6a IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR QUALITY CARE AMIDST INFRASTRUCTURE AND RESOURCE CONSTRAINTS THE CHALLENGE In low- and middle-income countries, distance and cost can keep people in rural communities from seeking and receiving care—even from the frontline health system. Even where public health facilities exist, these barriers—paired with (often justified) perceptions that the care available is low quality—can lead to extremely low use of available services, despite high need. Together, these forces create systemic gaps in essential health service coverage. To effectively engage rural communities in essential primary care, frontline health systems must develop innovative, locally-appropriate, and cost- effective approaches to staffing, logistics, and financing that overcome entrenched barriers to care. PUBLIC HEALTH FACILITIES ARE FEW AND FAR BETWEEN By their very nature, rural areas are sparsely populated; families may need to travel long distances to reach the nearest government services, including public health facilities. In rural Ghana, for example, the trip to the nearest health facility often more than 20 kilometers across poor terrain; as a result, families only use health centers in dire emergencies, foregoing preventative services and potentially delaying treatment for acute episodes.i In Niger, where most transportation takes place on foot, less than a quarter of the population lives within a one-hour walk of the nearest health facility during the rainy season—and children who live outside the one-hour radius are roughly half as likely to be fully vaccinated as children who live within in it.ii The journey to a distant health facility can be costly for individuals who may need to pay for transport and take time away from work and household duties. And even where facilities exist, they may not be consistently staffed with qualified health personnel given absenteeism and persistent health workforce shortages in low-income, rural areas (see Brief 15a). Japan Trust Fund for OCTOBER 2018 Scaling Up Nutrition IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR QUALITY CARE AMIDST INFRASTRUCTURE AND RESOURCE CONSTRAINTS Frontline Facilities Are Underutilized and Unproductive In the popular imagination, rural health posts are crowded and chaotic, with just a few staff Rural health care members serving huge numbers of needy patients who have come for care. In reality, patient often does not caseloads in primary care facilities are often extremely low: 5.2 outpatient visits per day per reach many of the provider in Togo, 6 in Uganda, and 7.3 in Tanzania, for example.iii In Nigeria, the average people who need it. health worker sees just 2.8 patients per day, spends 11 minutes with each patient during his or her visit, and is unable to correctly diagnose a common condition (pneumonia) or manage In reality, patient maternal and neonatal complications.iv caseloads in primary care facilities are Financial Barriers Deter the Poor and Marginalized from Seeking often extremely Entering Care low: 5.2 outpatient While rates of extreme poverty have dropped dramatically since 1990,v hundreds of millions visits per day per of people still live on less than $1.90 a day.vi The specter of financial ruin can keep families provider in Togo, 6 and individuals away from needed care. Every year, out-of-pocket expenditures on health care push about 100 million people into extreme poverty.vii Even during an emergency, in Uganda, and 7.3 financial considerations can prevent pregnant woman from seeking facility-based delivery in Tanzania, for services.viii example. THE PATH FORWARD: TOWARD ACCESSIBLE CARE FOR ALL Extending Care Beyond Static Facilities Creative staffing models can help extend care into remote rural communities and proactively Health care costs engage families in health-improving behavior—but efforts to date have yielded mixed results push about 100 at best (see Brief 7a). Many countries have deployed lay community health workers (CHWs) million people into rural communities. Common CHW engagement strategies have included home visits, patient tracing, individual needs assessment for special populations, role modelling, and into extreme accompanying patients to health care appointments.ix poverty every year and Top Interventions financial Intervention Evidence Strength Research Findings concerns can Community health workers Moderate Mixed keep families Self-testing for HIV High Positive away from Self-testing for HPV Moderate Positive needed care. Drone deliveries Low Mixed Conditional cash transfers High Positive Vouchers High Positive Small-scale studies have offered cause for optimism, but evaluations of large-scale CHW programs reveal uneven effectiveness and many implementation problems.x Evidence concerning the more successful programs suggests potential positive effects on use of family planning services, access to maternal health interventions, and the deployment of child survival strategies, among others.xi Historically, CHW programs have been largely ad hoc; the focus on volunteerism, particularly among poor rural women, has likewise led some to IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR QUALITY CARE AMIDST INFRASTRUCTURE AND RESOURCE CONSTRAINTS characterize the initiatives as exploitative and reinforcing local gender norms.xii Formalizing HIV self-testing is and professionalizing the work of CHWs (as in Ethiopia and Iran), paired with integrating now well- CHWs into a broader care team (as in Brazil and Costa Rica; see Brief 7a), can help increase established, and the legitimacy and effectiveness of CHWs and address common criticisms. Examples of other programs designed to bridge the geographic distance to care include the home-based self-testing for midwifery program in Indonesia and Ghana’s nurse-led Community-based Health Planning cervical cancer and Services (CHPS), both which have been associated with some improvements in access to screening has maternal and child care services.xiii Given mixed historical results, the potentially high cost of been piloted in training and maintaining a large and novel salaried cohort, and pervasive challenges in several African maintaining effectiveness at scale, all such programs should be rigorously evaluated if countries; a introduced. systematic review Technological Innovation for “Off the Grid” Care finds that self- Beyond novel staffing strategies, technological innovation can also facilitate community or testing for HPV patient-led entry into care—sometimes without direct involvement from health workers. Self- (human testing, for example, offers promise in settings with few qualified health personnel, since it papillomavirus) is transfers a layer of work from the health care provider to the patient and can help surmount cost-effective socio-cultural barriers to the uptake of certain sensitive procedures. HIV self-testing when it expands (discussed further in Brief 6b) is now well-established, and self-testing for cervical cancer screening has been piloted in several African countries; a systematic review finds that self- coverage to testing for HPV (human papillomavirus) is a cost-effective when it expands coverage to otherwise otherwise unserved populations.xiv Drone deliveries for certain medical products are likewise unserved much-hyped and are increasingly used in health systems logistics systems, particularly in East populations. Africa; while modelling suggests potential benefits and cost-effectiveness under some conditions, there is still limited empirical evidence to support drone-based delivery models (see Spotlight). Toward Affordability at the Frontline Financial barriers often deter people from seeking care. In the long-run, affordable front-line Technological services are best delivered through a comprehensive health financing strategy that mobilzes innovations can help resources and pools them mobilization; creates a locally-appropriate and affordable patients access care, prioritized package of health care services; and uses sustainable models to pay providers that sometimes even improve incentives while also lowering or eliminating out-of-pocket expenditure all these without a health measures should be considered in far greater depth as core elements of health system reform (see Topics 9, 12, and 13). worker. Self-testing (already common Where national-scale universal health coverage or national health insurance is for HIV) can be cost- underdeveloped—or where transport and opportunity costs prevent families from accessing effective. Drone even services offered with zero direct user fees—conditional cash transfers and vouchers can help improve uptake of specific health services within targeted populations. Conditional cash- deliveries of medical transfer programs, which offer payments to eligible beneficiaries when they meet pre- products may also specified conditions, are among the best evaluated health-enhancing programs within lower- be useful in some and middle-income countries (LMICs). Systematic reviews show an enormous range of health conditions, but the and access benefits even when the conditions are not specifically health-related—from empirical evidence increased contraceptive uptakexv to maternal health care,xvi dietary diversity,xvii reduced is still limited. sexual risk behavior,xviii and better preventative and curative care.xix Voucher programs likewise offer individuals free or subsidized vouchers for a specific health service, often accessible from a range of networked private providers. These programs have been widely OCTOBER 2018 3 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR QUALITY CARE AMIDST INFRASTRUCTURE AND RESOURCE CONSTRAINTS used to improve access to family planning services, with extensive literature mostly supporting their effectiveness at increasing contraceptive uptake.xx Systematic reviews also find moderate to strong evidence that vouchers can improve uptake of antenatal care, skilled birth attendance, facility births, and postnatal care.xxi SPOTLIGHT Drones ► In remote areas of LMICs, unmanned aerial vehicles—UAVs or “drones”—have emerged as a potential strategy to improve the reach and timeliness of medical deliveries. The technology is growing quickly in East Africa, with national scale-up in Rwanda and Tanzania of drone-based blood deliveries; empirical evidence for their impact is still limited, but drone operators report cutting typical blood delivery times from hours to under 30 minutes.xxii Early modelling studies from LMICs suggest that UAVs can be cost-effective or cost-saving for certain use cases; cost-effectiveness typically increases with scale and density of in-range health facilities, as capital costs are amortized over a larger number of deliveries.xxiii In Mozambique, for example, modelling finds that universal adoption of drones for routine vaccine delivery could increase vaccine availability and decrease logistics costs by about 20% compared to land-based transport networks;xxiv savings on fuel, personnel costs, time, and road vehicle wear-and-tear can sometimes help offset the increased cost of the technology.xxv However, the limited weight and distance capacity of drones, combined with their cost, may limit their routine use. Multi-scenario modelling in Malawi finds that drones were only cost saving for one of four simulated scenarios (hub-and-spoke delivery models with a single product), though the modelling did not consider health or system-level benefits from faster delivery times.xxvi Given the current costs of drone deliveries, they appear most appropriate for products with relatively infrequent but extremely urgent usage; that is, products that are not typically stocked in local health facilities but are needed immediately during emergencies. Products falling into this category include blood supplies, anti-snake venom, and rabies post-exposure prophylaxis. Long-Term Thinking: Using Vouchers to Increase the Accessibility of Long-Acting Contraception ► In 2011, Marie Stopes Uganda introduced a voucher program to make long-acting contraceptive methods more financially accessible to poor Ugandan women. Poor women would learn about the availability of vouchers through community meetings, advertisements on radio dramas, and direct outreach; they could then purchase the vouchers for roughly $1 from local distributors after verifying their eligibility through a household assets questionnaire. With the voucher in hand, the women could visit any of 400 partner facilities across Uganda to receive family planning counselling and a method of their choice, plus coverage for any follow-up services (e.g. removal of the contraceptive device). Marie Stopes trained and qualified eligible providers; oversaw voucher OCTOBER 2018 4 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR QUALITY CARE AMIDST INFRASTRUCTURE AND RESOURCE CONSTRAINTS distribution; and reimbursed the providers for the full cost of the service, effectively subsidizing care for participating women.xxvii Over a 4-year period, Marie Stopes Uganda provided over 330,000 women with contraceptive services through this program, helping increase the modern contraceptive prevalence rate by an estimated 1.4 percentage points. In 2014 alone, estimates suggest that the program averted over 200,000 unwanted pregnancies and 520 maternal deaths, and saved $14 million in direct health care costs.xxviii . ENDNOTES i Aminu Sulemana and Romanus D. Dinye, “Access to Healthcare in Rural Communities in Ghana: A Study of Some Selected Communities in the Pru District,” European Journal of Research in Social Sciences 2, no. 4 (2014): 11. ii Justine I. Blanford et al., “It’s a Long, Long Walk: Accessibility to Hospitals, Maternity and Integrated Health Centers in Niger,” International Journal of Health Geographics 11 (June 27, 2012): 24, https://doi.org/10.1186/1476-072X-11-24. iii PHCPI, “Service Delivery: Caseload per Provider (Daily),” Primary Healthcare Performance Initiative, 2017, https://phcperformanceinitiative.org/indicator/caseload-provider-daily. iv Daniel H. Kress, Yanfang Su, and Hong Wang, “Assessment of Primary Health Care System Performance in Nigeria: Using the Primary Health Care Performance Indicator Conceptual Framework,” Health Systems & Reform 2, no. 4 (October 2016): 302–18, https://doi.org/10.1080/23288604.2016.1234861. v World Bank, “Poverty: Overview,” Text/HTML, World Bank, September 24, 2018, http://www.worldbank.org/en/topic/poverty/overview; World Bank, “Decline of Global Extreme Poverty Continues but Has Slowed,” Press Release, World Bank, September 19, 2018, http://www.worldbank.org/en/news/press-release/2018/09/19/decline-of-global-extreme- poverty-continues-but-has-slowed-world-bank. vi World Bank, “Poverty: Overview”; World Bank, “Decline of Global Extreme Poverty Continues but Has Slowed.” vii World Health Organization and International Bank for Reconstruction and Development/World Bank, “Tracking Universal Health Coverage: 2017 Global Monitoring Report” (World Health Organization, 2017), http://documents.worldbank.org/curated/en/640121513095868125/pdf/122029-WP-REVISED- PUBLIC.pdf. viii Sabine Gabrysch and Oona M. R. Campbell, “Still Too Far to Walk: Literature Review of the Determinants of Delivery Service Use,” BMC Pregnancy and Childbirth 9, no. 1 (August 11, 2009): 34, https://doi.org/10.1186/1471-2393-9-34. ix Grace W. Mwai et al., “Role and Outcomes of Community Health Workers in HIV Care in Sub- Saharan Africa: A Systematic Review,” Journal of the International AIDS Society 16 (September 10, 2013): 18586; Maryse C. Kok et al., “How Does Context Influence Performance of Community Health Workers in Low- and Middle-Income Countries? Evidence from the Literature,” Health Research Policy and Systems 13, no. 1 (March 7, 2015): 13, https://doi.org/10.1186/s12961-015- 0001-3. x Anne Liu et al., “Community Health Workers in Global Health: Scale and Scalability,” The Mount Sinai Journal of Medicine, New York 78, no. 3 (June 2011): 419–35, https://doi.org/10.1002/msj.20260; 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. xi Mwai et al., “Role and Outcomes of Community Health Workers in HIV Care in Sub-Saharan Africa”; Valerie K. Scott et al., “Community Health Workers’ Provision of Family Planning Services in Low- and Middle-Income Countries: A Systematic Review of Effectiveness,” Studies in Family OCTOBER 2018 5 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR QUALITY CARE AMIDST INFRASTRUCTURE AND RESOURCE CONSTRAINTS Planning 46, no. 3 (September 2015): 241–61, https://doi.org/10.1111/j.1728-4465.2015.00028.x; Brynne Gilmore and Eilish McAuliffe, “Effectiveness of Community Health Workers Delivering Preventive Interventions for Maternal and Child Health in Low- and Middle-Income Countries: A Systematic Review,” BMC Public Health 13 (September 13, 2013): 847, https://doi.org/10.1186/1471-2458-13-847; Henry B. 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), https://doi.org/10.1146/annurev-publhealth-032013-182354. xii Kenneth Maes and Ippolytos Kalofonos, “Becoming and Remaining Community Health Workers: Perspectives from Ethiopia and Mozambique,” Social Science & Medicine (1982) 87 (June 2013): 52–59, https://doi.org/10.1016/j.socscimed.2013.03.026. xiii C. Ronsmans et al., “Evaluation of a Comprehensive Home-Based Midwifery Programme in South Kalimantan, Indonesia,” Tropical Medicine & International Health: TM & IH 6, no. 10 (October 2001): 799–810; Fiifi Amoako Johnson et al., “Evaluating the Impact of the Community-Based Health Planning and Services Initiative on Uptake of Skilled Birth Care in Ghana,” PLOS ONE 10, no. 3 (March 19, 2015): e0120556, https://doi.org/10.1371/journal.pone.0120556. xiv Rosa Catarino et al., “Smartphone Use for Cervical Cancer Screening in Low-Resource Countries: A Pilot Study Conducted in Madagascar,” PLOS ONE 10, no. 7 (July 29, 2015): e0134309, https://doi.org/10.1371/journal.pone.0134309; Margot Kunckler et al., “Cervical Cancer Screening in a Low-Resource Setting: A Pilot Study on an HPV-Based Screen-and-Treat Approach,” Cancer Medicine 6, no. 7 (July 2017): 1752–61, https://doi.org/10.1002/cam4.1089. xv M. E. Khan et al., “Conditional and Unconditional Cash Transfers to Improve Use of Contraception in Low and Middle Income Countries: A Systematic Review,” Studies in Family Planning 47, no. 4 (December 1, 2016): 371–83, https://doi.org/10.1111/sifp.12004. xvi Benjamin M. Hunter et al., “The Effects of Cash Transfers and Vouchers on the Use and Quality of Maternity Care Services: A Systematic Review,” ed. Stefan Gebhardt, PLOS ONE 12, no. 3 (March 22, 2017): e0173068, https://doi.org/10.1371/journal.pone.0173068. xvii Ebenezer Owusu-Addo, Andre M. N. Renzaho, and Ben J. Smith, “The Impact of Cash Transfers on Social Determinants of Health and Health Inequalities in Sub-Saharan Africa: A Systematic Review,” Health Policy and Planning 33, no. 5 (June 1, 2018): 675–96, https://doi.org/10.1093/heapol/czy020. xviii Owusu-Addo, Renzaho, and Smith. xix Owusu-Addo, Renzaho, and Smith. xx Ben Bellows et al., “Family Planning Vouchers in Low and Middle Income Countries: A Systematic Review,” Studies in Family Planning 47, no. 4 (December 2016): 357–70, https://doi.org/10.1111/sifp.12006. xxi Hunter et al., “The Effects of Cash Transfers and Vouchers on the Use and Quality of Maternity Care Services.” xxii Zipline, “Zipline,” accessed September 30, 2018, http://www.flyzipline.com/our-impact/. xxiii Chris Wright et al., “What Should You Deliver by Unmanned Aerial Systems?” (JSI Research & Training Institute, Inc., January 2018), https://www.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=19145&lid=3; Heike Würbel, “Framework for the Evaluation of Cost-Effectiveness of Drone Use for the Last-Mile Delivery of Vaccines” (University of Barcelone, ISGlobal, June 13, 2017), https://logcluster.org/sites/default/files/gm_files/master_final_project_heike_wurbel_13_jun201 7_003.pdf. xxiv Leila A. Haidari et al., “The Economic and Operational Value of Using Drones to Transport Vaccines,” Vaccine 34, no. 34 (July 25, 2016): 4062–67, https://doi.org/10.1016/j.vaccine.2016.06.022. xxv Würbel, “Framework for the Evaluation of Cost-Effectiveness of Drone Use for the Last-Mile Delivery of Vaccines.” xxvi N. Phillips et al., “Costs Associated with the Use of Unmanned Aerial Vehicles for Transportation of Laboratory Samples in Malawi” (VillageReach, June 2016), http://www.villagereach.org/wp- content/uploads/2017/06/Malawi-UAS-Report_MOH-Draft_-FINAL_14_07_16.pdf. xxvii Benjamin Bellows et al., “Increasing Contraceptive Access for Hard-to-Reach Populations With Vouchers and Social Franchising in Uganda,” Global Health: Science and Practice 5, no. 3 (September 27, 2017): 446–55, https://doi.org/10.9745/GHSP-D-17-00065. xxviii Bellows et al. OCTOBER 2018 6 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR QUALITY CARE AMIDST INFRASTRUCTURE AND RESOURCE CONSTRAINTS REFERENCE Bellows, Ben, Carol Bulaya, Sophie Inambwae, Craig L. Lissner, Moazzam Ali, and Ashish Bajracharya. “Family Planning Vouchers in Low and Middle Income Countries: A Systematic Review.” Studies in Family Planning 47, no. 4 (December 2016): 357–70. https://doi.org/10.1111/sifp.12006. Bellows, Benjamin, Anna Mackay, Antonia Dingle, Richard Tuyiragize, William Nnyombi, and Aisha Dasgupta. “Increasing Contraceptive Access for Hard-to-Reach Populations With Vouchers and Social Franchising in Uganda.” Global Health: Science and Practice 5, no. 3 (September 27, 2017): 446–55. https://doi.org/10.9745/GHSP-D-17-00065. Blanford, Justine I., Supriya Kumar, Wei Luo, and Alan M. MacEachren. “It’s a Long, Long Walk: Accessibility to Hospitals, Maternity and Integrated Health Centers in Niger.” International Journal of Health Geographics 11 (June 27, 2012): 24. https://doi.org/10.1186/1476-072X-11-24. Catarino, Rosa, Pierre Vassilakos, Stefano Scaringella, Manuela Undurraga-Malinverno, Ulrike Meyer- Hamme, Dominique Ricard-Gauthier, Juan Carlos Matute, and Patrick Petignat. “Smartphone Use for Cervical Cancer Screening in Low-Resource Countries: A Pilot Study Conducted in Madagascar.” PLOS ONE 10, no. 7 (July 29, 2015): e0134309. https://doi.org/10.1371/journal.pone.0134309. Gabrysch, Sabine, and Oona M. R. Campbell. “Still Too Far to Walk: Literature Review of the Determinants of Delivery Service Use.” BMC Pregnancy and Childbirth 9, no. 1 (August 11, 2009): 34. https://doi.org/10.1186/1471-2393-9-34. Gilmore, Brynne, and Eilish McAuliffe. “Effectiveness of Community Health Workers Delivering Preventive Interventions for Maternal and Child Health in Low- and Middle-Income Countries: A Systematic Review.” BMC Public Health 13 (September 13, 2013): 847. https://doi.org/10.1186/1471-2458-13-847. Haidari, Leila A., Shawn T. Brown, Marie Ferguson, Emily Bancroft, Marie Spiker, Allen Wilcox, Ramya Ambikapathi, Vidya Sampath, Diana L. Connor, and Bruce Y. Lee. “The Economic and Operational Value of Using Drones to Transport Vaccines.” Vaccine 34, no. 34 (July 25, 2016): 4062–67. https://doi.org/10.1016/j.vaccine.2016.06.022. Hunter, Benjamin M., Sean Harrison, Anayda Portela, and Debra Bick. “The Effects of Cash Transfers and Vouchers on the Use and Quality of Maternity Care Services: A Systematic Review.” Edited by Stefan Gebhardt. PLOS ONE 12, no. 3 (March 22, 2017): e0173068. https://doi.org/10.1371/journal.pone.0173068. Johnson, Fiifi Amoako, Faustina Frempong-Ainguah, Zoe Matthews, Andrew J. P. Harfoot, Philomena Nyarko, Angela Baschieri, Peter W. Gething, Jane Falkingham, and Peter M. Atkinson. “Evaluating the Impact of the Community-Based Health Planning and Services Initiative on Uptake of Skilled Birth Care in Ghana.” PLOS ONE 10, no. 3 (March 19, 2015): e0120556. https://doi.org/10.1371/journal.pone.0120556. Khan, M. E., Avishek Hazra, Aastha Kant, and Moazzam Ali. “Conditional and Unconditional Cash Transfers to Improve Use of Contraception in Low and Middle Income Countries: A Systematic Review.” Studies in Family Planning 47, no. 4 (December 1, 2016): 371–83. https://doi.org/10.1111/sifp.12004. Kok, Maryse C., Sumit S. Kane, Olivia Tulloch, Hermen Ormel, Sally Theobald, Marjolein Dieleman, Miriam Taegtmeyer, Jacqueline EW Broerse, and Korrie AM de Koning. “How Does Context Influence Performance of Community Health Workers in Low- and Middle-Income Countries? Evidence from the Literature.” Health Research Policy and Systems 13, no. 1 (March 7, 2015): 13. https://doi.org/10.1186/s12961-015-0001-3. Kress, Daniel H., Yanfang Su, and Hong Wang. “Assessment of Primary Health Care System Performance in Nigeria: Using the Primary Health Care Performance Indicator Conceptual Framework.” Health Systems & Reform 2, no. 4 (October 2016): 302–18. https://doi.org/10.1080/23288604.2016.1234861. Kunckler, Margot, Fanny Schumacher, Bruno Kenfack, Rosa Catarino, Manuela Viviano, Eveline Tincho, Pierre-Marie Tebeu, Liliane Temogne, Pierre Vassilakos, and Patrick Petignat. “Cervical Cancer Screening in a Low-Resource Setting: A Pilot Study on an HPV-Based Screen-and-Treat Approach.” Cancer Medicine 6, no. 7 (July 2017): 1752–61. https://doi.org/10.1002/cam4.1089. Liu, Anne, Sarah Sullivan, Mohammed Khan, Sonia Sachs, and Prabhjot Singh. “Community Health Workers in Global Health: Scale and Scalability.” The Mount Sinai Journal of Medicine, New York 78, no. 3 (June 2011): 419–35. https://doi.org/10.1002/msj.20260. OCTOBER 2018 7 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR QUALITY CARE AMIDST INFRASTRUCTURE AND RESOURCE CONSTRAINTS Maes, Kenneth, and Ippolytos Kalofonos. “Becoming and Remaining Community Health Workers: Perspectives from Ethiopia and Mozambique.” Social Science & Medicine (1982) 87 (June 2013): 52– 59. https://doi.org/10.1016/j.socscimed.2013.03.026. Mwai, Grace W., Gitau Mburu, Kwasi Torpey, Peter Frost, Nathan Ford, and Janet Seeley. “Role and Outcomes of Community Health Workers in HIV Care in Sub-Saharan Africa: A Systematic Review.” Journal of the International AIDS Society 16 (September 10, 2013): 18586. https://www.ncbi.nlm.nih.gov/pubmed/24029015. Owusu-Addo, Ebenezer, Andre M. N. Renzaho, and Ben J. Smith. “The Impact of Cash Transfers on Social Determinants of Health and Health Inequalities in Sub-Saharan Africa: A Systematic Review.” Health Policy and Planning 33, no. 5 (June 1, 2018): 675–96. https://doi.org/10.1093/heapol/czy020. Perry, Henry B., 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. PHCPI. “Service Delivery: Caseload per Provider (Daily).” Primary Healthcare Performance Initiative, 2017. https://phcperformanceinitiative.org/indicator/caseload-provider-daily. Phillips, N., C. Blauvelt, M. Ziba, J. Sherman, E. Saka, E. Bancroft, and A. Wilcox. “Costs Associated with the Use of Unmanned Aerial Vehicles for Transportation of Laboratory Samples in Malawi.” VillageReach, June 2016. http://www.villagereach.org/wp-content/uploads/2017/06/Malawi-UAS- Report_MOH-Draft_-FINAL_14_07_16.pdf. Ronsmans, C., A. Endang, S. Gunawan, A. Zazri, J. McDermott, M. Koblinsky, and T. Marshall. “Evaluation of a Comprehensive Home-Based Midwifery Programme in South Kalimantan, Indonesia.” Tropical Medicine & International Health: TM & IH 6, no. 10 (October 2001): 799–810. Scott, Valerie K., Lindsey B. Gottschalk, Kelsey Q. Wright, Claire Twose, Meghan A. Bohren, Megan E. Schmitt, and Nuriye Ortayli. “Community Health Workers’ Provision of Family Planning Services in Low- and Middle-Income Countries: A Systematic Review of Effectiveness.” Studies in Family Planning 46, no. 3 (September 2015): 241–61. https://doi.org/10.1111/j.1728-4465.2015.00028.x. Sulemana, Aminu, and Romanus D. Dinye. “Access to Healthcare in Rural Communities in Ghana: A Study of Some Selected Communities in the Pru District.” European Journal of Research in Social Sciences 2, no. 4 (2014): 11. World Bank. “Decline of Global Extreme Poverty Continues but Has Slowed.” Press Release. World Bank, September 19, 2018. http://www.worldbank.org/en/news/press-release/2018/09/19/decline-of- global-extreme-poverty-continues-but-has-slowed-world-bank. _____. “Poverty: Overview.” Text/HTML. World Bank, September 24, 2018. http://www.worldbank.org/en/topic/poverty/overview. 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. World Health Organization, and International Bank for Reconstruction and Development/World Bank. “Tracking Universal Health Coverage: 2017 Global Monitoring Report.” World Health Organization, 2017. http://documents.worldbank.org/curated/en/640121513095868125/pdf/122029-WP- REVISED-PUBLIC.pdf. Wright, Chris, Sidharth Rupani, Kameko Nichols, Yasmin Chandani, and Matiko Machagge. “What Should You Deliver by Unmanned Aerial Systems?” JSI Research & Training Institute, Inc., January 2018. https://www.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=19145&lid=3. Würbel, Heike. “Framework for the Evaluation of Cost-Effectiveness of Drone Use for the Last-Mile Delivery of Vaccines.” University of Barcelone, ISGlobal, June 13, 2017. https://logcluster.org/sites/default/files/gm_files/master_final_project_heike_wurbel_13_jun2017_ 003.pdf. Zipline. “Zipline.” Accessed September 30, 2018. http://www.flyzipline.com/our-impact/. OCTOBER 2018 8