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What Works When Implementing Community Health Worker Programs

In February 2024, Knowledge SUCCESS hosted three Learning Circles cohorts focused on implementing and scaling up community health worker (CHW) programs into health systems, with participants working in Asia, Anglophone Africa, and Francophone Africa. Throughout the learning sessions, participants discussed what works and what doesn’t when implementing and scaling up CHW programs, and discussed how to overcome persistent challenges.

On May 14, the Knowledge SUCCESS Project hosted a webinar to summarize the high-level success factors and solutions that were shared by family planning and reproductive health (FP/RH) professionals during the Learning Circles sessions. The webinar also featured a panelist from each of the three regional cohorts, to share some of their success factors and lessons learned from their specific context and experiences. Missed this webinar? Read on for a recap, and follow the links below to watch the recording. 

Watch the full recordings in English and French on YouTube.

Summary of the CHW Learning Circles Insights

Watch now: 9:02

Dr. Mohamed Sangare, SBC Regional Advisor at the Johns Hopkins Center for Communication Programs based in Senegal, was the moderator of the webinar and was the lead facilitator for the Francophone Africa Learning Circles cohort. During the webinar, Dr. Sangare summarized the key insights and themes that came up across the three regional cohorts – including what’s working well, what can be improved, and lessons learned – all related to implementing and scaling up CHW programs. 

What’s working well

  • Simple and effective data collection mechanisms 
  • Ownership and collaboration 
  • Provision of incentives to CHWs
  • Training, supportive supervision, mentorship
  • Involving CHWs in planning and monitoring 
  • Involvement of local influencers

What can be improved

  • Remuneration for CHWs
  • High turnover of CHWs
  • Scope of work for CHWs not always aligned with task sharing/shifting policy
  • Data collection and reporting 
  • Community trust

Lessons Learned

  • Political will
  • Integration of CHWs 
  • Sustained remuneration 
  • Co-ownership & multi-sector collaboration 
  • Clear roles and responsibilities
  • Ongoing capacity strengthening
  • Properly equipped CHWs
  •  Solid referral systems
  • Technology for data collection and reporting and documentation

Data Collection & Reporting Mechanisms: Experience in Pakistan

Watch now: 21:00

The first panelist, and a participant within the Asia Learning Circles cohort, was Aisha Fatima, a Senior Program Manager on MOMENTUM Country and Global Leadership (CGL) at Jhpiego, based in Pakistan. During her presentation, Aisha focused on MOMENTUM’s Community Health Workers Program, which is primarily focused on postpartum family planning (PPFP) and working at both the community level and the health facility level in Hangu and Kohat districts. 

She shared several of the program’s interventions, including:

  • Address barriers and develop innovative solutions for PPFP data analysis and use
  • Strengthen collaboration between two departments that both have CHWs – Department of Health and Population Welfare Department, including strengthening collaboration between the women and men CHWs
  • Enhance young couples’ awareness and agency in seeking PPFP information and services at community and health facility level

Aisha described some of their priorities, based on a situational analysis that concluded that there were two major gaps for their project to focus on – 

  1. Technical skills on PPFP counseling and provision of services and referrals to health facilities
  2.  Documentation and coordination gaps related to use of tools and capturing data as well as coordination between women and men CHWs

To address these gaps, Aisha shared the approaches that the program implemented, which  included consultative meetings, bridging gaps between men and women CHWs, joint review and revision of their PPFP tool, orientation and training on the revised tool and data analysis, and revitalization of data-driven monthly meetings, among others.

To conclude, Aisha shared the factors that contributed to the success of MOMENTUM CGL’s CHW program and the program outcomes.

Success Factors

  • Linking government strategy and field intervention
  • Joint reviews and endorsements
  • Regular recording mechanism and data reviews
  • Reminders on data importance and use
  • Improving understanding around adolescent and youth FP/RH needs at managerial and CHW levels
  • Linkages between CHWs and service providers to facilitate service delivery for adolescents and youth
  • Ongoing support and guidance

Program Outcomes

  • Standardization of tools and district team advocacy with provincial managers to scale up
  • Inclusion of PPFP messages in routine awareness session, PPFP indicators, and PPFP reporting on monthly basis
  • Sensitization of provincial and district officials on adolescents and youth, and follow-up on inclusion of adolescents and youth
  • Participation of CHWs in data review meetings at health facility level and joint planning

Community Ownership & Remuneration: Experience in Ethiopia

Watch now: 30:44

The next panelist, and a participant of the Anglophone Africa Learning Circles cohort, was Dr. Tadele Kebede, a Reproductive Health, Family Planning, Adolescent and Youth Health Expert at the Ministry of Health Ethiopia. During his presentation, he focused on Ethiopia’s Health Extension Program (HEP), launched in 2003 as a national community-based health care initiative to bring basic health services to rural communities, through health extension workers (HEWs). 

Dr. Kebede outlined the unique aspects and benefits of Ethiopia’s HEWs, which include:

  • They recruit women with a minimum of 10th-grade education
  • Work in pairs at the health post
  • Earn a salary
  • Have a clear career ladder
  • Part of the formal health system and recognized as health professionals

He also shared what makes the HEP successful in Ethiopia, including:

  • Government leadership and political commitment
  • Local community ownership of the program
  • Strong intersectoral collaboration
  • Multifaceted systematic approach
  • Infrastructure expansion
  • Development of mid-level health workers using supportive supervision and referral
  • Simplified, but standardized, health management information system (HMIS)
  • Adequate supplies and equipment 
  • Accountable supportive supervision
  • An innovative training strategy
  • Financial support from development partners
  • Adaptability

In his closing, Dr. Kebede spoke about how things are evolving, including Ethiopia’s work on a HEP Optimization Road Map, which outlines strategies through 2035, focusing on quality of services, financial sustainability, and community empowerment. He also shared a government initiative, the Willow Box, which was implemented and scaled up at the community and household level, as a means of following up with women, to address unmet need for FP in rural areas.

Training and Government Engagement: Experiences from Nine Countries

Watch now: 47:18

The final panelist, and a participant of the Francophone Africa Learning Circles cohort, was Dr. Yvette Ribaira, the MOMENTUM Integrated Health Resilience (IHR) Community Health Lead at JSI, based in Madagascar. Her presentation focused on how the project is working to strengthen community health systems and CHW resilience in fragile settings in Benin, Burkina Faso, Democratic Republic of the Congo, Mali, Niger, Sudan, South Sudan, Tanzania, and Yemen. She shared that in these settings, there is: high maternal and newborn mortality and morbidity, growing internal displacement and weak primary health care services, low access to essential lifesaving health services, conflicts, and climate change risks.

Dr. Ribaira outlined MOMENTUM IHR’s approaches related to CHWs, which occur at the operational and policy levels. They include:

Operational level approaches:

  • Support training, provision of equipment, supervision, and data reporting.
  • Strengthen resilience capacities of CHWs to continue service provision during shocks.
  • CHW program functionality assessment and improvement for service quality.

Policy level approaches:

  • Operationalizing MOH community health strategy.
  • Standardizing implementation guidelines and integrated curricula for CHWs.
  • Evidence-based development/revision of reference documents.
  • Task-shifting guidelines for lifesaving services.

She also shared the process MOMENTUM IHR undertook to expand the scope of work of CHWs to offer more services beyond their routine assignments – which included various types of training, adaptation of tools, and peer-to-peer learning and exchange across countries.

To close, Dr. Ribaira shared the factors that made MOMENTUM IHR’s CHW program successful. Those included:

  • Supportive policies for standardized integrated guidelines and training manuals that facilitate the quality and consistency of CHWs competencies.
  • Proximity of training with Health Worker providers as facilitators and supervisors for CHWs improving attendance, relationship and communication in between.
  • Balanced theoretical and practical pre-service training curriculum that enhanced CHWs skills to become polyvalent.
  • Integrated promotional, preventive and curative MNCH/FP/RH core and specific CHWs competencies are likely to increase FP services uptake even during shocks in fragile settings.
    • Availability and use of standardized training materials for CHWs service provision and data reporting to the health system. 
  • Partnership to complement integration for CHWs program effectiveness.

Q&A From the Webinar

Question: What role do health information systems and technology play in enhancing communication, data collection, and service delivery in CHW programs, and what are some examples of innovative technologies being used?

Aisha Fatima: Health information systems play an important role in better understanding services being provided, trends, concerns, and challenges a CHW may have. There is a dire need to equip this system with technology to streamline the process and minimize time invested in documentation and reporting. We didn’t use any technology in our program; however, the government is considering gradually equipping CHWs with digital support. Unfortunately, the project does not have funds to do so for CHWs, but we equipped 25 health facilities with technology to streamline documentation and reporting on the District Health Information System 2 (DHIS2).

Question: What mechanisms are in place to ensure the quality assurance and monitoring of CHW programs, and how do these systems inform program improvements and adaptations?

Yvette Ribaira: Ministry of Health (MOH) guidelines, aligned with global ones (World Health Organization (WHO) as appropriate), on measuring performance and quality of CHWs services such as supervision grid, observation checklist for dedicated supervisors, and also implementing a Quality Improvement (QI) team at the operational level and social accountability approaches such as Partnership Defined Quality (PDQ) and Community Score Card (CSC) to engage the community in supporting quality services at health facilities (HFs) and CHWs.

Question: Can you explain the concept of task shifting and task sharing in CHW programs, and how does it contribute to the efficient delivery of healthcare services?

Yvette Ribaira: A good definition can be found in this article. When the health system collapses and people cannot access the HF (most of the time in fragile settings due to insecurity), CHWs can continue to provide Maternal, Newborn, and Child Health (MNCH), Family Planning (FP), and Reproductive Health (RH) services. In Burkina Faso, the MOH developed a strategy and a training manual to train CHWs and Village Birth Attendants (VBAs) to provide vaccination to children under five years of age and facilitate hygienic delivery. In Burkina Faso and Mali, this has contributed to saving the lives of pregnant women able to deliver at home with trained VBAs and ensuring children receive their vaccination shots in the communities.

Question: Were these CHWs able to screen for Gender-Based Violence (GBV), especially domestic violence, and refer the survivors to available response services? Were CHWs oriented on the impacts of GBV upon women’s health?

Yvette Ribaira: In the MIHR (Maternal and Infant Health and Resilience) approach, we have the Young Child Advisory Teams (YCATs) and First-Time Parent (FTP) approaches where CHWs are trained, among other topics, on gender and Gender-Based Violence (GBV) to allow them to conduct awareness-raising sessions and referrals when doing home visits or conducting group discussions (e.g., in Niger).

Question: Pakistan being a somewhat patriarchal society, did you have issues with gender? Were there more males than female CHWs, and did that affect the counseling of the female adolescents, or did it make no difference? If there were concerns around that, how did you handle it?

Aisha Fatima: Yes, you are right. This is particularly true in the area we worked. There were gender-related issues regarding dependency on men in seeking FP/RH care and decision-making. As far as CHWs are concerned, we have two different departments in the health system. The Department of Health has all women CHWs, while the other department (Population Welfare Department) has both men and women. Thus, women are more numerous than men. Male CHWs can never be engaged in counseling; it has always been done by female CHWs. There were no issues, but even female CHWs discussing FP/RH with adolescents and youth is not easily acceptable. We had other interventions to engage youth in collaboration with the education department to sensitize the community on this age group’s needs.

Question: In your experience, do you think the CHW program in a rural setting is the same as in an urban setting? What are the specific parameters or components that need to be considered when implementing or scaling up CHW programs in an urban context?

Aisha Fatima: The CHW program is the same in both settings; however, the community in rural areas comparatively seeks more support from CHWs. Though our program was in typical rural areas, I can share key considerations for the urban community, such as equipping CHWs with adequate knowledge and skills, especially digital support, to align with the needs of the urban community and enhance their acceptance through service providers based at the health facility level. It is easier to get educated CHWs on board in urban areas, which also helps in urban settings. Hope this helps.

Question: How was the structure of supportive staff for CHWs? How many CHWs are supported by each supervisor? In total, how many CHWs and how many supervisors? What is your learning for sustainability after the project?

Generally, there is one Lady Health Supervisor for Lady Health Workers (n= 20-25) in the catchment area of a health facility. Likewise, the District Population Welfare Officer manages male CHWs (named Family Welfare Assistants, 25-30 in a district).

We observed that the use of monthly meetings at the health facility and/or district level (as planned by departments) to discuss issues and challenges as a group helps a lot. Because lack of operational support affects regular supervision at the community level.

We have equipped district managers, included postpartum family planning (PPFP) reporting mechanisms in their routine systems, and enabled the managers to provide feedback. There were also efforts to share learnings at the provincial level, like sensitization on adolescents’ and youths’ needs, so this revised tool can be scaled up and data can be tracked.

Question: How many man-hours are spent in the community by the Community Health Extension Worker (CHEW)? Any special packages or motivations?

Aisha Fatima: Usual work hours are 6-8 hours/day; however, as they are from the community, they are available to address concerns throughout the day. At times, a CHW may accompany women to a health facility in case of emergency need. Women also visit her house-based Health House to seek guidance and FP/RH services.

Question: What do we call CHWs? It will help us understand their contribution to the health system.

Yvette Ribaira: A CHW is a Community Health Worker, mainly aimed at enhancing health awareness. The scope of work may vary as per country policy. For example, a CHW provides FP counseling and contraceptive pills but may not be allowed to provide contraceptive injections. For additional information, please refer to the WHO guideline on health policy and system support to optimize CHWs program (2018), or the ResearchGate article on Task shifting in maternal and newborn health care: Key components from policy to implementation (2015).

Question: Are the CHWs paid, or are they volunteers, as both terms have been used in the presentations? If both exist, do you see differences in the quality of work?

Aisha Fatima: This varies from country to country. In Pakistan, we have paid CHWs who receive monthly stipends from the government departments. Regarding quality, there are still gaps as there are not enough CHWs per standard catchment population, like one CHW for 1000 people or 150-200 households. This definitely affects quality and limits their ability to reach the catchment population.

Question: What solutions can be found to improve reporting at the community level, despite the training efforts that have been made?

Yvette Ribaira: One promising approach is the use of digitized reporting tools such as mobile phones that can be used offline and linked to platforms like the District Health Information System 2 (DHIS2). In Burkina Faso, Niger, and South Sudan, this is under implementation, and with an enabling policy of digitization of MOH community health, the MOH is envisioning a progressive scale-up in co-creation partnership. In a stable situation, you can also have dedicated supervisors to ensure paper-based reporting from CHWs, but this is time-consuming and expensive. Periodic field Data Quality Assessment (DQA) at the CHW sites is also necessary.

Question: What is the supportive supervision structure, and what’s your sustainability plan? What challenges were experienced, and what mitigation measures did you take?

Tadele Kebede: Each health center (HC) is linked to five satellite health posts (HPs) to receive referrals, supply, conduct performance management, and provide support. The HPs (Health Extension Workers, HEWs). One of the roles of health centers is to conduct follow-up visits, mentorship, and supportive supervision to the HPs.

The community is highly demanding more additional services to come to their doorsteps with uncompromised quality because they know and compare services with nearby villages. Thus, we prepared a 15-year roadmap which tries to satisfy their demand phase by phase. It is done by shifting and sharing tasks from the HCs and helping the villages, households, and individuals to produce their own health. We believe if we address the existing high health illiteracy gap with the help of the HEWs and other community health volunteers, they can bring good health outcomes at the individual, household, and community levels.

A significant change in Ethiopia’s approach going forward will be to have a community-level structure share the responsibility for delivering the majority of basic services.

Question: Is 10th grade the highest level of basic education?

Tadele Kebede: 10th grade is the minimum level of basic education, recently because of the change in secondary level exams.

Question: What is the salary of HEWs? Are there any additional incentives? Any studies on Return on Investment (ROI) for financing HEWs?

Tadele Kebede: On average, 120 US dollars per month. They also live in a house constructed by the government, free of rent. Good performers will start their Bachelor of Science (BSc) degree earlier than their colleagues, receive certification, and will attend a national annual gala dinner program with our ministers (MOH).

Question: The package looks overwhelming. Are they supposed to deliver all the interventions in one sitting?

Tadele Kebede: There are three HP categories based on the community HCs accessibility and the level of interventions slightly differ from one to the other:

  1. Merged HEP Services: Defined Health Extension Program (HEP) essential packages that include health promotion, disease prevention, and basic curative services, provided in integration with HC’s routine health care services. In areas where HP is located within the compound of or too close to the HC or primary health (PH) center, services are delivered to the catchment population at the HC or PH and through household visits and outreach schedules. HC/PH’s health care professionals are mainly responsible for facility-based services, while HEWs handle health promotion activities at household and community levels and facilitate referrals to HC/PH.   
  2. Basic HEP Services: Packages of services consisting of promotive, preventive, and selected curative HEP services as outlined in the Essential Health Service Package (EHSP), 2019. These services are provided by two Level IV HEWs and a nurse or family health professional.
  3. Comprehensive HEP Services: A package of services comprising promotive, preventive, curative, and community-based rehabilitative HEP services. These encompass basic HEP service packages and additional services like provision of reversible long-acting family planning (RLAFP) methods, delivery services, Prevention of Mother-to-Child Transmission (PMTCT), HIV counseling and testing, screening for common Non-Communicable Diseases (NCDs), treatment of common adult illnesses, comprehensive maternal health care, and community-based rehabilitation services. These services are provided by a team of different professionals (Health Officer, Midwife, Nurse, and Level IV HEWs).

Question: What is the role of HEWs in NCDs?

Tadele Kebede: HEWs create awareness and screen for common NCDs. They promote protection from tobacco smoke, hazardous alcohol use awareness campaigns, increased physical activity, health warnings on alcohol products, community-wide mass sporting, education, and awareness campaigns for physical activity, screening, and management. This can be done at comprehensive health posts and sometimes basic ones, depending on their scope.

Question: Is there a reason why mostly females are considered for the HEP work?

Tadele Kebede: Women were primarily recruited as HEWs because most health intervention activities were related to women, mothers, and children. Most women are more comfortable discussing reproductive health (RH) openly with other women. In certain circumstances, like in pastoralist communities, males are also recruited. Two HEWs are assigned to one health post. HEWs provide key health services through fixed and outreach bases, spending half their working time on home visits and outreach activities and the remaining half at their health post providing basic curative, promotive, and preventive services.

Question: The approach seems to be a heavy investment given the HR-training, medical supplies, and the salaries. Is this solely funded by the government, or is it partly supported by development partners? Do you feel it’s sustainable?

Tadele Kebede: Their monthly salary is from the government, similar to the budget for other health professionals working for the government like me. Other clinical doctors and nurses share the same sources and are considered by parliaments as a must and priority budget allocated as a government salary. Now, partners support HEWs training, manuals, tools preparation, and performance evaluation plans. HPs construction materials are mostly from the government, but the community contributes in labor and sometimes financially, as they know it is their own HPs and are willing to support.

Question: What is the Health Development Army (HDA) platform?

Tadele Kebede: The HDA, or Women Development Army, promotes health among communities and works with HEWs. More than 990,000 HDA groups were organized by 2018/19.

Question: Can we say Ethiopian urban health extension professionals are CHWs? Because they are nurses (3 years at university/college) in the background and receive additional training. For me, as I read a bit, the definition of CHWs in Ethiopia and other countries is different. They are not entirely out of the community they serve. Can you please clarify a bit about the definition of CHWs?

Tadele Kebede: In rural settings at the health post (HP) level, HEWs (Level 3 or Level 4) are responsible, while in urban HEP, as you said, nurses are working. Level 4 HEWs are equivalent to nurses in rural settings and accredited at that level by our authorized body. What we learned from the 2003 rural program is that the urban setting needs a different approach. New versions of the HEP were adapted for pastoral and urban settings, and service packages were also expanded from purely promotive and preventive services to a more comprehensive package that now includes selected curative services. Thus, it is comprehensive within the context of urban health extension programs.

Question: Are the HEWs trained in conducting Rapid Diagnostic Tests (RDTs) for malaria? What is the referral system like for them in Ethiopia, and is it well adhered to? Are there cases of these HEWs stepping out of their work intervention areas to do much more than they were trained for?

Tadele Kebede: Yes, the Basic Health Posts (BHPs) managed by two Level 4 HEWs are responsible for diagnosis (RDT) and treatment of uncomplicated malaria cases and providing pre-referral treatment for severe and complicated malaria cases. The BHP provides both facility-based and community-based services and remains open 24 hours a day, seven days a week. Comprehensive health posts have a wider scope of practice, and Level 4 HEWs are part of it. Each has a defined scope of work and standards.

Question: What do you mean by political commitment? Do you think political commitment alone brings change?

Tadele Kebede: Government leadership ensures high-level political support, enabling coalition-building within the Ministry of Health and across other ministries at federal, regional, and district levels of government. It ensures the required financing from the nation’s budget, encourages pooled and earmarked funding from donors, facilitates the rapid scale-up of initiatives, and places the Health Extension Program (HEP) at the center of key health sector reform policies. Recruiting health workers, expanding infrastructure, and supply were key. The HEP was consistently a top priority and key focus of stakeholder discussions (e.g., Joint Consultative Forum). However, partners’ support and integration of work, including community ownership, were crucial for the program’s success. I recommend this publication for more information.

Question: Which cadres provide method insertion/removal at the health post? Any supporting policy, laws, and Standard Operating Procedures (SOPs)? Kindly share your experiences on this, especially failures.

Tadele Kebede: Level 4 HEWs can provide both insertion and removal of Intrauterine Contraceptive Devices (IUCDs) at the HP setting. The national family planning guideline supports them, and studies regarding their success in this area are available. Most of our population lives in rural settings and demands various services at HPs (from HC and PH). We address this through task sharing/shifting of some services. Continuous mentorship from nearby or catchment health centers and, in some cases, primary hospitals to HP/HEWs is necessary. This activity demands investment in refurnishing facilities and meticulously following up on infection prevention and overall clinical quality assurance. It is part of our flagship activity and supported end to end. Data from HPs on IUCD utilization is increasing, and demand creation, along with quality counseling for all method mix, is part of the strategy for the program.

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Elizabeth Tully

Senior Program Officer, Knowledge SUCCESS / Johns Hopkins Center for Communication Programs

Elizabeth (Liz) Tully is a Senior Program Officer at the Johns Hopkins Center for Communication Programs. She supports knowledge and program management efforts and partnership collaborations, in addition to developing print and digital content, including interactive experiences and animated videos. Her interests include family planning/reproductive health, the integration of population, health, and the environment, and distilling and communicating information in new and exciting formats. Liz holds a B.S. in Family and Consumer Sciences from West Virginia University and has been working in knowledge management for family planning since 2009.

Sophie Weiner

Program Officer II, Johns Hopkins Center for Communication Programs

Sophie Weiner is a Knowledge Management and Communications Program Officer II at the Johns Hopkins Center for Communication Programs where she is dedicated to developing print and digital content, coordinating project events, and strengthening capacity for storytelling in Francophone Africa. Her interests include family planning/reproductive health, social and behavior change, and the intersection between population, health, and the environment. Sophie holds a B.A. in French/International Relations from Bucknell University, an M.A. in French from New York University, and a master’s degree in Literary Translation from the Sorbonne Nouvelle.

Aisha Fatima

Aisha Fatima Senior Program Manager, Jhpiego Pakistan Aisha is leading Reproductive Maternal, Newborn and Child Health and Nutrition portfolio in Pakistan as a Senior Program Manager. At Jhpiego, she provides strategic and technical leadership to programs in the RMNCH. Aisha brings over 10 years’ experience in RMNCH&N strategy formulation, program designing, implementation and policy advocacy in both development and humanitarian settings. She has been leading maternal, new born, child health and adolescent/sexual and reproductive health, family planning and nutrition programs. She is an active advocate for RH/FP issues through her association with civil societies for more than 15 years. She is internationally trained in Minimum Initial Service Package, Clinical Management of Rape and family planning and post abortion care and have contributed in development of national and sub-national health and nutrition strategies and guidelines. She is basically a medical doctor with post-graduation in public health.

Dr. Tadele Kebede

Reproductive Health, Family Planning, Adolescent and Youth Health Service Expert, Ministry of Health, Ethiopia

Dr. Tadele Kebede is a Reproductive Health, Family Planning, Adolescent and Youth Health Expert at the Ministry of Health Ethiopia and he participated in the Anglophone Africa cohort. He has dedicated over a decade to serving the Ministry of Health, focusing on reproductive health, family planning, and adolescent and youth health to drive positive change in the healthcare sector in Ethiopia.

Yvette Ribaira

MOMENTUM Integrated Health Resilience Community Health Lead, JSI, Madagascar

Dr. Yvette Ribaira is the Momentum Integrated Health Resilience Community Health Lead at JSI based in Madagascar and she participated in the Francophone Africa cohort. In her role, she represents and coordinates community health system interventions in 7 partner countries in Burkina Faso, Democratic Republic of Congo, Mali, Niger, South Sudan, Sudan, and Tanzania.