Delivering Health Services to the Most Vulnerable During COVID-19
By Kyle Muther | Director, Advisory Engagements at Last Mile Health
Effective pandemic responses are dependent on strong health systems that rapidly deploy community health teams to prevent, detect, and respond to the virus
As of April 21, 2020 there are 2,314,621 confirmed cases of COVID-19 reported globally (WHO). In Africa, 45 countries have reported COVID-19 cases, increasing at an alarming rate of 73% in just a week. Sharp increases in cases will overwhelm health systems in countries with limited critical care capacity and shortages of workers and supplies. Not only will patients be at risk of contracting the virus itself, but as essential health services are often interrupted during times of crisis, they will also be vulnerable to preventable disease due to lack of access to primary healthcare. Compounding this issue is that many people face serious health issues — such as HIV, TB, malaria and malnutrition. Also, strategies to prevent the spread of COVID-19 like social distancing will be difficult to put in place in Africa, particularly in poor populations with many living in close quarters and working for their daily income in an already precarious informal economy. As a result, the virus is likely to disproportionately affect the most vulnerable.
In previous epidemics, like Ebola, rapidly expanding healthcare teams through community health workers (CHWs) was critical.* As part of interdisciplinary teams of nurses, doctors, and other health workers, CHWs played a vital part in reducing transmission through promoting prevention tactics and contact tracing, detecting, and referring individuals with suspected Ebola for testing, as well as referring Ebola patients to seek care early.
Another key lesson from Ebola is that effective epidemic response relies on resilient health systems that can maintain delivery of health care services while also responding quickly to the crisis. Resilient health systems are 1) aware of their strengths/challenges because they regularly collect high quality data on the available resources and health needs; 2) integrated in that they have good coordination mechanisms between the different levels of the health system; and 3) adaptive in that they are able to rapidly respond to crises or shifting conditions and use data and learning to improve.
For over 10 years, Last Mile Health has focused on building strong and resilient community health systems in partnership with government that deploy community and frontline health workers to provide life saving health care to rural and remote communities. Our experience responding to the West African Ebola outbreak and scaling a national CHW program under the Government of Liberia’s leadership is the foundation of our COVID-19 response. We are now exploring how to support the Government of Liberia and other partners to ensure community health workers can safely prevent, detect, and respond to the epidemic while also maintaining delivery of routine health services.
Prevent: CHWs play an important role in preventing common diseases like malaria through education and behavior change. In the pandemic, we are designing and supporting training of CHWs and their supervisors in infection, prevention, and control measures such as sensitizing communities in social distancing and hand washing. Though the worldwide shortage of personal protective equipment (PPE) is a challenge, we are also supporting the government to quantify how much PPE would be required to keep community health workers safe while they keep serving their neighbors.
Detect: CHWs reduce morbidity and mortality by diagnosing common ailments like diarrhea, malaria, and pneumonia before they become too severe. To respond to the pandemic, with a coalition of partners and Ministry of Health teams, we are supporting the development of curriculum and job aides that would allow CHWs to identify the signs and symptoms of COVID-19, report this information via the existing community events based surveillance system. In addition, we are coordinating with the Ministry of Health and partners to support procurement and deployment of rapid testing once available.
Respond: CHWs treat mild cases of pneumonia and diarrhea at community level, reducing the need for hospitalization. Building on this experience, we are exploring how CHWs can provide temporary monitoring of individuals with COVID-19 at the community level and facilitate rapid referrals for those requiring hospitalisation.
Maintain delivery of health services: During the West African Ebola outbreak, more people lost their lives by the interruption of essential, primary health services than the virus itself. To maintain consistent access to care, we are exploring how to modify existing clinical protocols to protect CHWs. For example, avoiding all physical contact with patients and basing assessments on patient history and observations. As Zack Flahnman, a registered nurse who supervises community health workers as part of Liberia’s national program, said, “Primary health care should continue because the community serves as the first point of contact, it is at the community where health promotion and disease prevention are first initiated. If there’s hindrance to the primary health care program in this COVID-19 pandemic, we anticipate that there will be high morbidity and mortality rate in our counties and Liberia at large.”
This pandemic underscores what we’ve always known to be true: we need resilient health systems that provide universal access to primary healthcare, and can be surged in times of crisis. This is why we will continue our work to support the Liberia Ministry of Health to strengthen and sustain the governance, management, and data systems of the national community health worker program, as it will protect the most vulnerable patients during this pandemic and the next one.
For more information on the role of community health workers in fighting the COVID-19 pandemic, a global coalition of 16 organisations working with governments from Haiti to Mali to Nepal issued a position paper and developed a technical resource wiki to support organizations seeking to optimally engage CHWs in fighting the COVID-19 pandemic.
*BRAC has partnered with Last Mile Health on various initiatives, including knowledge sharing with field staff in Liberia during the Ebola crisis, as well as on design aspects of community health workers to inform Graduation work being done in the Philippines, Uganda and Liberia.