By Dr. Ochiawunma Akwiwu Ibe and Dr. Doudou Diop
In 2021, Maimuna, a community health worker (CHW) in Mali’s Kadiolo district noticed a yellow tint in a young mother’s eyes. Suspecting yellow fever, Maimuna educated the woman and her family members on the risks associated with the disease and convinced the woman’s husband to take her to the nearby health center where Maimuna is affiliated. Staff there collected a blood sample and Maimuna’s suspicions were soon confirmed by the laboratory at the National Institute of Public Health in Bamako, Mali. Yellow fever is an infectious disease prone to epidemics because of its rapid spread by mosquitoes. The United States Agency for International Development’s Infectious Disease Detection and Surveillance (IDDS) project had trained Maimuna and other CHWs in community-based disease surveillance.
 Not her real name
Health worker teaching community members about yellow fever and the importance of getting vaccinated. (Photo by IDDS)
Empowering Community Health Workers to Detect Public Health Events
CHWs like Maimuna have traditionally been utilized to improve community health initiatives and fill gaps within the health care system. They have historically been involved in disease eradication initiatives such as poliomyelitis and measles, programs for disease control (HIV/AIDS, Malaria and Tuberculosis), and as early warning systems and responses to public health emergencies. When appropriately trained, supervised, equipped with medical commodities and personal protective equipment, and properly compensated, CHWs can help prevent the rapid spread of infectious diseases and mitigate their impact by supporting community-based infection prevention and control, facilitating safe sample collection, conducting contact tracing, accelerating vaccination roll-out, and providing home-based care.
Yet there is even more these essential workers can do, at a time when emerging and re-emerging infections with potential to cause disease outbreaks remain a constant threat to global health security (GHS). The Global Health Security Agenda (GHSA) is an international initiative launched in 2014. It aims to strengthen countries’ capacity to prevent, detect, and respond to emerging public health threats in a manner that aligns with International Health Regulations (IHR) 2005 requirements. The IHR 2005 and the corresponding Joint External Evaluation (JEE) Tool are the foremost international frameworks for building and assessing resilient public health systems, stipulating that countries should have a skilled and competent workforce for maintaining sustainable public health surveillance and response mechanisms. The GHSA’s original framework included 11 action packages, developed to facilitate regional and global collaboration toward specific GHSA objectives and targets measured by the JEE tool. More than 70 countries, including the United States, have committed to the GHSA and begun to strengthen several action packages, including surveillance, which calls for improved functioning of indicator- and event-based surveillance systems capable of identifying potential events of concern for public health and health security. Involving community members to identify and report health events for public health surveillance purposes—an approach commonly described as community-based surveillance (CBS)—has increasingly gained interest as the world continues to grapple with the fight against COVID-19 and recurrent infectious diseases outbreaks such as Ebola virus disease and Monkeypox.
CBS empowers CHWs, volunteers, and the communities they serve to:
- Identify risks and implement practices to prevent the spread epidemic diseases
- Recognize potential disease events (termed “alerts”) and notify authorities
- Engage with community gatekeepers and members to take early action to control disease spread
The CHWs, like other prominent community leaders, such as teachers and faith leaders, often serve as trusted voices in the community and are well placed to detect and monitor health events in the community, mobilize community action, distribute health information during outbreaks and request national assistance and emergency resources to protect public health. Recent CBS implementation experiences and results in Indonesia, Sierra Leone, and Uganda demonstrated that alerts generated by volunteers were highly accurate, matching community case definitions in 96 percent of cases in Sierra Leone, 90 percent in Indonesia, and 73 percent in Uganda. On average, 94 percent of these alerts were detected and reported to authorities within the optimal timeframe of 24 hours.
While these results are encouraging, CHWs require significant training and support if they are to be empowered to effectively implement CBS. In addition to Mali, IDDS has supported CBS implementation in other focus countries in sub-Saharan Africa, namely Guinea and Senegal. In Senegal, IDDS expanded the surveillance of eight human and six zoonotic priority diseases in Saint Louis and Tambacounda regions by training medical officers, animal health officers, environment officers, nurses, livestock staff, and community health volunteers, and has been supporting field investigations of cases reported through CBS. Using a One Health approach, this strategy allows public health and animal health professionals to be alerted by communities through a short message service (SMS), allowing real-time notification via an electronic tool and mobile platform (mInfosanté) that can integrate information across health databases to coordinate available resources and deliver assistance such as ambulances. In Guinea, the post-Ebola strategy focused on creating a strong network of trusted and well-trained CHWs to serve as the first line for disease detection and provide a critical link between the community and formal health services. IDDS supported the Guinea National Health Security Agency and CBS technical working group to update their existing CBS training materials for CHW to incorporate COVID-19 information. Subsequently, IDDS trained 84 health workers in Guinea during a pilot of their new training materials. IDDS trains and mentors frontline workers including CHWs on community- and event-based surveillance, integrates data collected in communities with data collected by health facilities, bolsters mobile early warning systems, and harmonizes approaches across animal and human health surveillance
Exercise of SMS sending via mInfoSante software – Community health workers training, Tambacounda, Senegal – Photo credit IDDS
Investing in the “First Mile” of Outbreak Prevention
In Africa, one of the main lessons learned from the 2014–2016 Ebola virus disease outbreak is that communities have a key role to play in GHS. During the outbreak, to contain the disease, the government of Sierra Leone, with support from the United Nations Population Fund and other partners, implemented responses at the community level. CHWs were involved in contact tracing (a method of tracking contacts, or people linked to confirmed or probable Ebola cases). In Kailahun District—the epicenter of the country’s outbreak and the most affected district—the CHWs went door-to-door to learn about people who might be affected, and then followed up with each possible contact. Their work allowed authorities to track the spread of the outbreak and ensured early detection of infections and immediate treatment. CHWs were also involved in educating the community about disease prevention, resulting in an increase over time in the proportion of safe burials and the rate of reported cases referred for medical care within 24 hours of symptom onset.
Pandemics begin and end in communities. To prevent and manage them, community engagement must be a priority. Communities need to be recognized as central actors in health systems and not simply recipients of health services. Engaging community members to collect health information from within their communities and report suspect cases and other events to public health authorities is a cost-effective way to halt the spread of epidemic-prone diseases. During the COVID-19 response, CHWs and volunteers were key to engaging communities and strengthening their capacity to limit the spread of disease. In recognition of these essential workers, the 72nd World Health Assembly adopted a resolution that recognizes that CHWs are an “integral part of all phases of an emergency health response (prevention, detection and response) in their own communities and are indispensable to contribute to ongoing primary health care services during emergencies.”
In promoting public health at the local level, CHWs and volunteers should be the first line of defense against an outbreak. During the crucial early stages of an outbreak, when there is highest risk for spread but the greatest opportunity for containment, community resources must be leveraged to capture health information and mount an effective response. Daniel H. de Vries and his colleagues suggest that the community and CHWs should be regarded as the “first mile” in disease detection rather than the last mile within early warning systems. By targeting investments to the community level, they argue that we will be able to hasten timely capture of information about an imminent disease and deliver more culturally appropriate responses. Often, the community is aware of a health risk, but those in a position to mobilize response resources, receive this information too late to stop the spread of disease and save as many lives as possible.
Integrating CBS into Existing Community Health Systems
The COVID-19 response highlighted the need to include CHWs in health policies and to invest in their training, equipment, and compensation, in line with WHO’s policy recommendations. Advocacy efforts should be centered on increasing the numbers of well trained, supervised, equipped, and compensated CHWs globally to build resilience (inherent and adaptive) in health systems, and provide emergency response capacity. As Ballard et. al recognize, “the best pandemic response is a strong, preexisting primary health care system integrated with the community level.” Therefore, GHS investments targeted at improving CBS as part of pandemic preparedness need to ensure that the support is integrated into the national health system instead of operationalized as vertical programs.
Looking ahead, the GHS and its frameworks should include building robust community health systems as part of the detection and response packages, instead of supporting CBS implementation in a piecemeal and non-integrated fashion, as observed in some countries supported with GHS investments. Ensuring that health security resources are invested in building strong primary health care systems has been duly recognized by the Global Fund to Fight AIDS, Tuberculosis and Malaria, which is the largest multilateral provider of grants for strengthening systems for health. The Global Fund is investing $1.5 billion a year in formal and community health systems through their core grants and their COVID-19 response funds, in recognition of the fact that strong community health systems play a critical role in increasing access to equitable and high-quality services. These investments in resilient and equitable primary health care systems position countries to achieve their universal health coverage goals.
Ballard et. al also advocate for doing away with earmarking resources or supporting short-term implementation of CHW-led activities in favor of pooling resources and making long-term investment commitments that align with a supported country’s priorities in building resilient health systems that promote “CHW institutionalization and professionalization.” As community health data plays an essential role in pandemic response, strong community data and data systems are key to successful pandemic preparedness and the future of GHS.
Disclaimer: Ochiawunma Akwiwu Ibe is a director for International Health Systems Strengthening and Global Health Security in ICF and currently the deputy project director at USAID Infectious Disease Detection and Surveillance (IDDS) project. She is also a member of the CHW TWG at HSG. Doudou Diop is Epidemic Preparedness and Response Team lead in PATH Senegal and the Surveillance Technical lead for the USAID IDDS project. IDDS strengthens the ability of health systems in low- and middle-income countries to detect, track, and respond to infectious disease threats. The views expressed here are the authors’ and do not necessarily reflect the views of USAID or the U.S. government.