Community health workers for pandemic response: a rapid evidence synthesis

IntroductionCoronavirus disease (COVID-19), a respiratory illness, first discovered in China in December 2019 has now spread to 213 countries or territories affecting millions across the globe. We received a request from National Health Systems Resource Centre, a public agency in India, for a Rapid Evidence Synthesis (RES) on community health workers (CHWs) for COVID-19 prevention and control. MethodsWe searched PubMed, websites of ministries, public agencies, multilateral institutions, COVID-19 resource aggregators and pre-prints (without language restrictions) for articles on the role, challenges and enablers for CHWs in pandemics. Two reviewers screened the records independently with a third reviewer resolving disagreements. One reviewer extracted data in a consensus data extraction form with another reviewer cross-checking it. A framework on CHW performance in primary healthcare not specific to pandemic was used to guide data extraction and narrative analysis. ResultsWe retrieved 211 records and finally included 36 articles on the role, challenges and enablers for CHWs in pandemics. We found that CHWs play an important role in building awareness, countering stigma and maintaining essential primary healthcare service delivery. It is essential that CHWs are provided adequate Personal Protective Equipment (PPE) and appropriately trained in its usage in the early stages of the pandemic. Wide range of policies and guidance is required to ensure health systems functioning. A clear guidance for prioritizing essential activities, postponing non-essential ones and additional pandemic related activities is crucial. CHWs experience stigmatization, isolation and social exclusion. Psychosocial support, non-performance-based incentives, additional transport allowance, accommodation, child-support, awards and recognition programs have been used in previous pandemics. We also created inventories of resources with guiding notes for quick utility by decision makers on guidelines for health workers (n=24), self-isolation in the community (n=10) and information, education and counselling materials on COVID-19 (n=16). ConclusionsCHWs play a critical role in pandemics like COVID-19. It is important to ensure role clarity, training, supportive supervision, as well as their work satisfaction, health and well-being. There is a need for more implementation research on CHWs in pandemics like COVID-19. Summary BoxO_ST_ABSWhat is already known?C_ST_ABSO_LICOVID-19 is a pandemic which has now strained health systems across the world. Community health workers (CHWs) are being deployed in many countries for COVID-19 prevention and control. However, there is no evidence synthesis on the issue. C_LI What are the new findings?O_LICHWs can play an important role in creating awareness, countering stigma, and maintaining essential primary healthcare delivery. C_LIO_LIAdequate provisions for personal protective equipment are essential for CHWs C_LIO_LIGovernments should provide a clear guidance to CHWs for prioritizing essential activities, postponing non-essential ones and for additional pandemic related activities, while also ensuring their health and safety C_LIO_LICHWs experienced stigmatization, isolation and were socially ostracized in previous pandemics. Psychosocial support, non-performance-based incentives, additional transport allowance, accommodation, child-support, awards and recognition programs have been used as enablers. C_LI What do the new findings imply?O_LIRoles of CHWs in a pandemic context must be clear. Apart from clear guidance adequate training and support should be provided. requiring adequate training and guidance is useful. Contact listing and identification should be done by separate trained cadre. C_LIO_LICountries without pre-existing CHWs program must consider applicability of available evidence before investing in ambitious new CHW programs. C_LIO_LIThere is a need for more implementation research on CHWs in pandemics like COVID-19. C_LI

Building capacity for health equity analysis in the WHO South-East Asia Region

“Leaving no one behind” is at the heart of the agenda of the Sustainable Development Goals, requiringthat health systems be vigilant to how interventions can be accessed equitably by all, includingpopulation subgroups that face exclusion. In the World Health Organization (WHO) South-East AsiaRegion, inequalities can be found across and within countries but there has been a growing commitmentto examining and starting to tackle them. Over the past decade in particular, WHO has been developingan armamentarium of tools to enable analysis of health inequalities and action on health equity. Toolsinclude the Health Equity Assessment Toolkit in built-in database and upload database editions, aswell as the Innov8 tool for reorientation of national health programmes. Countries across the regionhave engaged meaningfully in the development and application of these tools, in many cases aligningthem with, or including them as part of, ongoing efforts to examine inequities in population subgroupsdomestically. This paper reflects on these experiences in Bangladesh, India, Indonesia, Nepal, Sri Lankaand Thailand, where efforts have ranged from workshops to programme reorientation; the creation ofassemblies and conferences; and collation of evidence through collaborative research, reviews/synthesisand conferences. This promising start must be maintained and expanded, with greater emphasis onbuilding capacity for interpretation and use of evidence on inequalities in policy-making. This may befurther enhanced by the use of innovative mixed methodologies and interdisciplinary approaches torefine and contextualize evidence, with a concomitant shift in attention, developing solutions to redressinequities and anchor health reform within communities. There are many lessons to be learnt in thisregion, as well as mounting political and popular will for change.

Rural recruitment and retention of health workers across cadres and types of contract in north-east India: a qualitative study

Background Like many other low- and middle-income countries, India faces challenges of recruitingand retaining health workers in rural areas. Efforts have been made to address this through contractualappointment of health workers in rural areas. While this has helped to temporarily bridge the gaps in humanresources, the overall impact on the experience of rural services across cadres has yet to be understood.This study sought to identify motivations for, and the challenges of, rural recruitment and retention of nurses,doctors and specialists across types of contract in rural and remote areas in India’s largely rural north-easternstates of Meghalaya and Nagaland.Methods A qualitative study was undertaken, in which 71 semi-structured interviews were carried out withdoctors (n = 32), nurses (n = 28) and specialists (n = 11). In addition, unstructured key informant interviews(n = 11) were undertaken, along with observations at health facilities and review of state policies. Datawere analysed using Ritchie and Spencer’s framework method and the World Health Organization’s 2010framework of factors affecting decisions to relocate to, stay in or leave rural areas.Results It was found that rural background and community attachment were strongly associated withhealth workers’ decision to join rural service, regardless of cadre or contract. However, this aspiration waschallenged by health-systems factors of poor working and living conditions; low salary and incentives; andlack of professional growth and recognition. Contractual health workers faced unique challenges (lack of payparity, job insecurity), as did those with permanent positions (irrational postings and political interference).Conclusion This study establishes that the crisis in recruiting and retaining health workers in rural areaswill persist until and unless health systems address the core basic requirements of health workers in ruralareas, which are related to health-sector policies. Concerted attention and long-term political commitmentto overcome system-level barriers and governance may yield sustainable gains in rural recruitment andretention across cadres and contract types.