Until testing improves, CHWs’ reports on presumptive diagnosis of Covid-19 can help the government identify areas of risk and needs for lockdown or otherwise. This the final part of the two part series
The Covid-19 pandemic has spotlighted and added to the global crisis of the health workforce. Longstanding problems include shortages and a poor mix and distribution of workers in relation to public health needs, and providing equitable access.
Bangladesh, however, has assets that many countries do not: community health workers (CHW). The story behind these workers stems from the 1978 Alma Ata Conference on Primary Health Care which recommended CHWs as a way to promote health and prevent disease through working closely within communities.
Who then are the CHWs? According to the World Health Organisation (WHO), "Community health workers should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organisation, and have shorter training than professional workers."
Over the last four decades, CHW programmes have been established across the world in high- and low-income countries. Based on the successes and value for money of community health workers, and in response to the Covid-19 crisis, the African Union, has just recommended recruitment of two million CHWs, in addition to a million that are already working in various African countries.
In a webinar arranged by AMREF, a regional NGO in East Africa, which we attended, the speakers narrated the successful use of CHWs in controlling Covid-19 in various African countries – not the least in behaviour change which is a vital part of the response.
Little known within Bangladesh is the fact that our CHW programmes are recognised worldwide. In a recent review of CHW programmes globally by Last Mile Health, a US-based think tank, Bangladesh was not only highlighted for its strengths in community health work, but was cited as an example of best practice.
In this country, little is being said about CHWs in the discourse of and planning for Covid-19. Note that we have about 130,000 CHWs – 50,000 in the government, 50,000 in Brac and the rest in other NGOs. They are very significant assets.
In Brac, for example, CHWs include married women who are semi-literate, village-based, and are from relatively lower socio-economic segments of the society. They do not receive a salary but are provided with training as well as occasional incentives, including access to resources such as microfinance. Their work ranges from promoting healthy lifestyles, providing information on ways to prevent and treat common illnesses, and helping people detect and seek help for risks and early warning signals.
Relevant to Covid-19, their efforts with detecting and treating TB are heralded as a key reason for Bangladesh's ability to tackle TB. There is no doubt that much of Bangladesh's solid health gains of the last decades have rested upon the work of CHWs.
More recently, a selection of upgraded CHWs are being specially trained to identify and treat non-communicable diseases, such as diabetes and hypertension, and to recommend reading glasses to people with presbyopia. The successes have been such that the CHW model in Bangladesh has been exported to other countries, including Afghanistan, Liberia, South Sudan, and Uganda. A recent randomised control trial carried out by a Swedish university documented up to 26 percent reduction in childhood mortality in areas served by CHWs in Uganda.
If supported well, CHWs can certainly be effective frontline workers for Covid-19 control. As they do for other illnesses, CHWs can raise awareness of methods to prevent infection, and screen and provide basic care for the sick people within their own homes.
Again, similar to what CHWs do for other conditions, they can be easily trained to spot patients at risk, and refer those with the most complex of needs to hospitals. These are the principles of primary health care and we need this now more than ever. Our hospitals have limited support to offer and most of Covid-19-related illnesses can and should be dealt with at home.
Furthermore, if our hospitals are full, CHWs can coordinate with hospitals and alert the seriously sick as to when, if at all, they can be safely received and accommodated by hospitals. If there is no room, they can also be instrumental in providing care and medicines, as directed by doctors, and helping families make their sick members as comfortable as possible at home.
This approach is built on sound science and maximises the use of scarce resources. It also serves the interests of patients, their pockets and their time. It is also important to note that keeping patients away from health facilities helps reduce the spread of the virus among other sick people who are likely to suffer the worst, and among health workers who are already highly scarce and who we can ill afford to lose.
Furthermore, for each doctor, we now have hundreds of CHWs. Compared to doctors and nurses, CHWs cost less to train and pay, but also generally stay within their communities for years, if not for life. As members of their communities, their voices are trusted, which is essential during epidemics, as they can not only help with guiding people on what to do but with dispelling myths and stigmas which are rampant.
Elsewhere in the world and, we are glad to see, in some parts of Bangladesh, CHWs have started to engage in Covid-19 response supported by governments and NGOs. CHWs use checklists of coronavirus symptoms to make a presumptive diagnosis. Until testing improves in Bangladesh, CHWs' reports on presumptive Covid-19 diagnosis can be instrumental in helping the government identify areas of risk and needs for lockdown or otherwise.
As trusted community members, CHWs are also experienced in supporting the coordination of non-health specific needs, including mental health, and have helped with emergency coordination many times in the past. We envisage them helping organise isolation spaces and support services for the vulnerable and sick; providing soap, disinfectants and food; and guiding safe burials of the dead.
But to work safely in this environment, CHWs have to be prioritised for supplying with the best of personal protective equipment. They should also be supported with testing and healthcare if they need it.
In the long-term interests of the health care sector of the country, we believe CHWs should be systematically trained and integrated within the health system. We would like to see that they are recognised at long last as valued health professionals, something they are, and are paid as such too. This, for Bangladesh, is well within the realms of what is possible.
Such choices should not be viewed as second-best solutions for the poor but the best bet for health, and for addressing this pandemic and others which are likely to come. We urge that we build on these tested local strengths as a priority rather than aiming to replicate high-cost medical interventions with limited, and in some instances, unproven, prospects of efficacy.
Mushtaque Chowdhury is a professor of population and family health at Columbia University, and convener of Bangladesh Health Watch.
Fawzia Rasheed is a former senior policy adviser to the World Health Organisation