In July 2020, a group of global health experts recognised the emergent need to supply community health workers (CHWs) with personal protective equipment (PPE) during the pandemic. Like all health workers, CHWs – laypeople trained to provide health services in their neighbourhoods – need PPE (e.g. masks, gloves and eye protection) to continue providing essential health services and to fight COVID-19.
Unlike other health workers, CHWs often go unequipped, unsupervised and unpaid. When CHWs do not have PPE, they face an impossible choice: putting themselves, their patients, and families at risk or ceasing to provide care – jeopardising years of global health gains.
Our partners saw an opportunity to both respond to the PPE crisis and advance the professionalisation of CHWs for the long-term.
By integrating with national COVID-19 responses, our collaboration – the COVID-19 Action Fund for Africa (CAF-Africa) – was able to provide PPE to community health workers in a moment of acute need, and also contribute to recognition, equality and pay for CHWs across the continent.
Counting CHWs at the national level is both a critical precursor to understanding the severity of the PPE crisis and of CHW professionalisation. Governments cannot support those whom they cannot identify. Yet, at the start of the pandemic many countries did not have an accurate count of the CHWs operating within their borders.
We worked with an existing network of health practitioners and governments across more than 18 African countries to determine that 916,000 active CHWs serve 40% of the African population. These CHWs would need more than 300 million pieces of PPE to protect themselves and their communities while maintaining essential services. These counts, long overdue, were immediately put to work in requisition forms to secure the donated PPE.
Instead of estimating the numbers on our own, CAF-Africa worked directly with health systems. This simple act of counting CHWs raised their profile within national governments and helped lay the foundation for CHW registries, a necessary first step in providing health workers with the recognition and tools they need to serve their communities effectively.
CHWs are often understood as a stopgap measure in second-rate health programs, rather than an essential part of any resilient health system. CHWs have a unique ability to vastly extend access to high quality primary healthcare – even during pandemics – but this is only true when they are properly equipped.
Early in the pandemic, UNICEF predicted that the declining rates of polio vaccinations would lead to a resurgence of the deadly disease in the Democratic Republic of the Congo (DRC). Yet following the arrival of CAF-Africa PPE, CHWs were equipped like any other health worker. As a result, more than 8,500 CHWs were able to help administer polio vaccines door-to-door, playing a key role in the national health system’s effort to maintain essential health services.
This was not only true in DRC, but recent evidence suggests that prepared and protected CHWs were able to maintain community delivered care in multiple African countries. When we treat CHWs like professionals, they perform like them. Health systems are beginning to take note.
Crises present opportunities for landmark policy changes: it was after World War Two that Japan achieved universal health coverage and after Ebola that Liberia launched a national cadre of paid, professionalised CHWs.
Shortly after receiving donated CAF-Africa PPE, Uganda’s Prime Minister, Ruhakana Rugunda, reoriented their COVID strategy around CHWs. In their new Community Engagement Strategy for COVID-19 Response, the government pledged to pay monthly allowances to CHWs for the first time.
The provision of PPE helped spark a virtuous cycle. PPE enabled CHWs to safely become integral parts of national COVID-19 responses. Their contributions in this emergency made it all the more clear that they are a necessary component of any resilient health system and should be paid. When CHWs are recognised, equipped and paid, they are able to do their jobs and safely care for their communities.
The CAF-Africa collaborative has now been procuring and delivering PPE to CHWs for almost a year. While our coalition emerged as a response to the COVID-19 crisis, it is now clear that solidarity with our CHW colleagues sparked long-term system change.
But there is more work to be done. Unfortunately, the pandemic did not end in 2020 and neither did the PPE crisis. There is a continued urgent need to provide PPE for CHWs across Africa, and there are still several countries where CHWs are unequipped, unsupervised and unpaid.
Ultimately, we know that national health systems will outlast our efforts; working with ministries of health to strengthen community health provision ensures that we are all better prepared to face future pandemics.