A Mass Crisis Can Overwhelm Health Care. Liberia Found a Solution.

If one thing has been made clear by the COVID-19 pandemic, it is this: The health care system in the United States (and most other nations) is not set up to respond to a large-scale medical emergency that affects tens of thousands of citizens simultaneously.

But there is an example of at least one country, Liberia, that was able to meet a similar, deadly threat by supplementing a health care system emerging from decades of civil strife with a cadre of less trained, but highly capable, community health workers.

Could the Liberian model help with COVID-19 and future mass scale health events?

The ongoing pandemic is forcing a rethink of how the health care system operates in the United States as the death toll climbs, unemployment soars, and leaders debate how best to diagnose, vaccinate, and potentially treat millions of people.

In the US there are far fewer health care workers than required to accomplish such a planned massive expansion, from yet-to-be hit rural areas to overwhelmed urban health systems. As leaders consider how to tackle the task, they might look at the Harvard Business School case study of nonprofit Last Mile Health and its work in Liberia during the Ebola crisis.

Community training helps fight Ebola

A new case study about Last Mile Health by HBS Senior Lecturer Brian L. Trelstad and V. Kasturi Rangan, the Malcolm P. McNair Professor of Marketing, outlines how CEO Raj Panjabi’s determination to stick to his community training health care model played a crucial role in helping to combat Ebola in Liberia.

Founded in 2007 to serve the most remote of Liberia’s 15 counties grappling with the HIV/AIDS crisis, Last Mile Health recruits, trains and supports community members not already in the health care field to provide basic health care services in remote rural parts of the country. It provides workers with more highly trained supervisors, pays them a living wage, and coordinates with the existing health care system, mostly in urban areas.

“In retail mall parking lots, you could imagine a cadre of 10 people working in shifts of 12 to 14 hour days to test people, then process the tests and take them to a waiting area.”

When Ebola began ravaging the country in 2014, Liberia’s government came knocking on Last Mile Health’s door. The organization helped the government use its model across Liberia to train nearly 3,000 paid community health workers and 350 supervisors, according to Last Mile Health’s 2017 annual report.

Much of the model used for Ebola involved contactless testing for the community workers, so it eliminated some of the most dangerous risk with that virus. As a result, Liberia now has a community workforce trained to respond to a situation like the current global pandemic.

The case shows that if community health workers could be trained on the front lines, you might have access to capabilities to everything from initial screening to contact tracing on the back end, Trelstad says.

“You might be able to recruit and train people, including those who've been recently unemployed, to create a cohort of testers, screeners, and contact tracers that could help build the infrastructure to respond to the crisis and deal with some of the unemployment that we are seeing right now.”

Parts of the Last Mile Health model could be adapted for the novel coronavirus in the United States and beyond. Trelstad points to four requirements that Panjabi calls the “Four S’s” for community health workers: they must be skilled, they need access to supplies, they must have proper supervision, and they need to be salaried.

Last Mile Health recruits workers who are “literate and numerate, but otherwise not experienced in the health sciences” and trains them in the basics of health diagnostics and treatment, such that they can play an important role in a health outbreak,” Trelstad says. 

A curriculum of instruction could be put together quickly and efficiently for COVID-19 in the US, he says. The training modules cover four areas including epidemic surveillance; maternal and child health care; identifying Malaria, tuberculosis, and HIV; and referrals and chronic disease care.

Adjusting the model

The economic needs in the US, of course, are different, so living wages for community health workers and training costs would have to be established. Trelstad points to a recent column in Fortune from Panjabi and Mitchell B. Weiss, a professor and the Richard L. Menschel Faculty Fellow at Harvard Business School, that outlines potential steps.

“In retail mall parking lots, you could imagine a cadre of 10 people working in shifts of 12- to 14-hour days to test people, then process the tests and take them to a waiting area,” Trelstad says. “And well-trained community health workers, as Last Mile Health teaches us from their Ebola experience, can do this with a high degree of informational accuracy, calm, and safety.”

In 2013 in Liberia, ahead of the heaviest part of the Ebola crisis, some 79 percent of health care spending came from overseas development assistance, according to the case study. The government budget was $49 million, donor assistance was $124 million and out-of-pocket household expenditures were roughly $128 million.

The health care system in the US is larger and far more complex, and the virus is already widespread, making the staffing situation more urgent. Health care workers from areas where there are fewer cases are already traveling to hotspots like Boston and New York to help, Trelstad says.

Central to the case study is a decision Last Mile Health had to face early on in the Ebola crisis. The organization was invited to submit a proposal for a $23 million contract to help construct health care centers all over the country—an amount more than 10 times Last Mile Health’s 2014 budget and three times the $7 million in unrestricted philanthropy they were already working to absorb, according to the case study.

The problem? The partner providing funds for such a large contract asked Last Mile to give up its community training piece as part of the proposal. In the end, Panjabi turned down that contract, but ended up consulting on community training anyway.

“It’s an interesting case of ‘what do you do at a moment of crisis?’” Trelstad says.

Is Last Mile a model?

Panjabi attended a recent HBS class where Trelstad taught the case. The students were impressed by their guest. “He is a compelling person and the issue was topical,” Trelstad says. “The students were split as to whether to take the large grant or not, which was the central tension of the case.”

Philanthropists looking to help fight COVID-19 in the US may want to evaluate a community health model similar to Last Mile’s.

“The argument to philanthropists would be that we need to vastly increase our capacity to test people who are asymptomatic. And the capacity of our health care infrastructure, treating those who are symptomatic and not well enough to be at home, is being pushed to its limits in places that have not flattened the curve,” Trelstad says.

“A community health worker model could build needed public health infrastructure pretty quickly—infrastructure that doesn't currently exist—and address the economic crisis at the same time. And then the question to the philanthropists is, 'Is that worth it to you?'”

About the Author

Rachel Layne is a writer Based in Boston.

[Image: CasarsaGuru]

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