A conversation with: Maryse Kok, Reader in Health Systems, Liverpool School of Tropical Medicine
Community health workers (CHWs) are at the interface between the formal health system and the community. As a result, they are in a unique position to observe and understand the factors that influence health, improve access to health services for vulnerable or hard-to-reach groups, and help strengthen health services by tailoring them to meet the needs and realities of the community. However, CHWs’ interface role also brings tensions. Health system and community expectations of CHWs’ tasks are not always well aligned. Health managers may see CHWs as representing the voice of communities, while community members see them as government or NGO representatives. Managing expectations and demands from health professionals and managers on one hand, and community members on the other, is a balancing act that requires CHWs to build trusting relationships (Kok et al. 2017). Such trusting relationships are the base for CHWs’ contributions to improving everyday access to health services – and are also instrumental when preparing and responding to shocks.
Health systems and communities increasingly face shocks, such as epidemics, conflict, and climate-related emergencies. In such circumstances, resilience is needed – the systems need to maintain core functions and minimize negative consequences of disruptions. Resilience is a system’s ability to absorb, adapt and transform (Witter et al. 2023).
The interface role of CHWs is instrumental in preparedness, emergency response, and post-emergency interventions. The current literature is relatively silent on CHWs’ engagement in preparedness and post-emergency interventions. Evidence on their roles during emergencies clearly reveals their added advantages, because trusted CHWs:
- provide health education and counter misinformation;
- combat stigma and discrimination;
- mobilize communities to be part of the emergency response;
- maintain access to health services in contexts where health facilities are closed, or travel is hampered;
- reduce health inequities;
- conduct early case detection, contact tracing and quarantine follow-up;
- refer to services in other sectors (food security, social welfare);
- enhance community acceptance of and trust in the health system; and
- provide data and first-hand insights to facilitate decision-making.
It is not surprising, therefore, that health systems often turn to CHWs in times of shocks. Yet being on the frontlines of emergency situations adds additional stress to already overburdened and under-supported CHWs. For example, during the Covid-19 pandemic, increased interruptions in the supply chain and difficulties in organizing supervision and mentoring hampered CHWs’ work. A lack of personal protective equipment left CHWs fearing infection for themselves and their families. Community support for CHWs was also often strained. In some cases, CHWs were seen as carriers of infection and if they were involved in unpopular activities, such as monitoring quarantine, community members expressed dislike for or stigmatized CHWs. Community members refused CHWs entry into their homes or delayed calling for CHW assistance out of fear, until it was too late for CHWs to help. CHWs had to juggle a heavy workload and household responsibilities, when their own families were struggling in the face of the pandemic. In some cases, CHWs spent their own money to reach or assist community members, contributing to increased economic hardship (Bhaumik et al. 2020; Salve et al. 2023). Despite these challenges, CHWs played a critical role during the Covid-19 pandemic in many countries. A recent evidence synthesis stresses that their successful provision of Covid-19-related information and services was based on pre-existing trusting relationships at community level (Oliver et al. 2024).
In conflict-affected settings, CHWs deliver health services to displaced persons or in host communities. Travel poses the highest risks for CHWs in such contexts, particularly for female CHWs. There are also examples of CHWs getting accused of being part of certain (opposition) groups or being actively targeted by armed groups. CHWs encounter non-responsive households and referral services as well, the latter leaving them with enormous responsibility – trying to manage cases for which they are not trained. Other sources of distress among CHWs are lost resources, lost family members, fear of landmines, being away from family, trauma because of displacement, confrontation with suffering, distrust based on ethnicity, and late or no reimbursement (Habboush et al. 2023; Miller et al. 2020; Parray et al. 2021; Rajbangshi et al. 2021). Some of these stressors also exist in contexts of natural disasters, where CHWs are first responders during floods, droughts or disease outbreaks.
Needless to say, CHWs need more support in times of shocks than in calmer times. They require regular training, supervision, remuneration, supplies, and transport. On top of this, they may need security training; insurance; assistance negotiating safe access with authorities; reductions in geographic scope to decrease travel; provision of psychosocial support; emergency relief for themselves and their families; remote (mHealth) supervision or increasing possibilities for peer support; buffer stocks of commodities; and pairing of female and male CHWs in the context of gendered risks. Ensuring such support, both in calm and emergency times, is instrumental for attaining improved health.
The interface role of CHWs, and their trusting relationships with actors in the formal health system and in the community, are even more essential in times of shocks than in times of calm. Evidence shows that CHWs contribute to maintaining health systems’ core functions during emergency situations, but their ability to do so requires specific support from both the formal health system and the community.
Maryse Kok, Reader in Health Systems
Liverpool School of Tropical Medicine