Adapting health provision models during COVID-19 to support Community Health Workers delivering equitable care: sharing experiences across multiple contexts

Adapting health provision models during COVID-19 to support Community Health Workers delivering equitable care: sharing experiences across multiple contexts

HSR2022 Participant Blog Series

Adapting health provision models during COVID-19 to support Community Health Workers delivering equitable care: sharing experiences across multiple contexts

This blog is part of a series of blogs written by participants at HSR 2022 reflecting on some of the key messages and learnings emerging from the symposium.

The Health Systems Global Community Health Workers (CHWs) Thematic Working Group (TWG) hosted an organised session at the Seventh Symposium of Health Systems Research held from 31st October to 4th November 2022 in Bogota, Colombia. The CHWs TWG supports generation, synthesis and roll out of evidence on CHW programmes – across geographical and political contexts. The session was aimed at hearing from various CHW panellists, policy makers and civil society leaders on how they adapted to protect themselves and communities, interrupted transmission of the virus, maintained access to essential services, and shielded the most vulnerable during the COVID-19 pandemic. Carey Westgate, the deputy director of Community Health Impact Coalition, chaired the session on behalf of the TWG.

Henry Bugembe, a CHW from Wakiso district in Uganda, was the first speaker who shared his experiences in the COVID-19 response. He talked about how CHWs are a critical bridge between communities and health system in Uganda. CHWs link communities to health services; provide sensitisation on health; promote hygiene and sanitation; treat childhood illnesses; and participate in health campaigns such as distribution of bed nets. He added that the role of CHWs in supporting the public health response intensified during the COVID-19 pandemic as CHWs took on even more roles and responsibilities. Some of the examples he gave included supporting medication adherence by delivering drugs directly to patients when facilities were closed or otherwise inaccessible, supporting COVID-19 vaccination activities, educating communities on COVID-19 and dispelling myths that the disease was only for the rich and affluent individuals. CHWs in Uganda also transported vaccines and medical documents, as well as connected health workers to patients. Henry added that it was a very busy time for CHWs in Uganda. He commended the Ministry of Health for recognising the critical role filled by CHWs during COVID-19 and for committing – for the first time – to pay them for their work on the frontlines. However, more work is needed. Henry acknowledged that his work was enabled by a non-governmental organisation that provided fuel and transport support, but that this was not the case for all CHWs, for whom lack of transport remained an issue. Henry concluded with a call to action to support CHWs in their work as they have families to look after. Many CHWs work on a voluntary basis and need to be motivated more so as to perform better.

Henry Bugembe making his presentation in Bogota.

 The second speaker was Charanjeet Kaur, a CHW from India with two children. Her recorded remarks were translated by Dr. Clarence Samuel, a Professor of Community Medicine at Christian Medical College Ludhiana, India. Charanjeet noted that CHWs in India were at the frontline of the COVID-19 response – protecting communities and interrupting transmission – without appropriate tools and support, including personal protective equipment (PPE).  They carried out house-to-house visits and looked for symptoms of COVID-19. In so doing, they faced challenges and stigma, including meeting resistance at the community level. During this time, their relationship with the community suffered as people became hostile and aggressive, and some friction with communities ensued.  CHWs had to work when others were in lockdown, and they bore the brunt of the anger and misinformation in the community. She described how rumours abounded that health workers were given incentives if they found COVID-19 cases; this contributed to community suspicion and distrust of health workers. Despite these obstacles, CHWs continued to go into the community to test, screen, and carry out other roles – a testament to their courage and resilience.

Charanjeet’s profile on the screen before her recording was played.

The next speaker was Margaret Odera, a Community Health Volunteer from Kenya who was also involved in mentoring pregnant and nursing HIV positive women. She was recently recognised as one of  the 2022 heroines of health at the World Health Assembly. Margaret has lived with HIV for 22 years, her husband is HIV negative, and she explained how they are living happily together with their HIV-negative children.

In her presentation, Margaret showed how she embedded leadership at the community level, inspiring many others as a role model, and leading by example to address stigma and promote access to health care not only for HIV but also COVID-19 to interrupt transmission, maintain access to essential health services, and shield the community from devasting impact.

She noted that CHW pay is a social justice issue, and you can learn more about pay of Kenyan CHWs here: Below is Margaret’s story:

When I was sick, I was living on prayers and my sickness was getting worse – so I took ARVs, went to a hospital and got counselling. God’s grace has helped me. I help my fellow mothers – with spiritual support and importance of health care. I saw the critical need for mothers to know about taking ARVs; denial meant that people (adults and children) were dying. I found this unacceptable and then decided to set myself as an example, so mothers who were hiding children in their houses could get drugs. That is the reason I became a CHW: to educate the community, to eradicate mother-to-child transmission of HIV, be able to live long healthy lives, and give back to the community. I do community mobilisation, linkages of patients with facilities, referrals and follow up. During the COVID-19 pandemic, a lot of resistance and hesitancy was faced – I took the step to be an example, teaching people to wash hands, although a question came up how to do this with no water. So, we advocated for water and ultimately secured a bore hole in our community of Mathare North. Now with this water, people are washing hands and hygiene standards are being maintained. During COVID-19, I took the initiative and am fully vaccinated – there was a rumour if you get vaccinated you won’t be healthy and can become infertile. But I proved them wrong, and this has encouraged others – and people have accepted and been vaccinated. Fair pay is very important for CHWs. Because if I don’t receive pay, I have to divert my mind to do other things – without fair pay work, CHWs are half minded in health service delivery, and the other half is elsewhere.  Working without money is a mental health issue. Indeed, you can find yourself stranded to pay your own rent and take your children to school. Without fair pay, concentration will be poor and there will not be universal health coverage.  Outbreaks start and stop in the community – that’s why CHWs are vital. It’s an injustice for CHWs not be properly remunerated.

Carey Westgate introducing Margaret before her video was played.

The next speaker was Benilda Batzin from Guatemala who talked about shielding vulnerable communities during the COVID-19 pandemic. Centro de Estudiospor la Equidad y Gobernanza en los Sistemas de Salud (CEGSS) staff and defenders coordinated access to health and needs of indigenous people in Guatemala. CEGSS has been working closely with community organisations in rural indigenous municipalities to transfer the knowledge and skills required to challenge and overcome ethnic discrimination in the Guatemalan health system. By implementing an approach that integrates social accountability and legal empowerment. CEGSS is supporting the collective action of Community Defenders.

Community defenders are volunteers elected by their own communities to implement monitoring and evaluation of public policies and healthcare services. They also collect complaints and evidence of right to health violations in their communities and take them to the corresponding authorities. Community defenders also engage in strategic advocacy with municipal, provincial and national government with explicit demands to eliminate barriers to health care access including the discrimination experienced by rural indigenous families when seeking healthcare. Benilda indicated that some of these issues had been presented to the general assembly of UN in April 2019. Giving her talk in Spanish, some of the key issues in her presentation were the need for improved trust and collaboration in the community; the importance of using social media skills during pandemic response; responsive approaches to the needs of the community; and developing materials that are tailored to the realities of indigenous communities.

Benilda making her presentation.

The final speaker was Anne Ngunjiri, a Program Manager from LVCT Health in Kenya. LVCT Health has a long history in community health and understands the needs for capacity strengthening of this cadre.  Anne spoke about LVCT’s experience using technology and the digital health ecosystem to build resilience of CHWs during COVID-19; how CHWs adapted care models to prevent and respond to reports of gender-based violence; the devastating impact of COVID-19 on public health systems; the importance of a national emergency response committee; and the challenges associated with CHWs not being comprehensively trained on management of community transmission of COVID-19. As just one example of the power of the digital health ecosystem in accelerating adaptations during the pandemic, Anne described how LVCT analysed community feedback and developed COVID-19 messages in Swahili and English to address the most pressing issues, including sexual and gender-based violence. LVCT’s digital ecosystem included a call back / text back service which was linked to the Ministry of Health; this was an efficient way to reach a high volume of patients via a remote engagement platform. Read more here.

After the presentations, several questions were asked, and a discussion ensued on the role of CHWs in pandemic response and how they can be better supported. Some of the key issues discussed included what additional support CHWs need to perform their roles, as well as the role of CHWs in supporting indigenous communities to address local preferences for traditional medicine.

By the Community Health Workers (CHWs) Thematic Working Group (TWG). Find out more about the CHWs TWG here.

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