Community Health Workers in Pandemics: Evidence and Investment Implications

Madeleine Ballard; Ari Johnson; Iris Mwanza; Hope Ngwira; Jennifer Schechter; Margaret Odera; Dickson Nansima Mbewe; Roseline Moenga; Prossy Muyingo; Ramatulai Jalloh; John Wabwire; Angela Gichaga; Nandini Choudhury; Duncan Maru; Pauline Keronyai; Carey Westgate; Sabitri Sapkota; Helen Elizabeth Olsen; Kyle Muther; Stephanie Rapp; Mallika Raghavan; Kim Lipman-White; Matthew French; Harriet Napier; Lyudmila Nepomnyashchiy

doi:10.9745/GHSP-D-21-00648

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TABLE 1.

Examples of How CHWs Have Prevented, Detected, and Responded to Pandemics

	Intervention	Example^{^a}
Prevent	Educate communities regarding signs, symptoms, and transmission routes. Lead skill building for personal preventive measures such as social distancing, hand hygiene, coughing/sneezing into elbows, and water, sanitation, and hygiene interventions. Address public health misinformation as trusted messengers during in-person interactions.	DRC, Liberia: During the 2014–2016 Ebola epidemic, CHWs were part of the interdisciplinary teams of nurses, doctors, and other health workers who played a critical role in reducing transmission through promoting social distancing and other infection prevention and control measures.³ Global: By April 2020, CHWs reached 2.5 million households across 27 countries as part of countries' national strategies during the COVID-19 epidemic.⁴
	Supply: Support, lead, or reinforce community and facility-based infection prevention and control measures, such as construction of triage areas, use of personal protective equipment (e.g., face masks and gloves), and creation of hand hygiene stations.⁵ Distribute PPE to the community.	Cote d'Ivoire employed CHWs during the 2014–2016 Ebola epidemic for disease prevention and control as did Liberia, Sierra Leone, and DRC.⁶
	Vaccinate: CHWs have a critical role at every stage of vaccine rollout: planning; identifying target populations; outreach, engagement, and education; mobilization; and tracking and reporting outcomes.⁷ Critically, this requires that CHWs be protected with PPE and vaccinated as part of the initial allocation for health workers.	Ethiopia, India, Malawi, Pakistan: Health extension workers, accredited social health activists, HSAs, and lady health workers routinely provide intramuscular medicines.⁸^,⁹ HSAs currently serve as COVID-19 vaccinators in some parts of Malawi.
Detect	Detect signs and symptoms in community members and conduct rapid tests, where available.¹⁰	South Africa deployed 28,000 CHWs to screen more than 7 million people for COVID-19.¹¹
	Facilitate safe sample collection in communities and health facilities of samples and rapid transport to laboratories for analysis, thus reducing risks of nosocomial transmission.	Sierra Leone: As part of a post-Ebola laboratory strengthening, CHWs were enlisted to coordinate the collection and transport of sputum samples for tuberculosis testing from patients in the community to the laboratory.¹²
	Alert through integration into community events-based surveillance systems.⁵	DRC: During the 2014–2016 Ebola epidemic, CHWs filed alerts that were investigated within 24 hours.¹³ Madagascar: During the 2017 plague outbreak, 4400 CHWs and 340 supervisors were trained to conduct community-based active surveillance, contact tracing, and follow-up activities across the country.¹⁴ Kenya: During the COVID-19 pandemic, 6000+ CHWs were trained to use a mobile tool for community event-based surveillance, which was applied across 10 counties.¹⁵ Modeling indicates that CHWs participating in disease surveillance systems detect outbreaks to a comparable degree and with better timeliness compared to professional health care data entry staff.¹⁶
Respond	Communicate rapidly and effectively to residents in pandemic areas, including taking the time needed to communicate health information in a tailored and relevant way and combat the spread of misinformation.¹⁷	Malawi, Togo: As part of routine home visits, CHWs help track issues through community conversations and chats with informants, and tracking and media reporting, messaging, social media posts about COVID-19.
Respond	Enable self-isolation and Monitor patients in the community while ensuring delivery of food, social, and medical support. Monitor patients for clinical deterioration and support rapid referral of individuals who require hospitalization, reinforcing links between the health system and communities.	Kenya, India: CHWs led home-based care for COVID-19 patients not requiring hospitalization.¹⁸^,¹⁹
	Conduct contact tracing, symptom reporting, and monitoring of contacts of COVID-19 patients to ensure access to testing and treatment for those who develop signs and symptoms.¹⁷	Nigeria: CHWs' thorough knowledge of the landscape significantly shortened the commute time and led to more successful clinical outcomes. Their presence also served to facilitate community entry and acceptance among residents.²⁰ Africa CDC's PACT initiative supported over 18,000 CHWs across 27 countries to conduct contact tracing and testing referrals. A recent evaluation of the PACT CHW program, based on feedback from 10 countries, suggests that it positively influenced the COVID-19 response and elevated the importance of CHWs' roles within primary care (Diana Nsubuga, PhD, email communication, July 28, 2021). As of August 2021, the 18,000 CHWs deployed supported 2.5 million household visits for risk communication and community engagement activities, active case search and contact tracing of more than 1.6 million contacts, and facilitation of testing referrals for 78% of suspect cases.

Abbreviations: CDC, Centers for Disease Control and Prevention; CHW, community health worker; COVID-19, coronavirus disease; DRC, Democratic Republic of the Congo; HSAs, health surveillance assistants; PACT, Prevention and Access to Care and Treatment; PPE, personal protective equipment.
↵a The authors of the article work predominantly in South Asia and Africa, from which the majority of the examples are drawn.

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TABLE 2.

Considerations for Transforming the Status Quo in Community Health Financing

Community Health Financing Practices That Cause Harm	Community Health Financing Practices That Accelerate Impact
High transaction costs: Complexity of donor processes (different funding windows, application deadlines) and documentation requirements. Funding sometimes only reaches communities months or even a full year after an emergency starts Example: For any country's annual budget, multiple donors contribute 10%–12% each toward the budget. These funders have asynchronous funding cycles, documentation requirements, metrics, application lengths, and processes.	Pooling: Donors pooling funding not only reduces transaction costs but also facilitates greater alignment and the flexibility to respond to unexpected crises such as pandemics. Aligning grant requirements and templates to reduce application burden would best leverage limited government bandwidth. Example: One example of this is the Risk Pool Fund, “a collaborative experiment that makes fast, flexible funding available to pre-selected non-profits that are encountering an unexpected obstacle that threatens impact.”⁴⁴
Ear-marked and inflexible: Funding single disease areas (e.g., malaria) independently from the larger health system leads to inefficiency in limited resources Example: In one country, a CHW who has not received payment for months has received 5 smartphones to track disease-specific indicators. Not only is the value of the smartphones higher than the CHW's stipend payment, but the smart apps do not capture all duties, so the CHW has to carry both hard copy tools and the phones.	Unshackle: Give unrestricted funding or reduce restrictions on grants. Holding entire programs accountable for their performance is a more rigorous form of accountability than restricting line items. Examine any necessary restrictions for potential negative unintended consequences/spillover effects. Example: Collaborative funding for digital health across multiple technology providers to support pandemic preparedness and digital response from Rockefeller and other philanthropic entities. It appears that this collaborative, rather than competitive, funding model will continue in the wake of the pandemic and could be a strong model for building robust digital health systems. Similarly, several funders committed to providing unrestricted funds during the pandemic—such efforts should broaden and continue.
Contrary to evidence: RFPs and grant applications are not consistently designed and evaluated based on evidence-based guidelines like the CHW AIM tool and the WHO CHW guideline. Programs give priority to new or “innovative” approaches, at the expense of tried and true practices known to improve CHW program performance, like fair pay, ongoing training, and dedicated supervision. Example: A large foundation involved in the CHW space funded a vertical (malaria-specific), volunteer-based “project” in a country with an existing professionalized CHW program.	Evidence-based: Provide funding based on evidence-based guidelines and tools like CHW AIM to design RFPs and evaluate investment opportunities. Example: In Mali, the Global Fund pays for dedicated CHW supervision, based on government policy and studies published on results in trial sites. While the funding was originally for 1 year, it has now been renewed as part of a larger 3-year national funding package, NFM3.
Late to pay: Ineffectively designed mechanisms lead to late payment of CHWs and their supervisors and delayed procurement of the tools they need. This can destroy morale and program effectiveness. Example: We have seen funder lateness, as well as primary recipient (NGO) lateness to pay due to contingencies placed by the funder (for example, a paper report may need to travel from a remote village to the capital before a regular monthly salary is released, leading to months of delay). One author of this article is a CHW working on the COVID-19 vaccination campaign in Malawi where wages have been delayed for 3+ months—a fact he and his colleagues find profoundly demotivating.	Optimize disbursement: Optimize, and when needed, redesign disbursement processes to prevent delayed payment and procurement. Example: In Cambodia, a funds-flow analysis helped identify why these bottlenecks are occurring and what actions are needed to prevent them in the future (e.g., development of SOPs, expenditure tracking systems, standardized funds request forms).⁴⁵ In Liberia, mobile money payments to CHWs were instituted to prevent delays. ⁴⁶
Appropriation of sovereignty: Funding that does not align with and support national and sub-national government-led strategy can undercut government sovereignty, leadership, and effectiveness. Example: Almost no private philanthropic funders require CSOs/NGOs to (1) prove/substantiate in applications how their plans align and support national strategy, (2) confirm government partnership (e.g., via partnership agreement already signed).	Align with and support: government strategy and invest to build up the national system. Example: In 2021, the U.S. President's Malaria Initiative announced the removal of restrictions on the funding of CHW salaries.⁴⁷
Pressured exploitation: Funding restrictions have a wide array of unanticipated negative consequences. Multiple major funding agencies will not fund salaries at all, making it difficult for governments to implement global recommendations or to create long-term financing pathways for CHW payment, which often require a mix of international and domestic investment. Example: We have witnessed funders pressure governments and grantees to reduce pay for CHWs and their supervisors to well below minimum wage. Such pressure undermines years of work that went into establishing norms for fair and effective payment of community health workers and makes it much harder for governments to do the right thing (Notably, NGO CEOs are almost never asked to justify the sustainability of having funding agencies paying their salary yet are asked constantly to justify the sustainability plan for CHWs, who are predominantly women living in poverty.)
Short-circuiting change: Short grant and/or financing cycles move grantees toward the easiest strategies for getting funding quickly out the door (such as procuring a large quantity of a given commodity) and away from transformative, high-impact investments Example: While the speed of disbursement is critical and often lacking, duration of commitment is also often lacking. Delayed, slow disbursement of funds, particularly during Ebola 2014 and COVID-19 in 2020–2021, has negatively impacted outbreak response. Relatedly, short-duration commitments create pressure for less effective quick fixes and subvert government efforts to make transformative change in their health care systems.	Stay: Longer term, predictable investments support governments and their partners to commit to creating enduring, high-impact community health systems. Longer duration commitments allow governments to invest in recruiting, training, accrediting paid, professionalized CHWs in alignment with WHO guidelines and CHW AIM scorecard. Example: Thomas J. White, cofounder of Partners in Health, funded work in Haiti for his entire life. Institutional funders typically fund in months or years, not decades.

Abbreviations: AIM, Assessment and Improvement Matrix; CEO, chief executive officer; CHW, community health workers; COVID-19, coronavirus disease; CSO, civil society organization; NFM3, new funding model 3; NGO, nongovernmental organization; RFP, request for proposal; SOP, standard operating procedure; WHO, World Health Organization.