With the world currently experiencing a global pandemic alongside a shortage of health personnel to attend to millions of ailing people, Lynda Keeru of Pamoja Communications and Kate Hawkins from ReBUILD attended a timely webinar ‘The role of CHWs in future-proofing health systems in fragile and conflict-affected settings.’ The webinar brought together different speakers from a range of settings to discuss this vital topic.
Most countries in the global south have a shortage of formal, educated, healthcare workers and are increasingly looking into a range of Community Health Workers (CHWs) to fill this critical gap. CHWs are particularly critical in fragile settings where there are additional challenges with delivering healthcare. CHWs have proved to be essential, trusted and first-line responders providing health services in settings affected by conflict and disasters.
Bridging the gap
During the webinar, we heard that CHWs are part of communities and work closely with local leaders – they are familiar with the local norms and culture and are accepted. CHWs often have existing relationships that enable good access to the community, and on an individual level, they often have a sense of duty and willingness to serve their communities. As discussed by Mushtaq Khan, drawing on programme experiences in Yemen, Syria, and Jordan, CHWs are ideally placed to act as a bridge between their communities and health systems.
Their depth of community knowledge enables CHWs to innovate and mobilise local resources. For example, CHWs in Sierra Leone rigged up jerry cans to act as handwashing stations when the importance of hygiene to COVID-19 prevention became clear.
Despite these beneficial qualities, most CHWs lack the necessary support from the health system that would maximise their benefits.
Despite the great value that CHWs provide in fragile and conflict-affected settings, they, unfortunately, have had to deal with a host of challenges created by both health systems and the community. These challenges include low recognition, remuneration, training, and supportive supervision, and have been exacerbated by COVID-19 which has created more burdens and responsibilities.
In addition to daily responsibilities, COVID-19 has increased the burden of CHWs as they have taken on awareness-raising, the distribution of hygiene kits, tracking, screening, registering, referral of people with COVID-19, and psychosocial support.
Joanna Raven highlighted a gender difference in the roles of CHWs in some settings. CHWs revealed that many of them had to juggle work and their families which was a particular issue for women. The pandemic presented an increase in challenges with increased workloads, safety concerns (particularly during travel), and the constant fear of contracting the virus which heightened anxiety levels. There were disruptions in other forms of income-generating activities due to lockdown and travel restrictions. The increased price of staple goods led to an increase in stress levels and this was particularly challenging for female CHWs who were widowed or single mothers.
Joanna explained that for CHWs to successfully implement their duties, they require support from their communities and families. This support is not available for all CHWs in all settings because of the perceived voluntary nature of their work. Despite supervisors being aware of the challenges related to COVID-19, there was little support from the health system. Many of the CHWs experienced stigma and discrimination from their families and community members, and they were isolated from social activities as they were viewed as carriers of the virus. CHWs also reported a lack of equipment, training, and Personal Protective Equipment.
Saw Nay who presented the challenges of CHWs in contested political contexts, said the challenges included unstable political situations, over-reliance on international support, insufficient incentives for CHWs, and very low educational levels. In emergency settings, CHWs have to double both as humanitarian staff and as members of the community affected by the emergency. Therefore, regular training and supervision is crucial to ensure quality service provision and maintain the wellbeing of team members.
Mental health and the need for accessible psychosocial support for communities and CHWs is another challenge. Andreas Loepsinger and Olga Rebolledo shared learning on interesting approaches from northern Nigeria, supporting the development of multidisciplinary community-based psychosocial mobile teams who can respond to community needs through time and through different displacement phases. They highlighted the importance of ongoing supervision for the team in different forms (individual, peer, groups), sharing practical experiences, building safe spaces, and mutual support.
CHWs play a vital role in preventing, monitoring, and responding to disease outbreaks. It is therefore crucial that we accelerate investments in community health.
Sally Theobald from ReBUILD for Resilience said:
“It was a real privilege to chair this webinar which was jointly hosted by two Health Systems Global Thematic Working Groups: Fragile and Conflict-Affected Settings and Community Health Workers. The speakers spoke passionately about timely and relevant research and programmatic experience with community health workers from Syria, Yemen, Jordan, Myanmar, Lebanon, Nepal, Sierra Leone, and Nigeria, sharing experiences across these different contexts and highlighting how COVID-19 has brought new challenges and responsibilities. The key learning for me was the urgent and critical importance of further supporting this embedded cadre, who enjoy trust at the community level, and are a bridge between communities and health systems.”
There is no dearth of evidence regarding critical issues concerning CHWs including remuneration, capacity building, safety, and security. Joana Raven in responding to a question from the participants to the webinar said:
“Through this webinar and from literature, we see that there is huge evidence that CHWs need support from the health systems and the community. The question should be when and how do we start to see such evidence being translated into tangible actions that address the plight of CHWs in FCAS as well as across the other settings worldwide.”
Sally Theobald – LSTM/ReBUILD for Resilience
Mushtaq Khan – Health Advisor, IRC in South Asia and MENA
Joanna Raven – LSTM/ReBUILD for Resilience
Saw Nay Htoo – Director of Burma Medical Association
Andreas Loepsinger – International Organization for Migration
Olga Rebolledo – International Organization for Migration
Image by UNICEF Ethiopia is licensed with CC BY-NC-ND 2.0.