NGO Incubator Project to Train Community Health Workers

Physician density varies widely among countries, with around 500 doctors per 100,000 people at the high end and 3 per 100,000 at the low end. The lowest physician counts are usually found in the world’s poorest regions. With doctors and nurses absent or scarce, community members are left alone to heal the sick, deliver children, and address chronic illnesses.

 Moreover, these communities often suffer from broken communication links with official health agencies, and that has three consequences: First, these isolated communities receive scant information about disease prevention, and second, health agencies are perilously unaware of brewing health problems within these communities. Consequently, diseases spread far and wide when they could be stemmed with early interventions and improved monitoring. Third, healthcare systems are left vulnerable and unable to respond effectively to emergencies.   

 The core problem? Underserved regions face a shortage of health workers. The World Health Organization (WHO) states that there is a shortage today of 4.5 million medical professionals and 17.5 million health workers overall. The United Nations says that won’t change much by 2030. The shortfall ensures the lack of primary health care for countless people, undermining the UN Sustainable Development Goals of universal health care coverage by the target year of 2030.

 With no expectation of a sufficient number of doctors in low-resource regions, the WHO has proposed an expanded role for Community Health Workers (CHWs), not as substitutes for physicians, but as supplements offering basic clinical services, referrals, health training, and links to the larger healthcare system. Compared to physicians and nurses, CHWs can be well trained quicker and at lower cost. Yes, but here’s another problem: CHWs are also in short supply.

 The urgent call for qualified CHWs inevitably leads to questions about training and an appropriate curriculum. Specifically, how do we devise a core curriculum, and then, addressing WHO concerns, how do we adapt the training to address local differences in health conditions, cultural norms, government requirements and resource availability? Finally, how do we keep CHWs in the field up-to-date? 

 That brings us to the five operational problems this project addresses:

 How can we configure a universal core curriculum that can be adapted to local settings?

• How can we distribute the curriculum efficiently, even in remote areas?
• How can communities organize effective CHW training programs?
• How can communities sustain the successful deployment of CHWs?
• After CHWs have been trained and deployed, how can they sustain their knowledge and expand their skills over time, especially in remote places? 

Solution Overview.

WiRED, working in IT-based, community health education for 25 years, launched an initiative four years ago to develop a comprehensive Community Health Worker training program. WiRED’s panel of 12 physicians and nursing professors developed a WHO-compliant CHW training curriculum. The program offers a universal core syllabus that is adaptable to local settings. It does this through: 1) extensive elective options, allowing additional study in health conditions local communities face and 2) classroom training conducted by local physicians and nurses.

In addition to the core curriculum with adaptations to local conditions, this program provides a continuing health worker education platform (aka, Continuing Medical Education—CME) to keep CHWs current, to develop a health specialty and to expand their skills.

In Kisumu, Kenya, for example, our CHWs graduated from training less than a month before the coronavirus pandemic hit and were pressed into service earlier than expected. Despite the added pressures of Covid, these young CHWs provided vital health surveillance, care and education across a range of health conditions. During the past two years, these CHWs learned about science’s evolving understanding of the virus by way of WiRED’s CME program.

In the past year, WiRED has forged relationships with local NGOs in several test locations in Africa (e.g., Uganda, Liberia) and Latin America (e.g., Mexico, Peru). We provided coaching to the NGOs, showing them how to coordinate the training program and take part in the CHW deployment, if not directly, then as facilitators to other local agencies.

Each CHW becomes an essential link between the official health system and the community she or he serves, and we stress this role in our training. Accordingly, CHWs become valuable tools in the effort to fortify healthy and resilient communities.

 Solution Details.

WiRED’s solution has several integrated components that we have tested during the past two years with the added value of learning how these components worked under stressed conditions. The program:

 1. Cultivates local health-related NGOs (also clinics and faith organizations) to provide the organizational structure for training and deployment.

2. Works with the NGOs in preparing local doctors and nurses to teach the CHW classes.

3. Provides the core curriculum and electives for CHW training. The curriculum comprises 24 modules that can be downloaded to a smartphone or other device. Downloaded modules can be shared offline with others.

4. Provides assistance to local NGOs for proposal writing and deployment of the CHWs.

5. Maintains a continuing medical education (CME) app developed in-house that does the following:

• Offers hundreds of health topics. CHWs can choose items relevant to the health needs of their community. They can download all selected modules to smartphones and tablets.
• Alerts CHWs to emerging health problems (e.g., Ebola, Zika, Polio) and offers freshly written training modules on these urgent topics.
• Maintains CME records for credits earned and credits remaining for the year. We offer this CME program not only to CHWs who go through our training program, but to all CHWs, nurses, and PCPs and other health workers. 

Our target populations are low-income communities, with limited health services and weak ties to official health agencies.

People in underserved regions without adequate healthcare live sicker and shorter lives. Consider these WHO observations:

• People in the poorest countries live on average 18.1 fewer years than people in the richest countries.
• In low-income countries, 1 in 41 women dies from a maternal cause, compared with 1 in 3,300 in high-income countries.
• Child death before age five in low-income countries is 14 times higher than the risk for children in Europe and North America. The leading causes of their death are preterm birth complications, birth asphyxia/trauma, pneumonia, diarrhea and malaria.
• People in underserved countries suffer more coronary heart disease, more respiratory infections, HIV/AIDS, strokes, malaria and other illnesses.

This program will help people prevent illness and minimizes the impact of infectious and non-communicable diseases on individuals and the community. With a critical elective series on mother and child health, it can improve survival rates of mothers and children at birth and increase the chances of children remaining healthy in the early years of life. It elevates health concerns on the community agenda and provides health surveillance information from the communities back to official agencies.

We receive regular feedback from our CHWs in Kisumu, Kenya who are deservedly proud of their contribution to healthier, better-informed communities. The many moving stories they have shared with us often have one unifying theme – persons who once lived with the fear that serious illness was an unavoidable part of their lives now have more confidence that they have someone nearby to help them prevent diseases and better manage chronic conditions. For this reason, we consider our WiRED trained CHWs to offer a significant improvement in the health infrastructure of underserved communities.

 One final point we would like to stress: Our program works with local NGOs to train and support CHWs. While growing the number of urgently needed CHWs in low-resource regions, this strategy also increases local organizational capacity and builds sustainable structures, able to meet the demands of rapidly changing health threats and challenges in communities underserved or not served at all by medical professionals.   

Our longstanding mission of delivering health education to underserved regions remains our abiding interest as an organization. We have lived and worked in underserved communities in Kenya, Peru, Nicaragua, Kosovo, Armenia and many others that will receive the services described in this proposal. We know the health and living conditions, the economic and political challenges and have invited people from these communities to join our governing board. These measures ensure, as much as any preparations can, that we have a firm grasp on the needs and hopes of people we set out to help. Community-level perspectives are fully integrated into all WiRED’s planning and programs.  

We have not only reviewed our approach to CHW training with people in these communities, but we have actively engaged them in the process, and their input has played an important role in shaping the structure of the program. During the Covid pandemic, in the past two years, we have arranged training for CHWs in four low-income countries (India, Peru, Nicaragua, Kenya), three in masked and socially distanced settings and one entirely on Zoom. In all cases, we sat in on the local instructions through Zoom connections. Even under Covid conditions we maintained our relationships and continued our professional work and our friendships. When global health conditions permit travel in the near future, we will eagerly reestablish in-person visits.           

Our project packages CHW training programs for wide geographic regions and includes many communities beyond those in which we have long-standing, personal relationships. However, our 25-year history of fieldwork (e.g., Iraq, Kenya, Sierra Leone, Croatia, Albania, Kosovo, Serbia, Montenegro, Bosnia, Nicaragua, Honduras, El Salvador, Peru) has positioned us to be as familiar with conditions in underserved communities as anyone from a more affluent country can be. We believe that what we have experienced and learned over the years enables us to offer CHWs training programs not only to the specific communities we know so well, but to communities elsewhere facing similar conditions, problems and needs. 

Current status: Our CHW training program has been thoroughly tested in Kenya, Peru, India, and Nicaragua); the curriculum successfully prepares CHWs academically and practically for the role of the CHW in the field. While Covid slowed our rollout of the program, we have solid data from a team of CHWs who have been actively involved in community assistance for more than two years. Bottom line: This training program is successful in preparing people to be productive CHWs.

 As we start the growth phase of our program, we would very much value Solve’s assistance in addressing several issues:

•  While our consulting physicians, nurses, and NGO partners provide advice on health topics offered and on the curriculum overall, we would welcome the support of medical professionals available through Solve’s partner network to help us keep the program relevant to CHWs and other users of our program.
• Marketing the CHW curriculum and NGO-cultivation program to communities in low-resource regions.
• Publicizing the availability of WiRED’s CME program to Ministries of Health, hospitals and clinics, and health NGOs through media exposure and conferences. As noted elsewhere in this proposal, we are making the CME program available to an audience wider than WiRED-trained CHWs. All other health workers are invited to sign up and use the CME app and online resources.
• While most of our training and CME material is presented in an easy to digest format and follows best learning practices, we search constantly for interesting and effective ways to present material. On one level, this could be the mode of presentation (text, video, voice, interactive games, etc.). On another level, it could be new ways to organize the curriculum and structure the elements in a lesson. Guidance from Solve on these matters would therefore be valuable.
• We would request the input of Solve’s IT resources. We have put together an effective program that can be distributed efficiently to CHWs and others globally. In the past two decades, we have witnessed rapid advances in technology that have had a huge impact on our programs (e.g., from CD-ROMS, to thumb drives to online distribution of training material). We are always exploring new technologies that would strengthen our primary mission of advancing health training in low-resource regions.
• Like any NGO, WiRED, an all-volunteer organization, is forever seeking funds to support programs in low-resource regions. The venture we outline in this proposal poses increasing needs for funding to foster the development of local NGOs, by building their structure and capacity and helping them become self-sufficient. We would value Solve’s guidance on fund-raising for these efforts. 

CHW training programs are far and few between, and they vary from one hour classes to longer, more demanding programs approaching nursing training. In underserved regions, where we work, few rigorous programs are available. Accordingly, we developed a curriculum to be thorough and appropriate globally, following guidelines expressed for CHW training by the World Health Organization (WHO). The curriculum covers health basics (anatomy and physiology, non-communicable and infectious diseases), basic clinical practices, communication, community prevention instruction and community health surveillance. Localization of CHW training is also important, and so, as we describe elsewhere in this application, we address local needs by way of electives and local trainers—physicians and nurses—who teach the course and address the larger health elements in terms of local needs and conditions.

We accomplish this by preparing local NGOs to supervise the training and assist with CHW deployment. This approach offers a professionally developed curriculum, observing WHO standards, that is easily downloaded, even in distant locations. It then prepares local organizations to implement the training and provide follow-up deployment. Where needed, we provide NGOs guidance with their organizational administration and fundraising. A significant advantage with this approach is that we cultivate a local entity that can sustain training activities over time. Such capacity building enhances the potential for continued CHW training with only minimal assistance from outside organizations.

We have set up three impact goals for the next five years:

1. Advance a program that incubates local NGOs to provide a sustaining capacity to train CHWs and to arrange for, if not to operate, deployment of CHW teams.

We have started this process and are currently working closely with NGOs on the ground in three underserved countries. The amount of assistance the NGOs require varies in each case. Some already established NGOs need only a little coaching to focus on CHW training, whereas others need a lot of help to establish the organization framework, administration and funding strategies. We then train the trainers working through the local NGO to familiarize them with the CHW curriculum and teaching strategies.

2. Develop additional training material in support of CHW training and deployment. Specifically, to allow CHWs to grow their skills and specialize in key health and medical disciplines.

With hundreds of health modules already developed, tested and available, we have a good sense for how to present health information to CHWs. Further, we see a great advantage in adopting a strategy employed by many traditional healers in Africa. Each healer has basic health knowledge, but each also develops a healing specialty, for instance, maternal issues, childhood illnesses, fever, broken bones. We plan to increase our offerings in subspecialties in order for CHWs to develop a particular health focus. Our CHWs commonly work in teams, and this would enhance the value and the impact of CHWs, calling in a “specialist” when needed. We will provide training tools to advance this strategy.

• Enhance the continuing CHW education program (aka Continuing Medical Education—CME) to allow CHWs to grow their skills and specialize in key health and medical disciplines.

In the previous impact goal we discuss health subspecialties. Those training areas will be distributed through our CME app. We plan to expand the reach of this CME program to as many regions as possible, making it available not only to CHWs trained through our programs, but to other CHWs and then to nurses and in some cases to primary care physicians and other medical professionals. The app allows easy downloading of training modules; its wide array of health topics will appeal to global audiences in far-reaching underserved communities. Few of our goals offers greater potential to positively influence global health. 

Measuring the progress or our impact goals will vary, but each will have a strong empirical component.

• Advance a program that incubates local NGOs to provide a sustaining capacity to train CHWs and to arrange for, if not to operate, deployment of CHW teams.
  • How many NGOs have we worked with to successfully prepare CHW training programs?
  • What are the costs of preparing NGOs?
  • How many CHWs have the NGOs trained?
  • Have the NGOs continued operations or have they stumbled?  What variables contribute to the success or failure of the NGOs?
• Develop additional training material in support of CHW training and deployment. Specifically, to allow CHWs to grow their skills and specialize in key health and medical disciplines.
  • Account for each subspecialty for which have we developed packages of training modules. Why was each topic selected?(Note: all our material is evidence-based and peer-reviewed, so we will assume here that the material itself has successfully portrayed the best medical and health information.)
  • How many CHWs have opted to specialize in each topic?
  • What are regional/geographic adoption patterns?
  • Which new topics do CHWs propose that we develop?
• Enhance the continuing CHW education program (aka Continuing Medical Education—CME) to allow CHWs to grow their skills and specialize in key health and medical disciplines.
  • How many people have signed up for the CME program?
  • In which countries/regions have people enrolled in the CME program?
  • What is the specific occupation of the CME user—CHWs, nurse, physician, therapist, etc.
  • How many people sign up and how many continue use year after year?

Our end-goal is to help improve the overall health of underserved communities, where few medical resources are available. To us, “improve health” means to ensure the health of pregnant women and their fetuses; improve postpartum survival of mother and child; improve age 0-5 health and survival; minimize the spread and severity of infectious diseases; prevent, improve or stabilize conditions of non-communicable diseases. We also see improved health as providing confidence in neglected communities that they are not forgotten by the larger health system. It’s essential that people know they are visible to the larger regional health agencies and that they are part of it. Improved health to us means that people recognize they can influence their own health and that they understand basic conditions and behaviors that contribute to good health.

We have been guided to these views by our observations, over many years, of underserved communities. Our mission to contribute to improved community health is to provide health education. We believe strongly in providing people with the capacity to impact their own health and the health of their communities. They themselves have to be the agents of change, and we provide them with information resources that help in their decisions and practices. We stress prevention, because that’s where we see community health begin. In the recent pandemic, we taught communities about masking, social distancing, hygiene and other measures needed to minimize the virus spread. Teaching people how to address a contracted illness is the next step, and, of course, it’s critical. Nonetheless, prevention is the key.

Throughout most of WiRED’s two decades of operation, we have introduced medical and health training into communities around the world with the belief that giving people the tools of good health is an essential start. Yes, poverty, social and political issues have an impact, but arming people with health knowledge is the base-line, and that has become our mission.

The CHW program we’re proposing here makes a significant contribution to that mission. CHWs offer basic clinical services and health surveillance, but their most important job is to teach. They hold meetings in central squares, churches, schools, anywhere to gather groups for health classes. They use WiRED’s modules as the foundations for their lessons. A group in Armenia, for instance, met each Wednesday with people who had diabetes to discuss diet, exercise, good monitoring practices, warning signs and more. These sessions educated people and empowered them to have some control over their own health. CHWs in Africa hold classes in HIV/AIDS prevention, mother and child health issues, diet and clean water and good sanitation. Our goal is to see improved community health and our mission is to provide health education to achieve it.

 The steps involved in this project lead to an increase in the numbers and in the skills of CHWs. This alters our direct-to-community model by inserting CHWs in the process. We see them as force multipliers—when we train one CHW, we potentially reach hundreds or thousands of community members. They not only provide the essential health training we’ve been discussing here, but also basic clinical services and referrals when someone gets sick. And they also provide health surveillance, offering information back to the formal health system.

Finally, our proposed model takes one additional step that we feel is critical to sustain the training and deployment of CHWs: cultivate local NGOs to use a well-developed curriculum for CHW training. These NGOs reside in the community and have a stake in it. They are critical local resources to train, monitor and advance the work of CHWs. Our mission is to help develop the NGOs for this work and to offer them the health training curriculum that ensures solid, evidence-based material with which to prepare their CHWs.

So, to provide information and education in underserved communities, we introduce the involvement of CHW, and to train CHWs, we cultivate local NGOs. That’s the process we outline in this proposal. 

Our program is driven by some of the newest and some of the oldest technologies. Over the years, WiRED has adopted new communication technologies as they became available—for instance, early on we used CDs to deliver our training material, then thumb drives, and now we use only the Internet to deliver downloadable material. Although we make our programs available for direct use online, we recognize that most of our audience is not able to sustain long online sessions, because of cost and the poor reliability of connections. So, all of our material is downloadable to devices. This allows users to study offline. Moreover, it allows users to share training modules offline. One user may visit a town with an Internet connection, download modules, then take the modules back to transfer to other devices among people unable to access the Internet. A WiRED IT volunteer has developed an app (called Health Module Access Program or HealthMAP) that displays all available modules with summaries. Then, with one click, users can download any of the modules. It’s worth noting that our training modules use text, images, sound, videos and we expect soon, video games for training.

The oldest technologies, of course, are classroom instruction. As we describe elsewhere, our CHW training modules, while made available directly to students, are taught by physicians and nurses in a classroom setting. This localizes the larger health and medical lessons to focus on local conditions, and it also brings the abstraction of computer material to life in a human-delivered forum.

Finally, much of the work of CHWs involves hands-on practice. Our CHWs become health teachers, so we have them practice teaching lessons in the CHW basic training sessions. They also provide patient assessment, vital signs measurement and basic therapies. To enable students to develop these skills, we include clinical practice sessions in the curriculum. Where local regulations permit, we also provide training in vaccine distribution and administration and include practice sessions for these skills.

Technology delivers the content, which CHWs can study on their own and then is taught in person by professionals. Students also have clinical sessions where CHWs practice the hand-on components of their work. 

Our awareness and practice of diversity, equity and inclusivity starts with our mission: to provide medical and health education to underserved communities. Nearly all of our target audiences have been identified as marginalized, generally deprived of financial equity, political inclusion and educational opportunity. We not only happen to reach disadvantaged populations, but we focus on them. Poor health can be a significant barrier to overcoming serious inequities, and our programs, as described throughout this proposal, strive to improve the health of marginalized communities. This, we hope, will give people from these communities a chance to advance their lives and be less burdened by illnesses that have impacted people for generations before them.

 Before we introduce a program, we discuss details with community leaders and seek their buy-in. A clear example is in communities throughout Kenya, where we had long discussions with traditional healers in order to ensure that our community health information centers didn’t interfere with their long-standing prominence as healers in the community (https://www.wiredinternational.org/archive/wireds-community-health-information-centers/). We then asked for their advice on how to integrate our evidence-based medical information into their traditional system of healing.

 After planning, we involve community members as significant players in our programs. In fact, in nearly every instance, local people run the programs. We help arrange the programs and continue to support them with information updates and funding, but local people manage day-to-day operations. Their roles as program leaders provide the equity and inclusivity essential to the success of this work. We have adopted a view expressed well by this statement:

 We at WiRED have learned that assistance programs are like ropes: you cannot push them, the people must pull them for themselves. Give the people the tools, the training, the ongoing help when and where they need it, and they will take the programs to places you could not have imagined for them.”  

 Beyond local input and administration, we involve people from these communities in the administration of WiRED International. Serving on WiRED’s governing board are three people with whom we have worked abroad: An Iraqi physician, who was forced to leave her country by insurgents, joined our board in 2010. A young Kenyan man started working as a staffer on WiRED’s 22 Kenyan Community Health Information Centers in 2002. He later earned a Master’s Degree in epidemiology at the University of Hamburg, and joined our board last year. The director of a nonprofit organization that provides free prostheses to low-income people in Nicaragua has been working on our programs in his country since 2003. He, too, joined our board last year. These professionals participate in all levels of WiRED’s work and not just in programs involving their home countries. They keep track of all WiRED’s work and, like all board members, they contribute to the development of our programs. WiRED’s board membership is evenly split between men and women and our board chair is a woman.

With our programs created for distribution to broad geographic regions--with people of different ethnic identities--we do everything possible to present in our training modules visual images that avoid gender and ethnic biases. We use stylized, non-gendered images that depict an array of ethnicities. We avoid photos, except to depict a relevant health matter. This avoids gender and race stereotypes and allows all users to identify with the material in our modules.

As a social enterprise, WiRED seeks to provide health and prevention services to end users (not customers) through the efforts of our team members who donate their time to prepare and deliver programs. We have been encouraged to charge small fees for our services, but we need to stress that while such a strategy might be possible for many nonprofits working in more affluent regions, it is not realistic for people in our target countries. The people we serve barely have enough money for food and a shelter and nothing to spare for medical care. We have had difficulty explaining such profound poverty to business leaders in prosperous countries who urge us to charge a small amount for our services. We no longer entertain such advice.

For the past 25 years, WiRED has provided health education programs around the world, serving millions of people, and we have funded this social enterprise through donations, grants and small contracts. For instance, in the early 2000s, the U.S. National Institutes of Health provided significant funding for an innovative three-year project to use computers throughout Kenya to teach communities, and young people in particular, about HIV/AIDS prevention. That project was more successful than we could have imagined going into it. The use of community access education centers to explain HIV/AIDS expanded to include training for a wide range of infectious and non-communicable diseases. Among others, the American Ambassador to Kenya honored this project and WiRED exported the concept to other countries in Africa, Eastern Europe and Latin America.

From 2003-2009, The U.S. Department of State funded a major medical training project throughout Iraq, where WiRED set up Internet access facilities for physicians. Here, too, an innovative program demonstrated the use of computer technology to advance medical and health education on a large scale. While our target audience in Africa was community members, in Iraq it was medical professionals. In both settings, U.S. Government funding provided the resources necessary to accomplish the work.

Most of our other work to develop health training modules, distribute programs in underserved communities, purchase and set up hardware, staff local facilities and operate the administrative functions of this organization have come from companies and large foundations, family foundations and generous individuals. The Medtronic Foundation, the Christopher Reeve Foundation and Pfizer are among the larger donors. We have raised hundreds of thousands of dollars from generous individuals contributing from a few dollars to several hundred thousand dollars.

We understand that a steady, predictable revenue-generating stream is often seen as a requirement for many if not most non-profits. We cannot count ourselves among those organizations. We have not monetized our products or services, largely because of the nature of the impoverished audiences we serve.

In addition to relying on the good will of many supporters, we must point out that we operate with a mostly volunteer staff (an IT staffer receives a modest wage). Consider our board, members of which are active in our operations. We are grateful to the physicians and nursing professors who serve. One of the physicians is a former Surgeon General of the United States. We value the college professors from several disciplines on our board who contribute time and expertise. Computer developers, business men and women all on our board provide donated time and skills to our programs, as well as financial support to operate our organization. Many other volunteers give their time each month to write and edit, to help maintain the Website, to connect with people who operate our programs abroad and to work on the many tasks involved in operating an active nonprofit organization.

WiRED has developed many successful programs in the past 25 years using a model that pairs modest income with low operating costs. What about going forward? We anticipate following this model, while introducing new motivations to potential donors. While for the most part, our previous programs delivered health training directly to grassroots audiences, our new CHW training program shifts to a strategy that offers a ripple effect throughout the community. Training a CHW will yield an impact on many community members. In the past year, 12 CHWs in Kenya reached more than 61,000 people in the community with basic health services, illness prevention classes and health surveillance activities for local health agencies. Our argument: this is big bang for the buck. We know of few other ways to favorably impact public health in underserved regions than this one. Moreover, we’re partnering with local NGOs, training them and assisting with the administrative activities to accomplish our mission. As we point out elsewhere, this strategy creates a sustainable, local organization to continue the CHW training work. 

As we describe in response to the previous item, WiRED’s model for 25 years has been to involve a combination of income streams. Support for our work in the past depended, in part, on the nature of the project. Our work on HIV/AIDS in Kenya and on medical education in Iraq appealed to the U.S. Government. Our work to provide medical education in the Balkans, especially in war-affected Bosnia and Kosovo drew interest from the Medtronic Foundation and the Tatjana Grgich Family Foundation. Much of our work in CHW training has attracted the interest of individual donors, one of whom provided a substantial gift for projects in East Africa.

We plan to fund the upcoming work to cultivate NGOs to provide CHW training through small grants from family foundations with regional interests and individuals who value our record of using 93 cents of every dollar directly on the programs. Again, we are volunteers. We spend a small amount of our donations on required bookkeeping and audits and on software and Web services. 

As we noted in a previous response, in the early 2000s, the U.S. National Institutes of Health provided significant funding for an innovative three-year project to use computers throughout Kenya to teach communities about HIV/AIDS prevention. In the mid-2000s, the U.S. Department of State funded a major medical training project to outfit Iraqi hospitals with Internet facilities where physicians could access health information online and through live conferences with American medical schools and hospitals (which WiRED also arranged).

In addition:

• The Christopher and Dana Reeve Foundation funded a special WiRED medical education center at the National Spinal Injuries Centre in Baghdad in 2003.
• The Tatjana Grgich Family Foundation funded a variety of health and Internet access projects throughout the former Yugoslavia (1998-2006).
• In Kosovo in 1999, the U.S. State Department funded public access Internet centers to a group of organizations, including WiRED, to set up and provide staff training.
• The Medtronic Foundation funded a number of WiRED projects over the years throughout the Balkans, in Iraq, and Fiji. Medtronic also underwrote an ambitious, multi-part training course WiRED developed with experts at the Royal Children’s Hospital in Australia and Oxford in England: The Echocardiographic Diagnosis of Rheumatic Heart Disease for doctors and nurses in developing regions (see https://www.wiredhealthresources.net/EchoProject/index.html).
• Our partner, the Polus Center, funded our work to bring solar-powered computer facilities to clinics in villages in the Peruvian Amazon in 2015.
• A very generous private donor (in 2020) funded CHW training programs in Peru, Nicaragua, Kenya and India.
• Most of our other projects have been supported by the aggregated donations of many individuals who, each year, donate to our non-profit.

The point of the summary above is that we have had an eclectic funding base, where some of the projects were prescribed specifically by the donor, and others, involving foundations and individuals, who saw merit in our work and provided general funding that we used for projects where we determined our help was most needed.

We have stated elsewhere that we don’t charge for our services and programs because our audiences have scant resources to pay even small amounts. We have described our CME program in other sections of this proposal, and we need to note a possible exception to our rule. Here, we are considering a possible revenue stream, but it would not come from individual users. Our aim is to make this program as widely available as possible to as many health workers as possible and charging for it would undermine that key objective.

We have had requests from organizations and larger hospitals for access to the CME program for employees. CME across a wide range of topics is not widely available in many underserved regions, so officials have seen the WiRED program as a resource for staff development. We are currently in discussions about charging the institutions a small amount to enroll employees. At least at this point, we don’t anticipate a significant revenue stream, but it might provide enough income to offset some of the expenses of the program. We also could market this to funders, suggesting that they make it possible for groups of CHWs, nurses and others to enroll.