Community-based health workers are essential in combating the coronavirus pandemic in developing countries.
As the novel coronavirus moves through poorer parts of the world, many expect high infection rates. Cheek by jowl crowding, poverty, limited sanitation facilities, and the urgency to leave home for work to survive – all make social distancing and isolation almost impossible.
And yet, we expect that successes from these countries will emerge and pave the way for solutions elsewhere and that these will stem from the people and systems behind community-based primary healthcare.
Alarmed at the prospects of COVID-19, many cash-strapped health ministries – from Rwanda to Pakistan – began planning well before they registered their first cases. Hospitals were designated for treating coronavirus patients only and hotels and quarantine facilities were earmarked for returning travellers and those with less severe symptoms. Proposals to buy equipment, test kits and personal protective equipment (PPE) were also quickly put together.
However, glitches surfaced early. The fact that funds, supplies and equipment were largely unavailable, coupled with the rising number of infections, began to seed unease.
In India, doctors were evicted by neighbours fearing infection. In Pakistan, medical workers who participated in a protest to demand PPE were arrested.
In Bangladesh, many private clinics and hospitals closed, as staff were afraid of being exposed to COVID-19. Following large numbers of absentee health workers, the Bangladeshi government offered increased pay and life insurance to lure staff back to work. Workers who stayed away were sacked and maligned in the press.
No country, let alone poor countries, can afford to risk the health of, or indeed, drive away precious healthcare workers. Rather than put them at risk of infection, and in turn, risk infecting their patients, governments should consider alternatives.
In this respect, Rwanda showed leadership. Their whole-of-government approach included: deterring people with suspected COVID-19 infections from coming to health facilities unless seriously unwell; minimising contact between health workers and infected patients; and focusing on prevention and care within communities.
These approaches are relevant everywhere, but particularly for resource-poor countries where health facilities have little to offer in terms of beds, let alone ICUs and ventilators, or associated staff and resource demands.
Taking this route is not as difficult as it may sound.
However fragile, most poor countries have health systems designed around principles of primary healthcare – an approach based on health service delivery, disease prevention, screening and caring for the sick within the communities where people live. The idea is that only patients with the most complex of needs should be seen at hospitals.
This approach is built on sound science and maximises the use of scarce resources, including medical staff. The majority of sick people, including those with coronavirus symptoms, can and should be catered for at or close to home. This is in the interests of patients, their pockets and their time. And keeping patients away from health facilities also helps reduce the spread of the virus.
The good news is that following decades of investments, many resource-poor countries have fleets of community-based health workers (CHWs). These workers deliver door-to-door services and know their communities well.
They are trained in prevention of infectious diseases and in common-symptom management, so adding COVID-19 to the work they already do is relatively simple. Furthermore, for every doctor, there are hundreds of CHWs. Compared to doctors and nurses, CHWs not only cost less to train and pay, but they also generally remain within their countries. And, as members of their communities, they are known and trusted, which is essential during epidemics.
Indeed, CHWs are already widely engaged in the COVID-19 response. In the absence of test kits, CHWs use checklists of coronavirus symptoms to form the basis for diagnosis. Some agencies have developed apps to support CHWs diagnose, monitor and even track patients’ contacts.
Wherever CHWs work with community leaders, a lot can be achieved. There are countless examples where such partnerships have achieved the seemingly impossible following disasters – not least in countries such as Bangladesh, used to repeat onslaughts of epidemics, floods and cyclones.
CHWs can establish COVID-19 readiness, by raising awareness and dispelling confusion; arranging isolation spaces and support services for the vulnerable and sick; providing soap, disinfectants, medicines and food; and even arranging to safely bury the dead.
Community health workers are already innovating to work safely. In operations that we know of around the world from Uganda to Afghanistan, CHWs are finding ways to work and largely maintain distance, including using megaphones, phones, and working through others. With adjustments, CHWs can keep regular health services running while supporting COVID-19 needs too.
CHWs are backstopped by other health professionals, sometimes by phone, the internet and occasionally, through telemedicine, too. Community health workers can signal to a hospital if a person suspected of having the infection is seriously ill; and in turn, hospitals can indicate if they are able to accept patients.
The difference between theory and practice will surely be in ample evidence in the coming months. That said, much can be achieved if primary healthcare is prioritised over hospitals in the fight against COVID-19. Such decisions should not be viewed as second-best solutions for the poor because they represent the best bet for prevention, containment and care. We should be building on tested local strengths rather than scrambling to mimic high-cost medical interventions with limited, and in some instances, unproven, prospects of efficacy.