INTRODUCTION
Community health workers (CHWs)—people trained to meet the health needs of their communities by delivering care in their communities—have been a critical part of health care delivery across diverse contexts for over a century.1 They have also been woefully under-supported: recent estimates suggest that across the African continent, more than 4 in 5 CHWs are unpaid.2 In the context of increasing global health insecurity and a burgeoning health workforce crisis, this trend must change. The coronavirus disease (COVID-19) pandemic reminds us that CHWs who are equipped, trained, and paid as part of a well-functioning health system can help keep pandemics in check and maintain health services equity and access.
True pandemic preparedness and response requires replacing bi/multilateral aid and private philanthropic investments that hinder CHW institutionalization and professionalization (high transaction costs, earmarking, short-termism, appropriation of sovereignty) with investments made in partnership with a recipient country. In particular, these funds should be deployed rapidly and flexibly against government-set priorities.
In this commentary, we review the critical roles of CHWs during pandemics and discuss how rethinking common bi/multilateral aid and private philanthropic investment practices can help create resilient health systems everywhere.
CHWS ARE CRITICAL TO KEEPING PANDEMICS IN CHECK
CHWs—if equipped with ongoing training, supervision, remuneration, medical commodities, and personal protective equipment (PPE)—can prevent, detect, and respond to pandemics by carrying out tasks as diverse as leading community-based infection prevention and control, facilitating safe sample collection, conducting contact tracing, accelerating vaccination roll-out, and providing home-based care to those in quarantine (Table 1).3–20
Examples of How CHWs Have Prevented, Detected, and Responded to Pandemics
CHWS MAINTAIN ESSENTIAL HEALTH SERVICES DURING PANDEMICS
Pandemics often precipitate declines in essential health service utilization, which can ultimately kill more people than the disease outbreak itself.21 CHWs—if equipped with ongoing training, supervision, remuneration, essential commodities, and personal protective equipment—are critical in maintaining equitable access to these services.
Large disruptions in health care utilization occurred as a result of the COVID-19 pandemic and endured for many months.22 How do we maintain essential health services in crisis and ensure strong systems are capable of responding to changing care-seeking behaviors as a result of fear of facility-based transmission?
It is important to note that CHWs in most countries provide not only promotive but also clinical care.23 Common tasks include Integrated Community Case Management (iCCM) (pneumonia, diarrhea, and malaria treatment), providing oral and injectable contraceptives, treating malnutrition, and administering vaccines for children. In many contexts, CHWs provide a significant proportion of primary care services delivered to uncomplicated febrile patients. In Liberia, for example, 45% of malaria cases are treated by CHWs; in Rwanda 56%.24,25 Such levels of contribution by CHWs have been noted in other countries.26
Recent evidence from 27 districts across 4 countries in sub-Saharan Africa (Kenya, Mali, Malawi, Uganda) found that CHWs supported in line with the WHO Guidelines (i.e., paid, equipped, and continuously trained) and protected with adequate PPE were able to maintain speed and coverage of community-delivered care during the pandemic.27 Specifically, there were no disruptions to the coverage of proactive household visits or iCCM assessments or to the speed with which iCCM was delivered, pregnancies were registered, and postnatal care was received. While this study did not look specifically at equity, previous studies have established that many community-oriented primary health care programs have an explicit equity promotion component,28 CHWs promote equitable access to promotive, preventive, and curative services at the household level,29 and CHW-delivered interventions (including home visits) improve equity in maternal and newborn health.30 Despite such high potential and powerful equity dividend, the majority of CHWs globally remain unpaid, without essential medications,31 inadequately supervised, and largely unsupported. This evidence suggests that the opportunity cost of not professionalizing CHWs may be substantially larger than previously estimated in light of the inevitability of future pandemics.32
Despite the high potential and powerful equity dividend, the majority of CHWs globally remain unpaid, without essential medications, inadequately supervised, and largely unsupported.
THE BEST PANDEMIC RESPONSE IS A STRONG, ACCESSIBLE NATIONAL HEALTH SYSTEM
For CHWs to prevent, detect, and respond to pandemics and maintain delivery of essential health services in the context of significant disruption then, they must be treated as professionals. In other words, the best pandemic response is a strong, preexisting primary health care system integrated with the community level.
Two authors of this commentary work as CHWs in Kenya. They note the difference in how they were supported during the poliovirus 2 vaccination drive of May and July 202133,34 compared to other times during the COVID-19 pandemic. During the polio campaign, they were integrated into national data systems, received consistent supportive supervision, and received prompt payment for their work. The campaign was a success. What possibilities await the world if a similar focus was applied to supporting CHWs in their work at all times?
By leveraging well-established, evidence-based tools such as the Community Health Worker Assessment and Improvement Matrix35 and World Health Organization (WHO) CHW Guidelines,36 governments can design and invest in high-performing CHW programs during and after this pandemic.
The following recommendations have a high potential for long-lasting impact.
Include CHWs in National CHW Registries
Include CHWs in national, Ministry of Health (MOH)-governed human resources for health registries. CHWs cannot be supported to respond to pandemics or maintain essential services unless MOHs know who and where they are. Such registries are vital to support existing CHWs and to identify and close coverage gaps in pursuit of universal health coverage.37
Provide Accreditation
Institutionalize minimum practice standards to ensure CHWs possess the knowledge and competencies required to deliver quality patient care, build trust, and help formally acknowledge the key role CHWs in many cases already play. As with all accredited professionals, CHWs must be meaningfully included in decision making and represented on bodies that plan their work and working conditions.
Increase Accessibility
Ensure that care provided by CHWs is provided without charging point-of-care user fees, an approach that is proven to improve access to care and, therefore, equity.29
Provide Ongoing Skill Development
Provide CHWs ongoing training in the essential clinical and nonclinical skills and knowledge needed to support comprehensive community health care (including education and provision of curative care).
Equip CHWs With Adequate Supplies
Integrate CHW medical and nonmedical supply needs like PPE and essential medicines into national forecasting and supply chain processes (e.g., planning, quantification, distribution, and financing).
Provide Supervision
Ensure all CHWs have a dedicated supervisor. This is critical during pandemics as professional protocols evolve and health and safety risks increase. Having supporting supervisors review summary statistics of CHW performance, assess patient experience, and support CHWs improves the use of community-based care and quality of health delivery.
Offer Competitive Pay
Pay CHWs at a competitive rate relative to the respective market and pay them consistently, on time, and commensurate with the job. Give CHWs the benefits they deserve including hazard pay, family leave, compensation for overtime, and sick leave.
CHWs should be paid at a competitive rate relative to the respective market and paid consistently, on time, and commensurate with the job.
Offer Opportunities for Advancement
Offer professional advancement opportunities, including the possibility of becoming a dedicated CHW supervisor. Include CHWs in decision making at all levels.
Use Data for Performance Monitoring
Invest in comprehensive, nonvertical digital data systems, as well as training on data literacy to equip CHWs to document their visits consistently in a standardized format and report data to public sector monitoring and evaluation and logistics management information systems (e.g., health management information system). These data should be accessible to CHWs, their community, and their supervisor with tools for easy-to-understand data visualization and interpretation to inform performance management, public accountability, and robust monitoring and evaluation.
Ensure a Manageable Workload
To achieve universal health coverage and avoid overburdening CHWs, it is critical to map CHW task allocation and time use.38
In summary, CHWs must be fully and formally integrated into the national health system to identify and treat cases, perform contact tracing, and refer patients to health facilities to receive timely clinical care. Investments in routine community health system strengthening form the underlying foundation of resilient health systems that can adequately respond to outbreaks and pandemics.
INVESTMENT IMPLICATIONS: ENDING COVID-19 AND PREVENTING THE NEXT PANDEMIC
Global crises present opportunities for landmark policy changes. After World War II, Japan achieved universal health coverage, and after Ebola, Liberia launched a national cadre of paid, professionalized CHWs.
Responding to COVID-19 means addressing health crises, economic crises, and political crises at the same time. COVID-19 has exposed and exacerbated systemic inequalities, the sharp focus on which has diminished tolerance for inequality and catalyzed louder demands to dismantle inequitable systems. Multilateral, bilateral, and other donors have responded by increasing their investments in COVID-19 significantly, but not all investments in low- and middle-income countries are equal.
The best investment decisions are made in partnership with a recipient country and when funds can be deployed flexibly enough against government-set priorities as national health systems will outlast most civil society efforts. This is especially true through this pandemic where multiple shifts in priorities and quick decisions are needed to meet the challenges on the ground. MOHs can explain the complex funding landscape of multilateral, bilateral, philanthropic, and national investments; they will identify key gaps, funding priorities, and trusted implementing partners. Working with MOHs to strengthen community health provision ensures that we are all better prepared to face future pandemics. In addition, national civil society and local communities can play a key role in ensuring the equity, sustainability, and accountability in such partnerships.
Working with MOHs to strengthen community health provision ensures that we are all better prepared to face future pandemics.
One example of this type of government-led funding is the Community Health Roadmap Catalytic Fund, a unique fund designed to meet small-scale, flexible funding needs that are prioritized by community health coordinating mechanisms within MOHs.39 In this crisis, this fund supported the MOH COVID-19 response at the community level in Malawi and Zambia, getting funds to governments before large funding resources were available. Testimonials from MOH officials indicate this quick action helped both countries kickstart their response (Charles Mwansambo and Sylvia Chila, video communication, November 2020).
The best investments respond to the current crisis while also helping to build back better long-term through advancing CHW professionalization. An example of this is the COVID-19 Action Fund for Africa (CAF-Africa). By integrating with national COVID-19 responses, this collaboration was able to provide PPE to CHWs in a moment of acute need and also contribute to recognition, equality, and pay for CHWs across the continent.40 In Uganda, for instance, the government announced plans to compensate CHWs, known locally as village health teams, for their role in combating COVID-19 shortly after receiving a shipment of PPE. One official described this change as “a dream for the Ministry of Health for the last 20 years”—reinforcing the notion that crises present opportunities for landmark policy change.41
IDEAS FOR ACTION
As CHWs and allies with a vested interest and shared commitment toward professionalization of CHWs and who have witnessed firsthand the detrimental practices that hold back community-delivered care, we offer several considerations to funders that share our interest in redressing systemic issues and propelling community health systems into a new era of achieving their full potential. New philanthropic investments should align with and support government strategies according to their needs and changing circumstances, including the demands of civil society. Immediately available, flexible, and transparent funding with robust systems of accountability powered by national civil society and local committees could support the steady, long-term execution of existing strategies.
True pandemic preparedness and response requires global health actors to accelerate the shift from practices that cause harm to practices that accelerate impact. By dispensing with ways of working that hinder CHW institutionalization and professionalization, resilient health systems are within our grasp. For example, the vast majority of CHWs who deliver malaria drugs, conduct TB directly observed therapy, or accompany HIV patients, do not receive a salary, in contravention of WHO and International Labour Organization guidelines.42,43 Funders must understand the degree to which the success or “cost-effectiveness” of their grantmaking is underpinned by the unremunerated efforts of predominantly poor women of color (i.e., by measuring the percentage of unpaid CHWs who participate in their initiatives), and they must work until that percentage is “zero.”
By dispensing with ways of working that hinder CHW institutionalization and professionalization, resilient health systems are within our grasp.
Table 2 provides additional, though not exhaustive, examples of harmful practices and more promising alternatives for a wide spectrum of funder types and roles.44–47 These examples paint a picture of dynamics that have hindered the current response and can be reversed before the next pandemic.
Considerations for Transforming the Status Quo in Community Health Financing
CONCLUSION
The COVID-19 pandemic presents an opportunity for landmark improvements in the ability of health care systems to reach and serve everyone—even in difficult circumstances. CHWs have long played a critical role in preventing, detecting, and responding to pandemics across the globe. To expand, improve, and institutionalize these services, changes in the approach to bi/multilateral aid and private philanthropic investments in low- and middle-income countries are required. First, we must do no harm. Then we must do much more, much better. Practices that hinder CHW stability, support, and labor rights can be intentionally replaced with those that enable sovereign, resilient health systems to flourish. The time is now.
Acknowledgments
The authors would like to acknowledge community health workers (CHW) and CHW supervisors for their continued service.
Author contributions
Conceptualization & project administration: LN and MB. Original draft: MB, AJ, and IM. Idea generation, data curation, review & editing: all authors.
Competing interests
None declared.
Notes
Peer Reviewed
First published online: April 18, 2022.
Cite this article as: Ballard M, Johnson A, Mwanza I, et al. Community health workers in pandemics: evidence and investment implications. Glob Health Sci Pract. 2022;10(2): e2100648. https://doi.org/10.9745/GHSP-D-21-00648
- Received: September 17, 2021.
- Accepted: March 8, 2022.
- Published: April 28, 2022.
- © Ballard et al.
This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-21-00648
REFERENCES
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- Article
- INTRODUCTION
- CHWS ARE CRITICAL TO KEEPING PANDEMICS IN CHECK
- CHWS MAINTAIN ESSENTIAL HEALTH SERVICES DURING PANDEMICS
- THE BEST PANDEMIC RESPONSE IS A STRONG, ACCESSIBLE NATIONAL HEALTH SYSTEM
- INVESTMENT IMPLICATIONS: ENDING COVID-19 AND PREVENTING THE NEXT PANDEMIC
- IDEAS FOR ACTION
- CONCLUSION
- Acknowledgments
- Author contributions
- Competing interests
- Notes
- REFERENCES
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