7a OPTIMIZING STAFFING MODELS AND TEAM STRUCTURE… FOR QUALITY CARE AMIDST INFRASTRUCTURE AND RESOURCE CONSTRAINTS THE CHALLENGE In low- and middle-income countries, policymakers have long struggled to extend quality frontline care to remote, rural communities. Confronting poor infrastructure, health worker shortages, and limited fiscal space, many countries have used expanded community-based health worker cadres to improve “last mile” access to essential services. Yet to date, many such initiatives have been hampered by poor service quality, insufficient support, and lack of wider integration—ultimately yielding disappointing results. To harness the potential of frontline health staff in these settings, innovative staffing models are needed to integrate community health workers (CHWs) and mid-level cadres within effective frontline health teams. FRONTLINE HEALTH SYSTEMS DO NOT EFFECTIVELY SERVE RURAL HOUSEHOLDS. The global shortage of health workers disproportionately affects low-income countries— particularly people living in rural and remote areas.i About half of the world’s population lives in rural settings, but they are served by just 33% of the nursing workforce and less than 25% of physicians.ii Longer distances to health facilities and poor transportation further limit timely access to quality health care for rural residents. Rural communities face persistently worse health outcomes than their urban counterparts, even within the same country. For example, across low- and middle-income countries, the maternal mortality rate in rural areas is often at least twice the rate in urban areas.iii Task Shifting Models for Frontline Staffing Have Yielded Disappointing Results To deal with health worker shortages, many countries have adopted task-shifting models using CHWs and mid-level health workers on the frontline. Through task- shifting, workers with lower levels of training are upskilled to deliver tasks in which they were previously not competent, thereby allowing more efficient use of human resources.iv Yet despite initial enthusiasm for these strategies in the period following Japan Trust Fund for OCTOBER 2018 Scaling Up Nutrition IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE the 1978 Alma-Ata Declaration on Primary Health Care and promising small-scale Concerns regarding studies, many efforts to scale-up CHW programs have progressed slowlyv or fallen low quality of care short in achieving predicted health gains.vi Reviews of these initiatives have consistently highlighted low quality of care,vii insufficient supervision and training,viii by CHWs at rural weak referral pathways,ix and poor integration into the wider health system as health posts have factors that limit their effectiveness at scale.x For example, a 2008 review of the also been linked to Health Extension Program in Ethiopia identified weak referral linkages between poor use of services, village-based health posts and district-level health centers, limited by transport and with some patients communication barriers, as one of several obstacles to the program’s success. xi Similarly, India’s Accredited Social Health Activist (ASHA) program suffered from and families insufficient training and lack of clear supervision structures for the ASHAs. xii Concerns bypassing health regarding low quality of care by CHWs at rural health posts have also been linked to posts for larger poor use of services, with some patients and families bypassing health posts for health centers. larger health centers.xiii Better Frontline Staffing Models Are Needed to Serve Resource- Constrained Areas Under the right circumstances, CHWs can provide basic services on the frontline and serve as bridges between the community and the health system. But to effectively serve rural communities, they must be integrated into comprehensive frontline staffing models that recognize limits of what they can do, provide adequate supervision, and integrate their work into a wider primary health care team. THE PATH FORWARD: BUILDING EFFECTIVE CARE TEAMS AT THE FRONTLINE Community-Based Primary Health Teams Community based Community based primary health care teams—i.e., multidisciplinary teams of primary care primary health care providers working within the community—are increasingly recognized as a particularly teams—i.e., promising model for addressing the challenges of frontline health care delivery in low- multidisciplinary resource settings. Unlike standalone CHW programs, community-based primary health teams teams of primary can offer a comprehensive and integrated approach to frontline health services, helping strengthen referral pathways and better support supervision and quality assurance of care providers community-based services. While evidence supporting team-based delivery models is far working within the more developed in high-income countries,xiv several promising (though continuing to improve community—are and not yet fully evaluated) models have been implemented within resource-constrained increasingly settings, including Ethiopia and Ghana, and more recently in Zambia and South Africa.xv For recognized as a example, South Africa’s “ward-based outreach teams” (WBOT) consist of a nurse team particularly manager and 5–6 CHWs, all linked to a fixed primary health center; the team members carry out health promotion activities, active case finding, and doorstep care in communities.xvi promising model for Preliminary reviews have shown significant increases in measles immunization coverage and addressing the reductions in severe diarrhea cases in regions served by the teams, although formal challenges of evaluations are still needed.xvii frontline health care Evaluations of team-based care models have consistently identified several key components delivery in low- for success: community engagement, proactive outreach strategies, and geographic resource settings. OCTOBER 2018 2 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE empanelment (assigning primary care teams to patients in a defined catchment area).xviii The cost-effectiveness of these models has not yet been rigorously evaluated in low-income settings; in theory, however, integrated care may offer long-run efficiency advantages given rising burdens of noncommunicable and chronic disease.xix Optimizing Task Shifting: Safe and Effective Scopes of Practice Evidence shows that Optimal team-based care models require clearly define roles for each team member that also CHWs and mid-level reflect what is appropriate for team member’s level of training. Evidence shows that CHWs and mid-level cadres can effectively deliver a range of health promotion and basic curative cadres can interventions; these include managing common childhood illnesses;xx promoting antenatal effectively deliver a care and breastfeeding;xxi and supporting prevention and treatment of tuberculosis,xxii range of health malaria, and HIV.xxiii Studies from high-income settings also suggest potential for CHWs to promotion and basic support prevention and control of chronic disease including hypertension, diabetes, and curative mental illness.xxiv Less clear is the ability of CHWs to manage more complex diseases or interventions; these conduct skilled deliveries; their ability to safely perform these functions is likely to depend on include managing CHW training and experience, which varies across settings.xxv For example, in Ghana, upskilled professional community nurses with midwifery skills support skilled deliveries at rural health common childhood posts (though maternal outcomes are yet to be fully evaluated);xxvi elsewhere, some CHWs illnesses; promoting receive just weeks of training, implying clear lack of competence to assume such complex antenatal care and tasks.xxvii Within these models, CHWs should not be seen as a “stop-gap” substitute for nurse- breastfeeding; and or physician-led care, but instead embraced for their unique value linking communities to supporting health services and also facilitating proactive health promotion and disease prevention within prevention and local communities. treatment of No CHW Is an Island: Linking Community-Based Workers to Their tuberculosis, Facility-Based Peers malaria, and HIV. To effectively operate as part of a larger care team, community-based cadres need clear and consistent structures and processes that create ties to their facility-based peers. Supervision of CHWs (Topic 9) is consistently identified as a key enabling factor to optimize CHW performance on the frontlinexxviii by increasing staff motivation,xxix supporting training,xxx strengthening linkages with the health system,xxxi and offering greater legitimacy to their work.xxxii Likewise, task-shifting to low and mid-level cadres must be supported by clear referral pathways and the necessary communication and transport services to enable timely escalation of care (see Brief 10a).xxxiii Team-based primary care models may offer key advantages by clarifying and reinforcing escalation pathways. In Ethiopia, for example, larger health centers at the district (woreda) level serve as referral centers for up to 5 CHW-staffed community-level health posts xxxiv OCTOBER 2018 3 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE SPOTLIGHT Ethiopia’s Health Extension Program ► Since 2004, Ethiopia’s Health Extension Program (HEP) has trained nearly 40,000 Health Extension Workers (HEWs)—a new cadre in Ethiopia’s health workforce.xxxv HEWs are female community-health workers who deliver a package of 16 interventions across hygiene and sanitation, health education, maternal and child health care, and prevention and treatment for HIV, malaria, and tuberculosis.xxxvi Two HEWs work at each village-level (kebele) health post and live in the community, providing services to an assigned group of around 5,000 individuals.xxxvii HEWs are supported by a nurse or health officer from a district-level (woreda) health center, who makes supervisory visits to the health posts and handles referrals when additional care is needed.xxxviii Together, the five health posts and the associated woreda health center comprise a primary health care unit, which reports to a primary hospital.xxxix Ethiopia’s health outcomes have improved substantially since HEP was introduced, with statistics also suggesting increased uptake of antenatal care (from 28% in 2005 to 58% in 2014) and expanded primary health care coverage (from 75% in 2005 up to 90% in 2010).xl To date, however, no rigorous study has evaluated the HEP staffing model, in part due to the challenge of disentangling effects from concurrent interventions. A 2016 cluster randomized controlled trial evaluated the impact of HEWs in delivering integrated community case management of childhood illness. The study did not find a significant difference in child mortality rates in areas with the intervention compared to those without, potentially due to low use of HEWs by families.xli However, a study by Karim et al. (2013) showed that more intense HEP implementation was associated with greater uptake of antenatal and post-natal care.xlii Descriptive data from the Ethiopian Demographic and Health Survey suggest that HEP users are more likely to be rural, poor or from less educated backgrounds.xliii Ongoing challenges involve optimizing training and supervision for HEWs, with some HEWs feeling under-qualified to deliver the assigned care package.xliv Research on cost-effectiveness is limited, in part due to the difficulty of measuring program effect. However, a 2015 study estimated that HEP cost $1,000 per life year gained, suggesting marginal cost-effectiveness in the Ethiopian context.xlv Ghana’s Community Health Nurses ► Launched in 2000, Ghana’s Community Health Planning and Strategy (CHPS) recruited and retrained community health nurses, who then deployed to rural communities as community health officers (CHOs).xlvi CHOs were equipped with motorbikes and provided proactive, home-based health education, child immunizations, family planning, maternal care (including skilled deliveries), and basic curative care across a 3,000-person catchment area. The CHPS emphasized OCTOBER 2018 4 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE community mobilization and the commitment of traditional leaders to the program, including recruiting community volunteers to support the work of the CHOs.xlvii Despite promising results from the predecessor Navrongo Experiment, the CHPS initiative was slow to scale up in Ghana.xlviii Challenges included inadequate CHO training on skilled delivery and emergency care,xlix weak leadership at the regional and district levels,l bottlenecks in the referral process and escalation of care, administrative inefficiencies,li and lack of community engagement.lii In 2016, Ghana launched the successor CHPS+ program with a number of organizational and implementation reforms.liii The CHPS+ intervention package includes improved leadership and governance, emergency referral systems for pregnant women and children, and expanded training for CHOs in life-saving interventions such as neonatal resuscitation.liv Beginning in 2010, these interventions had been piloted in four of Ghana’s poorest and most remote districts through the Ghana Essential Health Interventions Program (GEHIP); the four districts achieved CHPS-implemented universal health coverage after just 5 years of GEHIP, compared to 50% in control areas. Care Teams of Last Resort: The Role of Mobile Health Units ► Mobile health units (MHUs) consist of a specially-equipped clinic vehicle, a driver, and one or more health care providers, who visit rural and remote communities to provide services.lv The World Health Organization and the International Committee of the Red Cross have identified MHUs as an important strategy for delivering frontline health care services in crisis settings, where such services are otherwise inaccessible.lvi They have been deployed in a number of fragile and conflict settings, including Iraq and Ukraine.lvii Some countries have also used MHUs to expand routine health care delivery.lviii In India, for example, 1,300 MHUs were in use by end-2014 as part of the National Rural Health Mission, with the goal of extending primary health care to remote and underserved communities.lix Despite their growing usage, evidence on the effectiveness and cost-efficiency of MHUs remains limited. Findings from small-scale studies suggest that MHUs may improve access to health services, though the impact on health outcomes and cost- effectiveness in LMIC remains inconclusive.lx Further, even if their stand-alone services prove effective, their core feature (mobility) precludes continuity of care and service integration.lxi MHUs may therefore be useful as a last-resort or to complement to mainstream services; however, they are generally inappropriate as substitutes for routine primary health care delivery. ENDNOTES i World Health Organization, “Framing the Health Workforce Agenda for the Sustainable Development Goals: Biennium Report 2016-2017 WHO Health Workforce” (Geneva: World Health Organization, 2017), http://www.who.int/hrh/BienniumReportRevised2017.pdf; World Health Organization, ed., Working Together for Health, The World Health Report 2006 (Geneva: World Health Organization, 2006); Xenia Scheil-Adlung, “Global Evidence on Inequities in Rural Health Protection: New Data on Rural Deficits in Health Coverage for 174 Countries,” ESS OCTOBER 2018 5 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE Document (International Labour Organization, 2015), https://reliefweb.int/sites/reliefweb.int/files/resources/RessourcePDF.pdf. ii World Health Organization, World Health Report 2006: Working Together for Health, The World Health Report 2006 (Geneva: World Health Organization, 2006). iii Scheil-Adlung, “Global Evidence on Inequities in Rural Health Protection: New Data on Rural Deficits in Health Coverage for 174 Countries.” iv World Health Organization, WHO Recommendations: Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions through Task Shifting. (Geneva: World Health Organization, 2012), http://www.ncbi.nlm.nih.gov/books/NBK148518/. v John Koku Awoonor-Williams, James F. Phillips, and Ayaga A. Bawah, “Catalyzing the Scale-up of Community-Based Primary Healthcare in a Rural Impoverished Region of Northern Ghana,” The International Journal of Health Planning and Management 31, no. 4 (October 2016): e273–89, https://doi.org/10.1002/hpm.2304; John Koku Awoonor- Williams et al., “Lessons Learned from Scaling up a Community-Based Health Program in the Upper East Region of Northern Ghana,” Global Health: Science and Practice 1, no. 1 (March 1, 2013): 117–33, https://doi.org/10.9745/GHSP-D-12-00012. vi Taddese Alemu Zerfu et al., “Reaching the Unreached through Trained and Skilled Birth Attendants in Ethiopia: A Cluster Randomized Controlled Trial Study Protocol,” BMC Health Services Research 17, no. 1 (January 26, 2017): 85, https://doi.org/10.1186/s12913-017-2041-6; Madeleine Ballard and Paul Montgomery, “Systematic Review of Interventions for Improving the Performance of Community Health Workers in Low-Income and Middle-Income Countries,” BMJ Open 7, no. 10 (October 25, 2017): e014216, https://doi.org/10.1136/bmjopen-2016-014216; Agbessi Amouzou et al., “Independent Evaluation of the Integrated Community Case Management of Childhood Illness Strategy in Malawi Using a National Evaluation Platform Design,” American Journal of Tropical Medicine and Hygiene 94, no. 3 (March 1, 2016): 574–83, https://doi.org/10.4269/ajtmh.15-0584. vii P. 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Perry, Rose Zulliger, and Michael M. Rogers, “Community Health Workers in Low-, Middle-, and High-Income Countries: An Overview of Their History, Recent Evolution, and Current Effectiveness,” Annual Review of Public Health 35 (2014): 399– 421, https://doi.org/10.1146/annurev-publhealth-032013-182354; Sarah Wood Pallas et al., “Community Health Workers in Low- and Middle-Income Countries: What Do We Know about Scaling up and Sustainability?,” American Journal of Public Health 103, no. 7 (July 2013): e74-82, https://doi.org/10.2105/AJPH.2012.301102. ix Gopinathan, Lewin, and Glenton, “Implementing Large-Scale Programmes to Optimise the Health Workforce in Low- and Middle-Income Settings.” x Perry, Zulliger, and Rogers, “Community Health Workers in Low-, Middle-, and High- Income Countries.” xi JSI, “The Last Ten Kilometers Project (L10K): Rapid Appraisal of Health Extension Program: Ethiopia Country Report” (John Snow International, September 10, 2008). OCTOBER 2018 6 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE xii Nirupam Bajpai and Ravindra H Dholakia, “Improving the Performance of Accredited Social Health Activists in India,” Working Paper (Mumbai: Columbia Global Centers, May 2011), https://www.researchgate.net/publication/265121185_Improving_the_performance_o f_Accredited_Social_Health_Activists_in_India_Working_Paper_No_1. xiii Amouzou et al., “Effects of the Integrated Community Case Management of Childhood Illness Strategy on Child Mortality in Ethiopia”; Catherine Kahabuka et al., “Why Caretakers Bypass Primary Health Care Facilities for Child Care - A Case from Rural Tanzania,” BMC Health Services Research 11, no. 1 (November 17, 2011): 315, https://doi.org/10.1186/1472-6963-11-315. xiv Gillian Lê et al., “Can Service Integration Work for Universal Health Coverage? 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Schneider, “Evaluating the Effect of Ward-Based Outreach Teams on Primary Healthcare Performance in North West Province, South Africa: A Plausibility Design Using Routine Data,” South African Medical Journal = Suid-Afrikaanse Tydskrif Vir Geneeskunde 108, no. 4 (March 28, 2018): 329–35. xvii Assegaai, Reagon, and Schneider, “Evaluating the Effect of Ward-Based Outreach Teams on Primary Healthcare Performance in North West Province, South Africa.” xviii McKenzie et al., “Primary Health Care Systems (PRIMASYS): Case Study from South Africa.” xix Lê et al., “Can Service Integration Work for Universal Health Coverage?” xx World Health Organization and Global Health Workforce Alliance, “Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems” (Global Health Workforce Alliance, 2010), http://www.who.int/workforcealliance/knowledge/publications/CHW_FullReport_2010 .pdf; Paul A. Freeman et al., “Comprehensive Review of the Evidence Regarding the Effectiveness of Community-Based Primary Health Care in Improving Maternal, Neonatal and Child Health: 4. Child Health Findings,” Journal of Global Health 7, no. 1 (2017): 010904, https://doi.org/10.7189/jogh.07.010904; Tarun Gera et al., “Integrated Management of Childhood Illness (IMCI) Strategy for Children under Five,” Cochrane Database of Systematic Reviews, no. 6 (2016), https://doi.org/10.1002/14651858.CD010123.pub2. OCTOBER 2018 7 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE xxi Mary Carol Jennings et al., “Comprehensive Review of the Evidence Regarding the Effectiveness of Community-Based Primary Health Care in Improving Maternal, Neonatal and Child Health: 2. Maternal Health Findings,” Journal of Global Health 7, no. 1 (June 2017): 010902, https://doi.org/10.7189/jogh.07.010902; Zohra S. Lassi, Batool A. Haider, and Zulfiqar A. Bhutta, “Community-Based Intervention Packages for Reducing Maternal and Neonatal Morbidity and Mortality and Improving Neonatal Outcomes,” The Cochrane Database of Systematic Reviews, no. 11 (November 10, 2010): CD007754, https://doi.org/10.1002/14651858.CD007754.pub2. xxii Simon Lewin et al., “Lay Health Workers in Primary and Community Health Care for Maternal and Child Health and the Management of Infectious Diseases,” The Cochrane Database of Systematic Reviews, no. 3 (March 17, 2010): CD004015, https://doi.org/10.1002/14651858.CD004015.pub3. xxiii World Health Organization and Global Health Workforce Alliance, “Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems.” xxiv Perry, Zulliger, and Rogers, “Community Health Workers in Low-, Middle-, and High- Income Countries.” xxv Dahn et al., “Strengthening Primary Health Care through Community Health Workers: Investment Case and FInancing Recommendations.” xxvi Frank K. Nyonator et al., “The Ghana Community-Based Health Planning and Services Initiative for Scaling up Service Delivery Innovation,” Health Policy and Planning 20, no. 1 (January 2005): 25–34, https://doi.org/10.1093/heapol/czi003; Evelyn Sakeah et al., “Can Community Health Officer-Midwives Effectively Integrate Skilled Birth Attendance in the Community-Based Health Planning and Services Program in Rural Ghana?,” Reproductive Health 11 (December 17, 2014), https://doi.org/10.1186/1742-4755-11- 90. xxvii Dahn et al., “Strengthening Primary Health Care through Community Health Workers: Investment Case and FInancing Recommendations.” xxviii Pallas et al., “Community Health Workers in Low- and Middle-Income Countries”; Dahn et al., “Strengthening Primary Health Care through Community Health Workers: Investment Case and FInancing Recommendations”; World Health Organization and Global Health Workforce Alliance, “Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems”; Zelee Hill et al., “Supervising Community Health Workers in Low-Income Countries--a Review of Impact and Implementation Issues,” Global Health Action 7 (2014): 24085; C. Bailey et al., “A Systematic Review of Supportive Supervision as a Strategy to Improve Primary Healthcare Services in Sub-Saharan Africa.,” International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics 132, no. 1 (January 2016): 117–25, https://doi.org/10.1016/j.ijgo.2015.10.004; Madeline Ballard et al., “Practitioner Expertise to Optimize Community Health Systems: Harnessing Operational Insight” (CHWCentral, n.d.), https://www.chwcentral.org/sites/default/files/Practitioner%20Expertise%20to%20Opt imise%20Community%20Health%20Systems%20-%20Harnessing%20Operational%20In sight.pdf. xxix Pallas et al., “Community Health Workers in Low- and Middle-Income Countries.” xxx World Health Organization and Global Health Workforce Alliance, “Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems.” xxxi Hill et al., “Supervising Community Health Workers in Low-Income Countries--a Review of Impact and Implementation Issues.” OCTOBER 2018 8 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE xxxii Hill et al. xxxiii Gopinathan, Lewin, and Glenton, “Implementing Large-Scale Programmes to Optimise the Health Workforce in Low- and Middle-Income Settings.” xxxiv Mary Jo Trepka et al., “Late HIV Diagnosis: Differences by Rural/Urban Residence, Florida, 2007– 2011,” AIDS Patient Care and STDs 28, no. 4 (April 1, 2014): 188–97, https://doi.org/10.1089/apc.2013.0362. xxxv Morankar Sudhakar et al., “Primary Health Care Systems (PRIMASYS): Case Study from Ethiopia” (World Health Organization, 2017), http://www.who.int/alliance- hpsr/projects/alliancehpsr_ethiopiaprimasys.pdf. xxxvi World Health Organization and Global Health Workforce Alliance, “Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems”; Huihui Wang et al., “Ethiopia Health Extension Program: An Institutionalized Community Approach for Universal Health Coverage” (Washington, DC: International Bank for Reconstruction and Development/The World Bank, 2016), https://openknowledge.worldbank.org/bitstream/handle/10986/24119/978146480815 9.pdf?sequence=2&isAllowed=y. xxxvii Wang et al., “Ethiopia Health Extension Program: An Institutionalized Community Approach for Universal Health Coverage.” xxxviii Wang et al. xxxix Elizabeth Anis and Hannah Ratcliffe, “Strengthening Primary Health Care Systems to Increase Effective Coverage and Improve Health Outcomes in Ethiopia,” accessed October 11, 2018, https://phcperformanceinitiative.org/strengthening-primary-health- care-systems-increase-effective-coverage-and-improve-health-outcomes-ethiopia. xl Wang et al., “Ethiopia Health Extension Program: An Institutionalized Community Approach for Universal Health Coverage.” xli Amouzou et al., “Effects of the Integrated Community Case Management of Childhood Illness Strategy on Child Mortality in Ethiopia.” xlii Ali Mehryar Karim et al., “Effect of Ethiopia’s Health Extension Program on Maternal and Newborn Health Care Practices in 101 Rural Districts: A Dose-Response Study,” PloS One 8, no. 6 (2013): e65160, https://doi.org/10.1371/journal.pone.0065160. xliii Wang et al., “Ethiopia Health Extension Program: An Institutionalized Community Approach for Universal Health Coverage.” xliv Gopinathan, Lewin, and Glenton, “Implementing Large-Scale Programmes to Optimise the Health Workforce in Low- and Middle-Income Settings.” xlv Barbara McPake et al., “Cost–Effectiveness of Community-Based Practitioner Programmes in Ethiopia, Indonesia and Kenya,” Bulletin of the World Health Organization 93, no. 9 (September 1, 2015): 631-639A, https://doi.org/10.2471/BLT.14.144899. xlvi Awoonor-Williams, Phillips, and Bawah, “Catalyzing the Scale-up of Community-Based Primary Healthcare in a Rural Impoverished Region of Northern Ghana.” xlvii Nyonator et al., “The Ghana Community-Based Health Planning and Services Initiative for Scaling up Service Delivery Innovation.” xlviii Awoonor-Williams, Phillips, and Bawah, “Catalyzing the Scale-up of Community-Based Primary Healthcare in a Rural Impoverished Region of Northern Ghana”; Awoonor- Williams et al., “Lessons Learned from Scaling up a Community-Based Health Program in the Upper East Region of Northern Ghana”; James F. 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