The role of CHWs in fragile and conflict-affected settings

By: Maryse Kok, Ph.D., KIT Royal Tropical Institute

On the 25th of November 2020, the Thematic Working Group organized a session titled ‘Supporting and strengthening the role of community health workers in health system development’ for the online Health Systems Global Symposium. This session, which focused on the role of CHWs in fragile and conflict-affected settings, had four speakers and about 65 participants. Readers can watch the session here.

There is a large global body of evidence on CHW programmes. Based on this evidence, the World Health Organization published a guideline on health policy and system support to optimize CHW programmes in 2018. There remains a need to learn more about the role of CHWs, and how effective CHW programmes present in fragile and conflict-affected settings.

CHWs play an important role in the provision of community-based services where formal health systems can be (temporarily) weakened or dysfunctional. CHWs and other community-level actors can also play a role in emergency and disaster preparedness and response. We all know that CHWs have been instrumental in the response to disease outbreaks; most recently in the Ebola outbreak in West Africa and currently in terms of the Covid-19 pandemic. CHWs have also proved to be essential providers of health services in settings affected by conflict or natural disasters.

Nate Miller started the session with an overview of what we know and can learn from the scientific and grey literature on CHWs in humanitarian settings. The scoping review includes evidence about CHWs in conflict (65%), disease outbreak (20%), natural disaster (11%) and nutrition emergency (2%) settings; and in the general population (83%) as well as refugee camps or camps with internally displaced people (21%). In most settings, CHWs were able to maintain essential services. CHW are first and trusted responders, before any outside support is provided. Major barriers are unclear policies, disruptions in supply chains and supervision, and short-term project funding. CHWs are hardly involved in emergency preparedness planning.

Just as in non-fragile settings, CHWs’ motivation and performance are positively influenced by selection by their communities, engagement of community leaders, and financial compensation and other incentives. Particular attention is needed for supporting CHWs with lower education levels, safety and security issues, as well as the mental health of CHWs in fragile and conflict-affected settings.

Haja Wurie continued with a presentation about CHWs in Sierra Leone. The CHW landscape in Sierra Leone had been quite fragmented but after the 2017 Ebola outbreak the Ministry of Health and Sanitation launched a new National Community Health Worker Policy (2016-2020) and a coordinated CHW programme, for which 15,000 CHWs were trained. During the Ebola outbreak, CHWs were social mobilisers, contact tracers, and part of burial teams. They were instrumental in bridging the gap between communities and primary health units by maintaining maternal, neonatal, and child health services. Some learnings for the current COVID-19 outbreak include: CHWs’ roles in sanitation and infection prevention at community level; making use of locally available materials; and CHWs’ linking roles with traditional leaders to enhance community trust in the health system.

From DRC, Amuda Baba talked about CHWs’ roles in material and neonatal health and in the prevention and mitigation of gender-based violence. The mostly female CHWs in DRC are well connected to households in their communities. As a result, community members, but also internally displaced people in camps, reach out to them in case they need advice or help. Transparency and trust partly exist because most CHWs are females and promote understanding when it comes to issues faced by women, including gender-based violence. CHWs face gender inequality in their daily work, and sometimes they can challenge it, but often not, as they work within the same gender norms and power relations that influence the communities they serve. However, there is evidence that CHWs work together with traditional birth attendants and traditional healers to help communities overcome gender-related challenges.

Lastly, Allone Ganizani presented a case from Malawi, where health surveillance assistants (HSAs) were involved in the emergency response following cyclone Idai in 2019. In areas where health facilities were destroyed or had become inaccessible, HSAs provided essential services, such as temporary village clinics and immunizations for under-5 children, and health promotion in relation to hygiene and malaria prevention. They were also part of health teams in camps. Barriers faced were lack of transport and equipment, and HSAs having to fill in too many reporting tools from different partners.

The presentations and discussion highlighted that CHWs are key and trusted health providers during emergencies and in conflict settings, because of their local knowledge and embeddedness in communities. In relation to disease outbreaks such as Ebola and COVID-19, CHWs are well placed to inform communities about emerging knowledge on the diseases, to enhance transparency and trust.

CHWs should not only be involved in post-emergency responses, but also in emergency preparedness and the recovery afterwards. It is also evident that challenges faced by CHWs in fragile and conflict-affected settings are partly similar to the challenges that many CHWs face worldwide. CHWs need support from the side of the health sector, in terms of remuneration, training and supervision, and from the side of the community, through their selection and structures such as community-level committees. Therefore, ministries of health and partners need to address the bottlenecks to CHW service delivery common in stable low-income settings, as well as the additional challenges unique to humanitarian settings, such as CHWs’ safety, mental health, and access to specific communities. Longer-term funding and integration of CHWs in national health systems should be prioritized to make this happen.