Tiyatien

- 2011 -

Health

Tiyatien Health aims to rebuild health - and hope - in the most remote corners of Liberia.

1 | 2011 Annual Report

An aerial view of the Liberian coast On the cover: Marcus, on a motorbike, off to see patients in a rural village Photo Credits: Emily Schiller
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The road to Zwedru from Monrovia, Liberias capital Photo credit: Maribel Zorrilla
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Table of Contents
Introduction Our Challenge Directors Message Liberia Our Model Year in Review Our Programs Bridge Access Improve Clinics Tackle Poverty Change Policy Refugee Response Profile: Alphonso Mouwon Selected Press and Honors 5 6 7 8 9 10 11 12 13 14 15 18

Finance and Governance 19 Financial Review Our Boards and Extended Family 22 Contact Information Back Cover

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Tiyatien Healths youngest frontline health worker, Joel Klah, after a home visit Photo Credit: Emily Schiller

The Problem
Traditional hospital-based services are failing to reach the worlds most remote villages. Nowhere is this crisis worse than in post-war Liberia, where more than 60% of the nations rural population lacks access to essential health care.

Our Approach
Tiyatien Health is creating a new health workforce to bring care to remote villages. We train community members and former patients to serve as frontline health workers, delivering comprehensive homebased medical and social services to communities previously deemed unreachable.

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Dear friends,
Out of darkness, light can still shine. When my colleagues at Tiyatien Health (TH) and I were children growing up in Liberia, we never imagined that we would come face to face with violence. But our lives were changed forever when Charles Taylor launched a revolution that would become one of the worlds most brutal civil wars. Lasting nearly 15 years, the war claimed a quarter million lives, sent our families fleeing, and left our country in shambles. When I returned to Liberia as a medical student in 2005, I heard stories of darkness from my patients. One boy suffering from depression told me how he had been drugged and forced to wield a gun at age 12. Men had tears in their eyes when they talked of carrying their pregnant wives on hammocks up to 17 hours by foot to reach the few clinics that remained standing. The war made our people vulnerable to disease, and left us with just 51 public doctors and too few resources to respond. Ignited in response to an AIDS epidemic, TH has since transformed into a broader, organized effort to rebuild Liberias rural health system. By employing people from villages as well-trained health workers, we are providing care in remote communities lacking doctors. In this past year, TH has seen unprecedented growth. Our community-based clinical services have grown in scope and quality. We have expanded HIV, mental health, primary health and social services in over a dozen communities. And, community health workers, who founded our work, remain at the core of these efforts. Others are beginning to recognize the transformative potential of our work -- not only for the rainforest communities we currently serve -- but also for the rest of rural Liberia. Based on early success, the Liberian Ministry of Health invited TH to pilot the HIV component of our model to improve care at 19 public clinics throughout Liberia. Our community-based mental health program treating victims of war has been recognized nationally as a rural center of excellence. But we think there is more that can be done. Imagine a village-based workforce that would do everything your family doctor would do but in places your doctor would never go. In 2012, we are taking community-based care one step further, building a new class of highly skilled frontline health workers to redefine the way villages in Liberia and perhaps around the world access health care. Ours is an unlikely story. It is story that would not be possible without you -- our supporters, our partners -- and the dedication, skill and contributions you bring to this effort. We look forward to working with you to bring light out of darkness.

Rajesh Panjabi, MD, MPH Co-founder Executive Director

1
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LIBERIA
For more than 140 years, Liberia suffered from toxic ethnic tensions and discriminatory politics until the country erupted in violence in the 1980s. The 14-year civil war killed an estimated 270,000 people and displaced hudreds of thousands more. Since the wars end in 2003, Liberians have pressed the nation to build back better, working to maintain peace while reconstructing their social, economic, and political systems. Yet, due to the widespread destruction and looting of clinics and hospitals during the war, the nations health system has struggled to rebuild. Today, in Liberia: There is only one doctor for every 74,205 people. One out of two children will not receive a full set of vaccinations. One out of every 12 women will die due to complications of childbirth. Half of all Liberians in rural regions lack access to essential health services.

LIBERIA
Monrovia

Tiyatien Health Zwedru, Grand Gedeh County

MILESTONES

Survivors of Liberias civil war found Tiyatien Health, launching Liberias first rural HIV treatment program.

TH & Harvard publish groundbreaking national study and develop rural treatment program on mental health.

Partnered with the Global Fund and the Ministry of Health, TH launches a national pilot of its HIV treatment model at 19 national health centers.

MAR 07 MAR 08
With support from UNHCR, TH expands comprehensive HIV/AIDS care and treatment in Zwedru.

AUG 08 MAR 10
TH partners with Ministry of Health and Merlin to deliver Basic Package of Health Services at 17 public clinics in southeastern Liberia.

APR 10 SEPT 10
Co-founder Dr. Raj Panjabi selected as PopTech Social Innovation Fellow for THs pioneering community-based model of care.

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OUR MODEL
Tiyatien Health is pioneering a community-led system to deliver comprehensive home-based medical care and social services to the rural poor. We have three major goals:
1) Connect rural communities to essential health services
Our frontline health workers deliver care to patients in their homes, bringing life-saving treatment and prevention for diseases like HIV, tuberculosis, and mental illnesses to the places where rural Liberians live and work. To reduce stigma, malnutrition, and the costs of seeking care, frontline health workers organize patients and women into economic cooperatives, such as farms and sewing projects, while linking them to food and other forms of social support. Tiyatien Health trains government physicians and nurses to support and supervise frontline health workers, while providing policy planning, research, and health care delivery support.

2) Overcome barriers to health care

3) Partner with government to rebuild health systems

Ministry of Health invites TH to participate in writing 2011-2021 National Health Policy and Plan.

TH partners with UNHCR in response to the Ivorian refugee crisis, providing health and referral services in the refugee camps.

THs commitment to redefine how remote villages in Liberia access health care featured at the Clinton Global Initiative.

OCT 10 FEB 11
Dr. Raj Panjabi selected as a Rainer Arnhold fellow for THs scalable solution to the rural health care access gap.

MAR 11 MAY 11

SEPT 11

Dr. Raj Panjabi and Peter Luckow are selected as Echoing Green fellows for THs leadership in the field of social entrepreneurship.
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FHWs leading a coping group Photo Credit: Katie Kentoffio

16,912

home visits conducted

525 66 22

counseling sessions led

Photo: Accompaniers leading a coping group

BRIDGE ACCESS

patients under FHW care active FHWs

In response to Liberias massive health worker shortage, Tiyatien Health is building a novel network of paraprofessionals to deliver health care in rural communities. Since 2007, we have trained and employed community members and former patients to serve as frontline health workers (FHWs), bridging the gap between clinics and far-off villages. Supported by clinicians based in health centers, FHWs deliver therapy to patients in their homes, monitor for side effects, and offer much-needed psychosocial support. In 2011, Tiyatien Healths 23 FHWs conducted nearly 17,000 home visits, providing significantly more care, supervision, and accompaniment than would ever be possible through conventional, hospital-based health systems. This year, Tiyatien Health designed a program for a more extensive training curriculum to enable new FHWs to provide comprehensive health services in even more remote communities.

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IMPROVE CLINICS 1,323

While THs primary focus is on setting a new standard for village-based health delivery, our patients often require advanced levels of care at clinics or hospitals. TH has partnered with the Liberian Ministry of Health, Merlin, and Harvard Medical School to rebuild rural clinical services by providing direct medical and surgical care to mothers, children, and adults hospitalized at Tubman Hospital, serving a catchment population of 200,000 people. TH is also strengthening access to quality care for mothers and children suffering from HIV/AIDS, tuberculosis or mental illness, training over 90 nurses, physicians assistants and midwives to deliver testing and treatment in rural clinics. TH and its partners are committed to ensuring every patient gets the care they need from the village to the ward.

646 335 211 130

HIV clinical visits

mental health clinical visits

patients receiving ARVs

new HIV patients in care new mental health patients in care

Entrance to Martha Tubman Memorial Hospital in Zwedru Photo Credit: Emily Schiller

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498 266 100 75 50

patients received transport grants food stipends disbursed

OVERCOME BARRIERS
More than 85% of the Liberian population is unemployed, fueling a vicious cycle of poverty and illness. Redressing sickness therefore requires guaranteeing other social and economic rights in addition to medical care, such as housing, food, gender equality, and jobs. To break the chain of poverty and disease, Tiyatien Health provides food and transportation stipends to patients, conducts agricultural and small business trainings, and facilitates the regions only community-based support groups for people living with HIV/AIDS and depression. Zwedru Women United for Change (ZWUC), a group designed and led by patients and frontline health workers, has brought dozens of women together to form a sewing cooperative and communal support groups to discuss and advance womens rights.

women in ZWUC patients in coping groups graduates of sewing classes

Members of our womens sewing cooperative at work Photo Credit: Maribel Zorrilla
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Tiyatien Health trains frontline health workers in Monrovia as part of the national scale-up. Photo Credit: Kate Cummings

CHANGE POLICY

To extend our impact beyond Zwedru, Tiyatien Health accompanies the Liberian government to develop stronger national health policies. By leveraging our relationship with Harvard University, we share our evidence-based research on a number of health policy planning committees in order to shape bolder national strategies, particularly in the realm of rural health delivery. This year, Tiyatien Health worked in partnership with the Liberian Ministry of Health and Social Welfare, the National AIDS Control Program, and the Global Fund to scale-up our model at 19 sites across the country. 95 frontline health workers were specially trained to accompany HIV patients through their illness. Our hope is that this national pilot will provide an advocacy base for use of well-trained, fairly-paid frontline health 8 workers for complex health delivery, particularly in remote regions.

20,000

nation-wide home-based care visits

400 95 19

new patients enrolled

new FHWs trained regional sites across 12 counties

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Theo Neewrayson, a Frontline Health Worker Leader teaches an Ivorian refugee how to install a mosquito net inside his home in the PTP refugee camp Photo Credit: Avi Kenny
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REFUGEE RESPONSE
Between December 2010 and May 2011, more than 180,000 refugees crossed into Grand Gedeh County, fleeing political violence in Cote dIvoire. Many of the Ivorians who arrived in Liberia had provided shelter and safety for our own staff when, fifteen years earlier, Liberians had sought safe haven in Cote dIvoire. Emboldened by this solidarity, Tiyatien Health mobilized our team to respond to the refugee crisis in the refugee camps and clinics. We deployed dozens of frontline health workers to provide community outreach in the camps, including mental health services, malaria prevention, hygiene promotion, and HIV treatment and prevention. Together with the United Nations High Commission on Refugees (UNHCR), we coordinated a fleet of three ambulances between the refugee camps, facilitating more than 1,000 emergency referrals to Martha Tubman Memorial Hospital.

70,985

refugees in Grand Gedeh County

6,031
4,800
1,000+ 400+

people served by community awareness sessions bednets distributed refugees attended health talks refugees trained in health education and promotion

UNHCR camps like this one can be found Refugee food distribution in Toe Town refugee camp County throughout Grand Gedeh Photo Credit: Katie Kentoffio Photo Credit: Dr. Raj Panjabi
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PROFILE: ALPHONSO MOUWON

As a child, Alphonso Mouwon dreamt of becoming a doctor. From a young age, Alphonso contributed to the good health of his community, leading a health-oriented student group and taking it as his responsibility to take ill community members to the hospital. Today, Alphonso continues to care for his neighbors, now employed as Tiyatien Healths Frontline Health Worker Supervisor. Alphonso first met Tiyatien Health at Martha Tubman Memorial Hospital, where he was providing care to tuberculosis patients in the wake of the war. In 2007, Dr. Raj Panjabi encouraged Alphonso to join the Tiyatien Health team. Alphonso quickly became a leader within Tiyatien Healths FHW program and he was soon promoted to the FHW Supervisor position, tasked with the management and quality improvement of the initiative. When Alphonso explains the power of the FHW program, he says that FHWs are more than ordinary community health workers - they understand their patients problems to greater depths and accompany the patients consistently through their sickness. People trust their FHWs as family members and approach them first for assistance. Before, patients with HIV immediately thought that they were going to die. Today, FHWs show that they can continue living their lives with HIV and instill hope in their patients. Alphonso believes that this work has empowered him to make real change in his community, I love this frontline health work because... it makes me know peoples problems and how to solve the peoples problems... and not just die for nothing.

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Alphonso Mouwon showing the way to Tiyatien Health Photo Credit: Emily Schiller
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Where Tiyatien Health surpasses most NGOs is making sure that patients responding well to therapy enjoy rights beyond the right to health care - including the right to work and be a productive community member.
Co-founder, Partners in Health

- Dr. Paul Farmer

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SELECTED PRESS AND PUBLICATIONS

Harvard College Global Health Review, Global Mental Health, Post-War Liberia, and the Urgent Need for Better Primary Care Systems (Spring 10) Huffington Post, In The Shadows of Liberias Civil War, Rajesh Panjabi and Leymah Gbowee (May 11) Need To Know on PBS, After Conflict in Ivory Coast, Native Liberians Return to Help Refugees Overcome Crisis (May 11) PRIS The World, Ivorian Refugees Affecting Liberian Health Care (May 11) Scientific Americans Lives, New Answers for Global Health, Inspiring Lives: Rajesh Panjabi (Fall 10) XVIII International AIDS Conference, Effect of Community Health Worker Supplementation to ART Delivery on HIV Patient Survival and Retention in Resource-Poor, Post-Conflict Liberia (Summer 10)

HONORS

Clinton Global Initiative, Featured Commitment Echoing Green, 2011-12 Fellowship PopTech, Class of 2010 Social Innovation Fellows Rainer Arnholds Fellows Program, 2011 Fellowship

Dr. Raj Panjabi with President Clinton and our featured commitment at the 2011 Clinton Global Initiative Annual Meeting Photo Credit: Clinton Global Initiative
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FINANCIAL REVIEW
Financial Statement
Strengthening systems for transparency and planning Financial transparency and accountability is a top priority for Tiyatien Health. To that end, we graduated this year from an Excel-based system to professional Quickbooks accounting software, and added additional staff in Liberia and the United States to focus on financial tracking and planning.

Leveraging partnerships to maximize U.S. donations Individual contributions from the United States, especially unrestricted donations, allow Tiyatien Health to implement bold programs and drive innovation, such as paying community health workers and transporting patients out of the country for advanced care. To maximize the potential of these individual gifts, we have built partnerships with the Minstry of Health and other institutions to cover our core operational and support costs, allowing for private, unrestricted donations to go directly to the patients in most need.

Diversifying our funding base At our inception in 2007, Tiyatien Health was fueled by wedding donations from our co-founders. This initial catalytic gift laid the foundation for our work, which grew exponentially this year with major grant support from The Global Fund and the Liberian Ministry of Healths Pool Fund. These new grants enabled us to grow our work in clinics and communities through Grand Gedeh County, in addition to strengthening our Liberian management team. In the coming year, we hope to sustain these substantial grants while investing heavily in growing our United States donor base, which will strengthen our ability to innovate and expand our services to the most remote corners of Liberia.

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June 30, 2011

Statement of Activities
SUPPORT AND REVENUE
Individual Contributions Direct Liberia Grants* Total Support and Revenue $125,744 $350,214 $475,958

FY2011 Revenue
26%

Individual Contributions

EXPENSES

Program Services US Contribution Direct Liberia Grants* Total Program Services Supporting services Management and General Fundraising Total Expenses

Direct Liberia Grants

74%

$75,347 $350,214 $425,561 $7,507 $7,230 $440,298

FY2011 Expenses
Programs - Direct Liberia Grants
Programs - US Contribution

80%

* Direct Liberia Grants include monies overseen by Tiyatien Health that were arranged to be sent directly to our Liberian sister organization, including major grants from the Liberian Ministry of Healths Pool Fund and The Global Fund to Fight AIDS, Tuberculosis, and Malaria. These figures are prepared from unaudited statements.

17%

2% Management 2% Fundraising

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An initial meeting of Tiyatien Health to identify the needs of the community Photo Credit: Dr. Pat Lee On the back cover: Benjamin Grant, Kah Kadi, and Stevie Davis walking toward Dougee refugee camp Photo Credit: Michael Jaung
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OUR BOARDS
Board of Directors
Lynn Black, MD, MPH Edward Cardoza, MA.Min Joia Mukherjee, MD, MPH Amisha Raja, PsyD Leslie Vensel, MD

Advisory Board
Lisa Cooper, MD, MPH Peter Ehrenkranz, MD, MPH Paul Farmer, MD, PhD Robert Lawrence, MD Nancee Oku Bright, DPhil

OUR EXTENDED FAMILY

Ashoka Changemakers Brigham and Womens Hospital Direct Relief International Echoing Green The Global Fund Global Health Corps Global Neighborhood Fund GlobeMed at University of Michigan The Greenbaum Foundation Havard Medical School Kansas Wesleyan University Keller Family Fund The Lester Fund Liberian Ministry of Health & Social Welfare Massachusetts General Hospital Partners In Health PopTech Rainer Arnhold Fellows Program Segal Family Foundation Still Harbor UNHCR

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A: P: M: W: T:

666 Dorchester Ave, Boston, MA 02127 +1-617-297-7482 info@tiyatienhealth.org www.tiyatienhealth.org @tiyatienhealth

Tiyatien Health is a 501(c)(3) nonprofit corporation and a Connecticut public charity.