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.

Pandemics often lead to reduced utilization of essential health services, which can ultimately kill more people than the disease outbreak itself.

During the 2013 – 2016 West African Ebola outbreak, use of primary health services dropped by 18%. A decade earlier, a similar outcome was experienced during the 2003 severe acute respiratory syndrome (SARS) epidemic in Taiwan, where ambulatory care decreased by 23.9%.

As evidence started to emerge of widespread disruptions in healthcare delivery and child well-being during the COVID-19 pandemic, we set out to determine whether adequately supported community health workers (CHWs) could facilitate the ongoing provision of essential health services during the COVID-19 pandemic.

CHWs and Pandemics

CHWs have long been recognized as an essential part of the primary healthcare system. When adequately supported and resourced, they can effectively deliver a range of essential health services to vulnerable and hard-to-reach populations.

Even before COVID-19, CHWs had helped manage the Ebola outbreak in West Africa. And there was already evidence that they could help reduce the negative impact of health system shocks, the likes of which were being experienced as a result of COVID-19.

In 2021, at the height of the COVID-19 pandemic, we conducted a multicountry time series analysis to assess the extent to which professional CHWs (proCHW) – those who are salaried, skilled, supervised and supplied – were able to reduce essential health service disruption.

In short, we found that proCHWs can help maintain community healthcare provision during COVID-19, and by extension, can assist with preparedness for the inevitable future pandemics.

A Community Health Worker measuring the arm of a child while two other adults assist her

Last Mile Health

Assessing Essential Health Service Provision.

To investigate the role of CHWs in preventing essential health service disruption, we assessed monthly routine CHW data for the period January 2018 to June 2021, from 27 districts across four countries: Kenya, Uganda, Mali, and Malawi. The sites had a total catchment population of more than 5.2 million people, served by 7,845 CHWs.

Continuity of essential health services was examined across six primary health care (PHC) indicators, including:

Deliveries Coverage – Percent of newborns delivered at a health facility.

PNC Speed – Percent of women with home delivery receiving first postnatal care (PNC) visit within 48 hours of delivery.

Proactive Coverage – Percent of households visited at least one time per month.

iCCM Speed – Percent of cases where integrated community case management (iCCM) was initiated within 24 hours when required.

Pregnancy Speed – Percent of pregnancies registered in the first trimester.
U5 Coverage – Percent of children under five with a symptom of malaria, diarrhea, or pneumonia assessed within 24 hours of symptom onset.

Two women seated outdoors with a mother and a baby

Nyaya Health Nepal

Preparedness and Protection.

In addition to gathering data on speed and coverage of essential health services, sites that were part of the study self-assessed the level of functionality of their CHW programs using the evidence-based Community Health Worker Assessment and Improvement Matrix (CHW AIM).

This information was absolutely vital for the integrity of the study. Because too often, CHWs are inadequately supported and resourced, and then judged as not being effective in achieving program goals.

Our desire was to understand how proCHWs could maintain continuity of care, not what happens when CHWs are expected to deliver high-quality healthcare without adequate salaries, skills, supervision, or supplies.

On the whole, CHWs at participating sites were supported in line with the WHO CHW Guideline. Importantly, they also received adequate COVID-19-specific training, support, and supplies.

Within 45 days of the first case in their country:

All CHWs’ service delivery protocols were adapted to the COVID-19 context.
CHWs at each region received training on COVID-19 (including: how the virus spreads, common symptoms, how to protect themselves, how to communicate with community members about COVID-19, and roles they will take in combating the spread of the virus).
The vast majority (over 85%) of CHWs received PPE, and nearly all were equipped for the duration of the pandemic period.

The Results.

In all of the six PHC indicators measured from January 2018 to June 2021, speed and coverage were maintained at an equivalent level to pre-pandemic activity.

In one area—proactive coverage—activity significantly improved.

Full results are detailed in the table shown here (click/tap to open in new tab).

Our study demonstrated that CHWs supported in line with WHO recommendations (e.g., paid, in-stock, consistently supervised), and consistently supplied with personal protective equipment (PPE), were able to maintain continuity of community-based essential health services during the COVID-19 pandemic.

Graph displaying the mean percentage for each PHC indicator by month

For proCHWs, Service Doesn’t Stop!

For the 7,845 CHWs we studied, who were providing primary healthcare services to 5.2 million people in Uganda, Kenya, Mali, and Malawi services didn’t stop during the COVID-19 pandemic! Because these CHWs were protected and prepared for the pandemic, they were able to support their respective health systems and maintain speed and coverage of community-delivered care during the pandemic period.

Considering the disruptions in essential health services reported in other areas of the world, combined with the inevitability of future pandemics, the opportunity cost of not adopting proCHW policies may be larger than previously estimated.

Given that the majority of CHWs globally remain unpaid and largely unsupported, our paper highlights the importance of supporting the global proCHW movement.

The starting point is to pay all CHWs for their vital work now, but they also must be skilled, supervised, and supplied.

RESOURCE LIBRARY

Community Health Workers in Pandemics.

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

Roles for CHWs in COVID-19 Vaccination.

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

The COVID-19 Action Fund for Africa.

Key activities, outcomes, and future directions in the fight to protect community health workers (CHWs) during the pandemic and beyond.

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