The comparative agility of the community health worker cadre in fragile & conflict-affected contexts

Editor's Notes

• #2: Second, future-proofing health systems will benefit from the flexibility of roles of CHWs in changing contexts. So in this presentation I want to focus on a study that we are just finishing that has looked at how CHWs have adapted their roles during the COVID 19 pandemic.
• #3: Most countries in the global South, and particularly FASP contexts, have a shortage of formal health workers and are increasingly looking to a range of CTC providers (eg. Community Health Workers and traditional birth attendants) to fill the gap and reach the most marginalised2. The COVID-19 pandemic has demonstrated the value of CTC providers and their importance in the response. In this study we have particularly focused on the gendered experience of CTC providers - gender roles and relations are context embedded and dynamic, shaping the social determinants of health as well as the experiences of CTC providers3 and need understanding and addressing to appropriately support CTC providers as they navigate new and existing challenges.
• #4: We have conducted the study in settings in 4 fragile countries – Lebanon, Nepal, Myanmar and Sierra Leone.
• #5: We used three methods: 1. Reviewing documents and policies about chws in COVID19 2. Interviews and FGDs with CHWs: There are ranges of CHWs in each context. We selected for each context Myanmar: female auxiliary midwives who work on maternal and reproductive health and male community health workers who work on environmental health and disease control. Nepal: Female Community Health Volunteers (FCHVs) support health promotion and prevention activities at community level. National guidelines call for FCHVs to be part of the COVID-19 response, in coordination with local governments. Sierra Leone: CHWS as part of the national CHW programme who deliver a package of services at the community level Lebanon: The study included only Syrian HW employed informally: Syrian refugees with health background employed regularly in non-authorized informal healthcare venues established by the Syrian community and Syrian refugees of different background employed informally by authorized NGOs as volunteers. 3. Key informant interviews with managers, supervisors, leaders of CHWs from facilities, and communities. (SL: CHW peer supervisor, Mammy Queen, DHMT; Myanmar: facilities; Nepal: supervisors, mayors, ward chair person, municipality managers. Lebanon: NGO facility and outreach supervisors, managers ) Drawing on the findings from these 4 settings I want to present about the adapting roles of CHWs during COVID19; the challenges that they face in taking on these roles; and the support that they need.
• #6: starting work Firstly, when the pandemic started, in some settings CHWs did not start COVID 19 work immediately. Myanmar: routine work stopped for first few months; did most of their work via phone; then started work – visiting homes, doing health education. Nepal: Some FCHVs were working from the very beginning of COVID- 19 /lock down, whereas some started work after a few months of lockdown. Although, FCHVs regular roles and responsibilities, which primarily requires home visits and personal interaction, were interrupted during the initial few months of lockdown due to fear of transmission, some FCHVs contacted women and elderly people via telephone through the personal networks to get and provide update on any relevant issues. Lebanon: health centres closed at start, then gradually reopened – and workload increased SL: CHWs had COVID specific roles in the first three months of the COVID-19 response Layering of roles What we saw was a kind of layering of roles – so CHWS has their regular roles of general health education, maternal and child health care, clinical work; and on top of this they had the COVID19 roles such as awareness raising about hygiene and physical distancing, contact tracing, screening, following up, referral of people with COVID, attending to people who were in home quarantine, providing psycho social support We also saw a gender difference in roles in some settings: Lebanon: men hold posts with greater responsibilities – require more overtime and shifts; women as health educators. Men are trusted with assignments with more responsibility, requiring longer schedules Women refuse overtime to rush home, losing both extra money and professional opportunities Myanmar: Administrative roles were more likely be taken by men, whilst women were more likely to take on health educators/informers of information role, preventive activities and collecting lists of people with COVID-19 and their family members so that they can access quarantine services Reasons they were able to take on these roles Community trust – CHWs were familiar to the community – level of trust already there, most were from these communities. these existing relationships enabled them to access families They were willing to take on these roles – saw it as their duty in a time of emergency Could draw upon their links with community leaders and organisations to do their work Able to innovate to use local resources e.g. In Sierra leone, they encouraged communities to use jerry cans as hand washing stations The health system, employers wanted to use them - allow cost available resource In Myanmar – the CHWs were the first to respond to covid in the community – they wer the first to give advice etc In Sierra Leone, CHWs drew upon their experience of working during EVD – how to talk with people and reduce fear, how to do contact tracing
• #7: There are several challenges that CHWs faced in adapting their role and these are from the individual perspective: 1. Juggling multiple tasks: Community gender norms in all the settings, meant that women CHWs faced having to juggle multiple tasks of CHW work – regular, and COVD, housework, looking after families and home schooling during lock down 2. Increased workload: There was increased workload – again this layering of tasks, roles. For example in Sierra Leone, CHS were expected to provide twice daily reports on families / individuals in quarantine. It was particularly challenging when additional work came up unplanned – women CHWs found this particularly difficult as they were trying to manage their homes and families too. 3. Travel and safety: Challenges in traveling to and from work safely were raised. In Myanmar: women have restriction especially late nights and need to be accompanied by their families. Men are freer to move without any restriction. In Lebanon: public transport is unsafe for women CHWs – risk of assault especially in Taxis. It is unaccepted socially to be unaccompanied especially when dark: “Their thinking is like: you are a girl and you are attending camps by yourself. People ask: You have nobody else? And even when we quit the camp and look for a car, we are not viewed positively, Outreach CHW, Lebanon 4. Fear of COVID: Getting COVID -19 infection was a common fear. This caused anxiety and stress amongst the CHWs: highly contagion, less safety measures, inadequate information; and there were no support mechanisms for anxiety and mental stress 5. Halted or limited income generating activities: This was specifically raised in Sierra Leone, there was disruption in small businesses and other sources of income generation due to lock down and travel restrictions; halt in other income generating activities to focus on COVID-19. There was also an increase in prices of staple foods. This led to increased stress. It was particularly challenging for women CHWs who were widows or single parents “It was not easy… especially for us with kids… we were just working in the community and we had nothing… so the little we had is the only thing we were using.” (Bonthe, CHW, Female)
• #9: Family support was really important for CHWS to be able to do fulfil their work during COVID-19. For example, in Nepal, family members assisted by completing household chores (cooking food, taking care of children). In Myanmar, families helped with organising transport and accompanying them when doing their work. However, this support was not provided for all CHWs and in all settings. Some CHWS did not receive this kind of support because: Voluntary nature of work without any form of benefits and monetary incentives Concern around safety of CHWs themselves and their family members considering their engagement and exposure to COVID 19 Not getting the dinner on the table, or not doing their household chores - scolded by their husbands and elder family members CHWS developed coping mechanisms to accomplish both social and professional responsibilities: Waking up early to complete household chores before staring their CHW work Ignoring the scolding Despite supervisors knowing these challenges, no support from health system Lebanon : In Lebanon, women workers do not contest especially their primary caring role. Some do not trust their household responsibilty to husbands even when those are willing to help  
• #11: Stigma and discrimination from community members towards the CHWS themselves but also their families. Community members were reluctant to listen to their advice and health message and receive care; they were also isolated from any social activities. They were viewed as carriers of the virus. In Sierra Leone, some CHWS were accused of prolonging COVID so that they could receive more money – assumption that they would be receiving good payment. The stigma and discrimination appeared to reduce as the pandemic continued for example in Myanmar stigma was observed in the early phase of the COVID 19 as community fear about contracting the disease. But as they practice wearing mask and hand washing less stigma is seen in the second wave. CHWs were able to reduce this stigma and discrimination through talking with community members, drawing on the trust they had gained with them before the pandemic. Reluctance to listen to women CHWs: this was seen in Sierra Leone and Myanmar and Nepal – where women CHWs struggled to convey messages and advice to some men in the communities. In Sierra Leone, some supervisors paired women with men CHWs to overcome this issue.
• #13: 1. Limited training and supervision In Myanmar and Nepal reliance on informal sources of information and support, such as radio, TV, Facebook; quick updates via phone In Lebanon and Sierra Leone, training was provided which helped them to understand about COVID 19, use of face mask, physical distancing. In Lebanon, training was reinforced through online reminders Nepal supervision: Mostly quick update and reporting was done either through regular phone calls from health post in-charge, or through monthly meeting with FCHVs at health post  2. Limited equipment and supplies PPE, masks, hand sanitisers ran out; non fitting PPE; CHWs often bought their own; often resused them  3. Not prioritised for vaccine This came up in Myanmar  4. Limited financial support for additional roles despite policy In Lebanon: Officially men and women paid according to duties and posts however men are privileged as men are more likely to take overtime and extra pay; and men are usually at higher positions (even with equal education) because of community demand of men in leading positions In Sierra Leone: were meant to receive $20 per week for COVID 19 resposne activities, but this was not seen as enough compared with workload, not being able to take on their usual income generating activities and increase in prices of food. some did not receive, and others it was late, or not full amount. In Myanmar – get some financial support from NGO programmes but nothing extra for their COVID-19 prevention activities. pay out of own pocket for transport for household visits. Nepal: Most CHWs did not receive any kind of incentives/remuneration according to the policy (C-19 specific); unaware about policy and what they should receive; key informants reported that allocation of limited budget at the local level was major constraint to provide incentives to CHWs
• #14: finally: CHWS need support to be able to take on these important roles during a shock like COVID 19: Families: need their help in doing their work – household chores, transport, understanding. This could be done through more communication with families, greater recognition from the health system and community for their work. Community: need to strengthen the links between community leaders and organisation to enable women and men CHWs to do their work and be supported in this. Not completely rely upon the CHW relationships with community – give them some back up Health system: strengthen the training and access to information – e-health, m health could help here; incentives policy is transparent and followed so that this does not damage CHW relationship with the community as seen in Sierra Leone. providing adequate equipment and supplies to protect from infection mental health support and support to develop coping mechanisms and recognition of this is important.