Introduction
Over recent years, the world has faced two Ebola outbreaks, a constant threat of pandemic influenza, and now the global spread of the COVID-19 coronavirus. In developing countries, these threats risk exacerbating existing high burdens of communicable diseases- associated with millions of preventable deaths. Community health is essential for pandemic preparedness (prevention, surveillance, response) and remains essential for achieving the SDGs. The global scale and impact of the current pandemic demonstrates that this cuts across geographies, levels of income, and types of health systems.
Central Africa is currently emerging from its most recent Ebola outbreak. On March 3, the last Ebola patient was discharged from a health facility in the Democratic Republic of Congo. The 19 month long epidemic claimed the lives of 2,264 people. The 2014-2016 Ebola epidemic in West Africa was responsible for 11,310 deaths, with an associated economic cost estimated by the World Bank to be over $2.8 billion. As of March 17, COVID19 has claimed the lives of over 7,000 individuals. Early simulations demonstrate that even in the best case scenario, it will have a significant economic impact. The majority of cases and deaths to date have been in developed countries with relatively strong health systems and pandemic response mechanisms. If the COVID19 crisis expands to Africa and other developing countries, which predominantly have sub-optimal health systems and severe health-worker shortages, the impact could be harrowing.
Since 2016, the Financing Alliance for Health (FAH) has worked to co-build the community health systems necessary to respond to these pandemic threats and meet the health needs of everyday citizens. It achieves this by partnering with governments and other primary health care organizations to finance and scale effective community health programs. Community Health Workers (CHWs), if equipped and empowered, can play a pivotal role to prevent, monitor, and respond to both the current outbreak and future challenges.
Prevent
Community Health Workers play a critical role as community advocates for health promotion and reliable sources of health information. They help to avert the spread of misinformation and myths that can antagonize intervention efforts. As a trusted voice in their communities, they promote hygiene practices such as hand washing, personal hygiene, water and sanitation interventions, infection prevention and control, and reduction of indoor air pollution.
During the 2015 Zika virus outbreak in Brazil, for example, CHWs known as ”brigadistas” played a key role in prevention, using a wide variety of approaches. The brigadistas provided important prevention messages to communities at risk prior to the peak of mosquito season and they distributed Zika prevention kits to pregnant women. Their communities, usually characterized by poor sanitation practices, cleared mosquito breeding sites for prevention and increased their use of condoms to avert the sexual transmission. During the height of the outbreak, brigadistas performed community level triage and conducted active case finding, linking patients with local primary healthcare centres.
Monitor
During both Ebola epidemics, the consequence of weak health systems was delayed recognition of the outbreak. This delay may have resulted in a higher number of cases and fatalities. The surveillance capabilities of community health workers are the first line of defence against the spread of pandemic diseases. They are ideally placed to identify and report outbreaks as they happen so that regional, national, and international expertise can respond. Given that a majority of emerging infectious diseases are zoonotic in origin, leveraging CHWs’ competence as social mobilizers could improve surveillance of the communities at risk while providing timely, accurate and culturally relevant information that leads to successful behavioural change.
In Sierra Leone, one of the countries severely hit by the Ebola outbreak in 2015, community health surveillance by the CHWs was critical in containing the epidemic. Following a missed diagnosis and unsafe funeral in a village in Kono district, CHWs sprang to action to conduct contact tracing and community education. Their efforts quickly identified and sequestered suspected new cases, thus preventing further spread of the disease. In Nigeria, CHWs trained to support the national polio eradication program were tasked to support contact tracing after a patient with Ebola arrived in Lagos. Their efforts effectively prevented further widespread community transmission.
Respond
CHWs provide first line therapy for a wide variety of diseases, and link rural, last mile areas with local primary care facilities and regional specialist level resources. In many cases, this can prevent prolonged, sometimes unnecessary transport and other delays in care. In the wake of pandemic disease outbreaks, formal healthcare systems are often overwhelmed. CHWs can be leveraged as a public health reserve during these emergencies. Their work in responding to pandemic outbreaks can be focussed on community mobilization, active case finding, and filling health service gaps. Rwanda, for example, has directed patients with symptoms suspicious for COVID19 to consult with local CHWs for screening and referral.
Conclusion:
Community health workers play a vital role in preventing, monitoring, and responding to pandemic threats. It is therefore critical that we accelerate investments in community health in our response to the COVID19 pandemic. In the short term, we can ensure that CHWs have immediate access to quality information and referral guidelines, so that they can counter misinformation and guide members of their community to health facilities when necessary. In the medium term, donors and countries alike must increase their investment in community health, including CHWs, so that they are equipped to prevent future outbreaks, monitor for new ones, and respond as they unfold.
In Sub-Saharan Africa alone, community health is underfunded by an estimated $2 billion every year. The case for investing to close this gap is compelling, considering the significant human and economic costs of pandemics. Early estimates indicate that the coronavirus pandemic could cost the global economy $2 trillion. The Financing Alliance for Health, has to date supported 12 governments, mobilizing >US$30 Million towards community health, and continues to work to close the funding gap. These efforts will help partner governments respond to the challenges of today, like COVID19, and the communicable and non-communicable disease challenges of the future.
About the authors: Angela Gichaga, CEO, Financing Alliance for Health, Amit Chandram an emergency physician and global health specialist based in Washington, DC. He serves as a board member for the Financing Alliance for Health, Clair Qureshi, Office of the Who Ambassador for Global Strategy,Nelly Wakaba Financing Alliance for Health, and Mila Nepomnyashchiy, Community Health Acceleration Partnership.