Community Health Workers in Pandemics.

In the wake of the COVID-19 pandemic and a growing health workforce crisis, Community Health Workers (CHWs) have never been more important to improving global pandemic preparedness and health equity.

When they are treated as the professionals they are, by being salaried, skilled, supplied, and supervised, CHWs have repeatedly demonstrated their ability to maintain essential health services and support struggling health systems during pandemics. 

We saw this during the height of the COVID-19 pandemic in sub-Saharan Africa, where professional CHWs (proCHWs) ensured there were no disruptions in several primary health care (PHC) services. And several years earlier, CHWs were vital to the response to the West-African Ebola outbreak of 2013 – 2016. 

ProCHWs have been indispensable to efforts to control the spread of COVID-19 in many countries, playing roles as diverse as case identification and surveillance, contact tracing, community engagement and education, testing and vaccination, and supporting home isolation of infected patients. 

Clearly, resilience against the inevitable future pandemics requires proCHWs who are equipped, trained, and part of a well-functioning health system. Yet that’s still not the case in most countries.

Recent estimates suggest that across the African continent, more than 80% of CHWs are unpaid. And these same workers are operating in an environment where they face essential medicine stock-outs approximately 30% of the time and have trouble accessing even basic personal protective equipment (PPE). 

One of the contributing factors to this problem is the use of investment practices that cause harm, primarily through high transaction costs, earmarking, short-termism, and appropriation of sovereignty.

At the Coalition we reviewed these challenges in the context of pandemic preparedness and response, in a paper titled Community Health Workers in Pandemics: Evidence and Investment Implications. 

In our paper, we identified the following 10 points from the aforementioned documents as having a high potential for contributing to the creation of effective and long-lasting CHW programs:

• Include CHWs in National CHW Registries – CHWs can’t be supported to respond to pandemics or maintain essential services unless Ministries of Health (MOH) know who and where they are (see this article for further information on establishing a national CHW registry).

• Provide Accreditation  – CHWs are health professionals and should be subject to accreditation standards just like other medical and allied health staff.

• Increase Accessibility  – Abolish any point-of-care user fees for CHW services to improve access to care and equity.

• Provide Ongoing Skill Developmen  – CHWs must receive adequate and ongoing training for all aspects of the care they provide.

• Equip CHWs With Adequate Supplies  – CHWs are often “last-in-line” for medical and non-medical supplies, like PPE and essential medicines. They should be included in national forecasting and supply chain processes.
• Provide Supervision  – Ensure all CHWs have a dedicated supervisor.
• Offer Competitive Pay  – CHWs should be paid at a competitive rate relative to local market conditions. Pay should be consistent, on time, and commensurate with their roles and responsibilities.Offer Opportunities for Advancement  – Offer opportunities for advancement, including the possibility of progression to a dedicated CHW supervisor and involvement in decision making.
• Use Data for Performance Monitoring  – Invest in data systems and training that allow CHWs to complete standardized documentation that feeds into MOH information systems.
• Ensure a Manageable Workload  – Map task allocation and time use to avoid overburdening CHWs and ensure delivery of high-quality care to patients.

COVID-19 exposed and exacerbated systemic health system and societal inequalities. In response, multilateral, bilateral, and other donors increased their investments significantly, but not all investments in low- and middle-income countries (LMICs) are equal.

To be truly prepared for the next pandemic, investment in proCHWs must move away from financing practices that cause harm, toward community health financing practices that accelerate impact.

The best investment decisions occur in partnership with a receiving country and allow funds to be deployed flexibly against government-set priorities. This is especially true in pandemics, where priorities shift rapidly and require prompt actions to address risks to population health. MOHs are best placed to respond in the agile manner required and should be given the flexibility and support to do so.

Effective crisis-driven CHW investment responds to the current challenge, while also helping to build better long-term outcomes by making sure proCHWs are the norm worldwide. The COVID-19 Action Fund for Africa (CAF-Africa) is a prime example of this. Not only did the collective provide PPE to CHWs in a moment of urgent need, but they also contributed to recognition, equality, and pay for CHWs across the continent.

Considerations for Transforming the Status Quo in Community Health Financing

Below is a table from our paper detailing financing practices that cause harm, alongside alternatives to accelerate CHW impact.

Read the Paper