Roles for CHWs in COVID-19 Vaccination.

Our contribution to the World Health Organization (WHO) vaccination implementation support guide

Since the COVID-19 pandemic, it has never been more apparent that our individual health is only as strong as our neighbor’s.

The unprecedented global COVID-19 vaccination rollout was one of the key initiatives in responding to and controlling the virus. And while higher-income countries generally had the resources and infrastructure to coordinate mass vaccination campaigns, low- and middle-income countries (LMICs) faced an uphill battle.

In fact, while most of the globe has now achieved satisfactory nationwide vaccination levels, more than 20 LMIC countries, including much of Africa, still have vaccination rates below 60%.

In early 2021, as the first commercial vaccines were becoming more widely available, we partnered with the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) to develop an implementation support guide titled, The Role of Community Health Workers in COVID-19 Vaccination.

This advisory was designed to support national governments in developing their national deployment and vaccination plans (NDVP) for COVID-19 vaccines, by outlining the possible roles, needs, and opportunities for professional community health workers (CHWs) to contribute.

Why CHWs?

Half the world’s population lacks access to essential health services.

Issues such as insufficient and unevenly distributed resources, inequalities in access based on gender and other social demographics, and mistrust in health systems are some of the main contributing factors to this statistic. These are also the same barriers that commonly hamper vaccination initiatives in LMICs, especially among vulnerable and hard-to-reach populations.

As members of the communities within which they work, professional CHWs (proCHWs) – meaning CHWs who are salaried, skilled, supplied, and supervised – are ideally placed to overcome these barriers.

Not only do proCHWs have a strong track record of delivering a wide variety of primary health care services, they have proven invaluable in the management of viral outbreaks and infectious diseases as varied as Ebola, HIV, tuberculosis, malaria, and Zika virus.

12 months prior to the vaccination implementation support guide, we identified that in response to COVID-19, CHWs could play a role in:

Interrupting the virus
Maintaining existing healthcare services; and
Shielding the most vulnerable from socioeconomic shocks

In light of the above, having CHWs contribute to vaccination efforts was a logical extension of the contribution they had already made and would continue to make, to responding to the pandemic.

A Community Health Worker extracting liquid from a vial with a syringe

Community Health Impact Coalition

Key CHW Roles in the COVID-19 Vaccines Rollout

In the implementation support guide we identified key roles for CHWs in the vaccines rollout:

1. Planning and coordination

In terms of planning and coordination, recommendations were to:

Include CHW representatives on national and subnational planning committees
Include CHWs as part of the first wave of vaccinations of the essential health workforce
Clearly define and cost the role of community health workers in the vaccine rollout

All of these measures are essential to benefit from the unique insights CHWs have about the communities they serve, and to ensure the CHW role is protected financially and from a health systems perspective.

2. Identification of target populations

The most vulnerable populations tend to be the most difficult to immunize due to a lack of contact with the health system. Yet CHWs are often already in touch with these patients, or can help identify them.

With adequate training, CHWs can also expand the use of digital information systems to assist with:

Forecasting for vaccines inventory
Tracking and locating target populations
Identifying vaccine recipients for multi-dose administration and follow-up

3.Vaccine acceptance and uptake

Mistrust of health services and a lack of vaccine acceptance were flagged as potential barriers to the rollout of the vaccine.

Global evidence shows that CHWs can play an important role in vaccine promotion and acceptance, through community dialogue and engagement, education, trust-building, myth-busting, on- and offline social listening, and facilitating community entry.

4. Community mobilization for service delivery

In light of the potential challenges achieving cold chain transport of vaccines to remote communities, CHWs canplay a role mobilizing community members to accompany them to vaccine centers. They can also facilitate vaccination staff to visit target populations, through facilitating transport and lodging, plus ensuring community members are present for the visit.

5. Vaccine rollout tracking and follow-up.

CHWs can help overcome challenges around achieving high coverage of difficult-to-reach populations, through conducting patient registration, tracking vaccine delivery and timing between doses, and monitoring for adverse events.

Evidence also demonstrates that CHWs can play a critical role in identifying and linking defaulters up to immunization services.

Human Resources to Optimize CHW Roles and Support

The WHO strategic advisory group of experts on immunization (SAGE) stresses the importance of ensuring sufficient financial and human resources to ensure continuity of essential health services alongside vaccine delivery.

Therefore, to assist with this aim, we also provided guidance on strategies to optimize the role of CHWs within existing interdisciplinary health worker teams. This would not only strengthen national responses to the pandemic, but also help alleviate general and COVID-specific health workforce shortages.

Policy and regulatory preparedness

Recommendations in this area included:

Create supportive policies and regulations to recognize and remunerate CHWs
Tailor tasks according to the local context
Issue time-limited regulatory practice waivers for relevant tasks
Enroll CHWs in regular health workforce systems

Resources and funding

The processes and costs involved in engaging CHWs in the vaccine rollout should be clearly defined and budgeted for. This would include training, deployment, supplies (hand hygiene and personal protective equipment; PPE), supervision, and remuneration. The budget must be in addition to other essential health services, including routine immunization.

Training and supervision

Competency-based education and learning programmes, tailored to local conditions, are needed to prepare CHWs and their communities for vaccination campaigns. Areas to cover include preventing the spread of COVID-19, use and disposal of PPE, the vaccines themselves, and community engagement. Additional supervision will likely be required to facilitate this training.

Counting and vaccinating CHWs

Including CHWs in national health workforce counts has been a core component of our proCHW mission since the inception of CHIC. Put simply, unless CHWs are counted as members of the health workforce, it is almost impossible to include them in a coordinated vaccines rollout. And by extension, CHWs should be given the same prioritization for vaccination as other health professionals

Infection prevention and control

Countries will need to plan for, resource, and implement infection prevention and control measures (IPC), both for vaccination stations and mobile workers involved in vaccines related activities. Relevant supplies, including PPE, hand sanitizer, and mechanisms for safe disposal of contaminated equipment will be required, at a minimum. Plus, CHWs will need comprehensive training in IPC, particularly as it relates to COVID-19.

Health system strengthening

The introduction of a new vaccine provides the opportunity to improve not only the country’s immunization programme, but also its wider health system. In line with the WHO Guideline on health policy and system support to optimize community health worker programmes, countries can seize the opportunity to achieve a well-trained and motivated health workforce and to advance gender equality in the mainly female CHW workforce – 70% of CHWs are women.

A Community Health Worker writing down the details of a patient in a log book

Wandikweza

Toward True Pandemic Preparedness.

The COVID-19 vaccines rollout presented a dual opportunity for countries to respond to the current crisis at hand while strengthening their national health system against the inevitable next pandemic.

CHWs can assist with every stage of managing disease outbreaks, from interrupting viral transmission, to maintaining existing health services, and shielding the most vulnerable from socioeconomic shocks. But CHWs can only achieve this when they’re treated like the professionals they are, by being salaried, skilled, supplied, and supervised.

With the The Role of Community Health Workers in COVID-19 Vaccination implementation support guide, we provided a step-by-step guide, based on evidence and best practices, for nations to effectively incorporate CHWs into their vaccines rollout.

resource library

Community Health Workers in Pandemics.

Toward financing practices for community health programs that avoid harm and accelerate impact.

Service Doesn’t Stop: CHWs Maintain Continuity of Care During COVID-19.

Paid and protected CHWs continued to provide health services to 5.2 million people during COVID-19.

The Case for CHWs: Champions of the Health System.

The role of community health workers (CHWs) in improving health equity and coverage.