Resilience or coping? Community health workers’ adaptive strategies in response to COVID-19
25 May 2022
Solomon Salve and Kate Gooding of Oxford Policy Management, and Joanna Raven of Liverpool School of Tropical Medicine have been involved in a cross-country ReBUILD for Resilience study on health system resilience, with a focus on the role of community health workers in COVID-19. In this post they outline some of the learning from their work. [Update: A full paper on the research is now available.]
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Community health workers (CHWs) are an important workforce for healthcare in many low- and middle-income countries (LMICs, see WHO) with a central role in reaching the most marginalized. There has been growing recognition of CHWs’ contributions during pandemics, and the past two years have witnessed CHWs’ importance for an effective COVID-19 response (see Ballard et al). This blog post contributes to growing learning about CHW experiences and adaptations during COVID-19, based on evidence from India, Bangladesh, Pakistan, Sierra Leone, Kenya and Ethiopia.
Contributions and challenges in COVID-19 response
CHWs made a range of contributions during the COVID-19 response, including roles in surveillance, education, and support for people and families with COVID-19. They received some support – training, personal protective equipment (PPE), and financial support – as well as support from families, peers and communities. However, the support they received varied between countries and CHWs, and there were significant gaps, leaving CHWs vulnerable to infection and increased stress. CHWs experienced a range of challenges in conducting activities related to COVID-19 response as well as their routine activities. These included health system issues, such as limited staff and consequent high workloads – a particular difficulty for female CHWs who were also balancing domestic responsibilities – and disruption to medical supply chains. Their work was also affected by COVID-19 public health measures, such as restrictions on gatherings and travel, and by demand-side aspects related to community access and attitudes, including distrust and stigmatization of CHWs as being infectious or informers.
In the face of these challenges, some CHW services were reduced or stopped altogether. In some countries, government guidance was to halt some CHW services. CHW home visits and community outreach activities were suspended during the initial COVID-19 period in several countries, and some routine reproductive, maternal, newborn and child health services did not function during lockdowns. For example, in India CHW community outreach days for antenatal care (ANC) and immunisation and the Village Health Sanitation and Nutrition Days were paused partly due to guidelines against group gatherings. In Bangladesh, household visits to distribute contraceptives were paused.
Adaptations to overcome challenges
However, there were also adaptations to CHW services to allow some continuity of routine care. For example, in many countries CHWs used phone contact to replace household visits. In Bangladesh and Pakistan, some CHWs opened up the doors of their homes to provide services to people with tuberculosis (TB) and ANC for pregnant women. In Ethiopia, some CHWs divided villages into smaller units for service delivery and outreach activities, to overcome restrictions on size of gatherings and avoid the risk of large groups. There were also some adaptations to provision of drugs. For example, in India and Bangladesh people with TB were provided with extra quantities of medicines to avoid gaps in treatment, as many TB programme staff were diverted to COVID-19 duties. Similarly, CHWs in Bangladesh provided clients with additional quantities of oral contraceptives and male condoms before the lockdown began. There were also examples of using COVID-19 activities to provide routine services. For example, in India, COVID-19 survey household visits were used as an opportunity to conduct TB case finding, and in some cases CHW were advised to provide ANC, child health and other services during these survey visits.
Other adaptations involved CHWs using their own money and time to cope with shortages, increased transport costs and higher workloads. For example, in India CHWs were busy with COVID-19 response activities during the day, so worked at night to provide their routine and expected service of escorting pregnant women to facilities for delivery. In India and Bangladesh, CHWs covered extra transport costs and purchased PPE with money from their own pockets.
Resilience – or struggling to cope?
The question arises whether these adaptations involve CHW agency and resilience – or coping? Some have argued that while there is growing attention to resilience in health systems discussions (see Saulnier et al), a robust underlying health system is essential – without this underlying strength, adaptations in response to shocks can involve negative coping strategies, rather than resilience (see Abimbola & Topp). Robustness therefore involves “the capacity of a system to absorb and recover from shocks and stress, without major negative consequences” (ibid). Without this system focus, adaptation can rely on individual action and coping – with “people digging deep as they draw on internal strengths and resources to make up for weaknesses in the health system”. In our findings, adaptations can to some extent be seen as indicating CHWs’ personal commitment and agency – with efforts to work around problems and find solutions.
However, some adaptations came at personal cost for CHWs. For example, using personal finances for transport or PPE has implications for household finances. In addition, CHWs with low or no salaries (such as some cadres in India), were less able to make these adaptations and purchase their own PPE – consequently relying on alternatives such as using scarves and facing increased vulnerability. Adaptations involving increased workload also brought additional stress for CHW. Rather than agency, some CHWs felt a lack of choice and power. For example, in India some CHWs described their situation during the pandemic as involving ‘majboori‘, or helplessness and being without options.
The lack of a robust health system that could adequately support CHWs suggests that in some contexts at least, some adaptations involved ‘coping’ rather than effective ‘resilience’. Other researchers have also emphasised the need to balance recognition of CHW agency and commitment with recognition of their vulnerability and adequate support (see Nanda et al and Lotta & Nunes).
We need to remember that CHWs are not machines in the system; they are not even ‘just another pair of hands’ (see Kane et al). Rather, they are critical health actors, and need to be supported by making our health systems sufficiently robust (see WHO).
Image: Fight Against COVID-19 @ Jangamakote Village, India – Trinity Care Foundation via Flickr [opens new tab]