As COVID-19 continues to spread globally, countries are tirelessly working to contain the virus and prevent disruptions to critical primary healthcare services, including vaccinations and routine care for mothers, children, and families affected by communicable diseases such as malaria, HIV, tuberculosis, as well as non-communicable diseases.
Past crises have shown the world that integrating community health workers into primary healthcare teams can strengthen an epidemic response, while also laying the foundation for a robust health system that is prepared to respond to future outbreaks. Investments in routine primary healthcare systems are among the most compelling long-term investments in global health security. Long after an epidemic is contained, these integrated community health worker programs continue to improve health and fight disease outbreaks. In countries like Liberia, community health workers were critical in the country’s Ebola response efforts, teaming up with nurses to carry out screening and contact tracing tens of thousands in Ebola-affected communities. As countries look to adopt and adapt COVID-19 response strategies, now is the time to invest in national community health worker programs so that robust primary healthcare systems can be surged during crises.
There is a growing global consensus based on evidence from multiple countries, that national community health worker programs have been vital contributions to making rapid progress in improving health outcomes for the most vulnerable. While the pandemic continues to test the quality and resiliency of health systems globally, Last Mile Health believes that leveraging approaches that have worked in certain countries and adapting them to other contexts is critical. Ultimately, adapting best practices locally is not just paramount in times of crisis—but is a strategy to address all global health challenges.
What can the world learn from the experiences of other countries?
Over the last two years, Last Mile Health has partnered with Exemplars in Global Health to identify success factors from countries (across different geographic areas and economic strata) that have made notable progress in establishing and scaling community health worker programs that outperform their peers. Partnering with local research institutions¹ in each of the four countries, we identified trends on establishing and sustaining high-performing community health worker programs. We found that the national community health worker programs in Bangladesh, Brazil, Ethiopia, and Liberia have achieved impressive successes in reaching scale and improving primary healthcare access. Together, these countries offer valuable lessons that can help leaders design and develop effective community health worker programs.
While each country context is different, the study found that all Exemplar community health worker programs achieved success at scale by doing five key things:
- Using a problem-driven approach to program design. Countries were precise in defining the populations community health workers could serve and the health outcomes they could impact—and designed their programs to focus on these areas. For example, Brazil designed its national program to lower the number of patients with hypertension and diabetes who dropped out of care.
- Securing community support. They cultivated active—not passive—engagement of communities, relying on them to select community health workers, bolster supervision, and increase demand for healthcare. In Bangladesh, community health committees have played a key role in constructing rural community clinics where community health workers are affiliated.
- Cultivating political will and building government-led coalitions. Countries acknowledged health challenges as national crises and secured long-term support from top national political leadership across sectors. Ethiopia is famous for asking all partners to work under one plan, one budget, and one reporting scheme.
- Investing in systems, not just the services community health workers deliver. These countries built systems to strengthen community health worker selection, skills, supervision, salaries and supplies (the “5-S’s”), in line with the WHO Guidelines on Health Policy and System Support to Optimize Community Health Worker Programs. By investing in the 5-S‘s, Liberia transformed community health workers from being volunteers to paid professionals; built digital training platforms to up-skill these workers; and hired nurses to supervise community health workers and integrate them with clinics—increasing access to primary healthcare and improving detection of malaria cases by 50%.
- Harness data to inform continual innovation and adaptation. Countries built feedback systems to ensure programs adapted to improve performance quality and expanded or shifted to serve changing needs. In Ethiopia, an independent assessment of the national program is being used to improve performance.
Public health crises demand resilient health systems, making countries with strong national community health worker programs better equipped to respond to COVID-19. As Bangladesh, Brazil, Ethiopia, and Liberia are applying these lessons to deploy rapid and robust COVID-19 responses Exemplars in Global Health is disseminating core learnings so that they can be replicated in comparable settings. The infrastructure these countries built to support their community health systems is allowing them to quickly pivot community health workers towards COVID-19 prevention, detection, and response, while still sustaining primary healthcare services––underscoring that effective epidemic response relies not only on a strong emergency response, but every day, community-oriented, primary healthcare systems that can be surged during times of crises.
Exemplars in Global Health aims to help country-level decision-makers, global partners, and funders make strategic decisions, allocate resources, and craft evidence-based policies in consultation with both their global peers and technical advisors. To access research, tools, and resources across Exemplar topics and countries, visit the Exemplars in Global Health website.
¹Last Mile Health is grateful to partner with following research partners as part of the Exemplars in Global Health Research Project: Bangladesh: BRAC and BRAC University and BRAC James P Grant School of Public Health; Brazil: Fiocruz Oswaldo Cruz Foundation; Ethiopia: International Institute for Primary Healthcare-Ethiopia; Liberia: University of Liberia School of Public Health