms. The fact that 57 WHO Member States developed internally driven commitments was ground-breaking. Some even read their commitments aloud. This provides an opportunity to begin working on their needs.
Second, the message came out clearly that to succeed HRH needs to reach beyond Ministries of Health and the formal sector. We need other actors, civil society engagement and especially private sector input. If we follow through on these recommendations – private sector could add a new dimension. The message for broadening constituencies to work together came out strongly; I hope people take that point seriously.
Finally, CHWs need to be front and center in any national strategy that is developed. Although we have heard this before, donors are now committing to put resources and energy into this. The focus needs to stay on integrating CHWs into formal health systems.
2. Were there things that could have been done differently?
Pape Gaye: Definitely! Things were missing; especially the civil society, private sector and CHW voices. Even IntraHealth’s Switchpoint session, the only one focused on the private sector, could have done a better job about highlighting the role of the private sector. Why wasn’t this a major theme? We could have had private sector representatives speak in plenary. We missed an important opportunity. I also wish we heard more voices of health workers and CHWs. The award ceremony did recognize front line health workers, but more was needed. Overall we moved the HRH agenda slightly – from that standpoint, I think it was a success.
3. What do these commitments mean and how can they be implemented?
Pape Gaye: The value of having something truly tangible, from countries themselves for a change, something that was not an imposed agenda but came straight from the countries own needs, is important. What will we do with these commitments? I hope we don’t turn to policing them. In reality, we know many of these countries don’t have the resources required and lots will need additional support.
There is a need for donors, contractors and implementers to act on the fact that their own health workforce strategies are needed to move the global commitments to the next stage. As we see, USAID is in the process of doing just that, which makes this an opportune time to act. We can take a lesson from global advocacy campaigns, such as Every Woman, Every Child and FP2020, to ensure that CHWs become an integral part of the HRH strategies. I am not sure this is obvious to all; sometimes health workers can even be part of the problem. Contacts between CHWs and communities need to be multiplied and we need to continue advocacy efforts so the importance and centrality of the health workforce to national health systems and economic development is understood.
4. Who should take leadership?
Pape Gaye: I think GWHA could have a role in preparing country level decision makers to start asking for support. Country-led strategies are more relevant, sustainable and successful.
Just think about this: if countries start saying – from now on we will institute a plan that 10% of any funding goes to support the health workforce. Why not? We should work with governments to get them to act; it will be far more credible if the message comes from them. If we want to move the Recife commitments, I feel that people at country level have to be more strategic, forceful and deliberate about asking for support. For example: Can you help us develop a health workforce strategy or integrate CHWs? Can you write this into the programs that you are developing? At the end of the day, it has to be a felt need at the country level, which donors should support.
Globally, we could put more pressure on the need to mainstream HRH. Organizations, like IntraHealth, involved in implementing HRH, systems strengthening and other health programs should start doing this. We cannot continue ‘silo-ed’ conversations.
5. What would be on the top of your priority list of CHW needs?
Pape Gaye: Better recognition! It was music to my ears when I met the Minister of Health from Togo, a doctor himself, who confessed that he was once skeptical about the role of CHWs. He visited a CHW program that was providing injectables (contraceptives) in the north of Togo. It changed his whole view; he is now a strong advocate. He returned to lobby the government to create a budget line item to support CHWs annually. Yes, it was very symbolic and small. But it was a way of recognizing these communities and it enabled them to celebrate in their unique way. Small gestures can make big differences. Of course they also need better working conditions, just as other health staff, and basic supplies and transport.
6. How can we maximize lessons learned from past programs for stronger programs and better health outcomes?
Pape Gaye: Communities of Practice, like CHW Central, can be effective in creating space for guests to discuss themes, share stories and provide opportunities for discussion. We should also have space to share what we learn from failures.
If done right, well-managed South to South visits can be impactful. In the past USAID sponsored study visits, taking decision makers from francophone Africa to Malawi to exchange ideas. Because of the importance of cultural norms, these groupings should be done regionally to build on common interests. It is also sad that we have not found more ways to learn from Asia; task shifting was dealt with in many countries in this region 50 years ago. They also have highly successful national front line health worker programs. What we are doing is not new; we are not re-inventing the wheel.
7. As we move forward what other changes do you see as important?
Pape Gaye: I am very intrigued about the shifting paradigm. How can we leverage what everybody is doing? How we create new partnerships? Social entrepreneurs and creative staff from innovation hubs are waiting for a problem statement so they can focus on solutions. Let’s find a way to bring these people to the table and see what they can produce, perhaps 2-3 brilliant ideas to better support information flow and tool development for CHWs.
We are in the midst of a changing landscape in the international NGO sector. What do classical INGOs need to do to stay relevant? We don’t want to be relegated to dinosaurs – we need to reinvent ourselves and become more mission driven. If we don’t change, we will die out! So I think we need to make space for – what I see – are three new categories of players: a) universities (academics, scientists, and engineers), b) private sector and c) technology (social entrepreneurs). They need a chance to test their theories and their horizon is short – they want things to have happened yesterday. Let’s give them a chance.
8. As we think of change: What are your thoughts about the future role of INGOs?
Pape Gaye: We need to only look at the next five years. We won’t disappear, but our role will change. The trend from USAID through USAID Forward is to fund countries and local organizations directly with a goal of 30% by 2015. This is already being done by other donors. The private sector is important, but there are issues they won’t touch and places they will prioritize to develop new markets. What is the right strategy for working with private sector?
Progressively we have to move from implementation to intermediation between recipient and donor countries. Our strength is that generally we know what donor communities think and how their emphasis changes. If we are good, we also know the realities of the field. We should be a broker in helping ministries advocate for donor investment in CHWs – no one is doing this. Many of us are just doing the usual. These are exciting times with new opportunities, but we need to rethink our approaches and prepare for the new future.
Pape Gaye is CEO and President of IntraHealth International, a non-profit organization based in Chapel Hill, North Carolina, U.S.A. For over 30 years, in more than 90 countries, IntraHealth has empowered health workers to better serve communities in need. Under Gaye’s leadership, IntraHealth has garnered a strong reputation as an organization that fosters local solutions to health care challenges by improving health worker performance and strengthening health systems, harnessing technology and leveraging partnerships.
Photo by Geeta Sharma, courtesy of IntraHealth International
Donna Bjerregaard, Initiatives Inc., the manager of CHW Central, interviewed Pape Gaye for this feature.