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Unsung heroes: Community Health Worker lessons in Sierra Leone post-Ebola

By Pietro Dionisio
on April 19, 2017

Community Health Workers (CHWs) are a critical component of the health workforce in low-resource settings, but they do not get – at least for now – due recognition in many of these settings. After the Ebola outbreak in Sierra Leone, the government laid the foundation to formalize and concretely recognize the work of CHWs. Could this revised plan be used as a “best practice” template which could be scaled up and transferred to other countries of the African region? 


By definition Community Health Workers are individuals “carrying out the functions related to health care delivery [who are] trained in some way in the context of the intervention [but have] no formal professional or paraprofessional certificate, or degrees tertiary education [in a health-related field]”. Furthermore, the WHO states that CHWs “should be members of the communities where they work, selected by the communities, answerable to the communities for their activities, and supported by the health system but not necessarily a part of its organization.”

CHWs played an important role in working towards the health related Millennium Development Goals (MDGs). Their contributions extended from work on reducing child mortality and improving maternal health, to combating HIV/AIDS, malaria and other diseases. It seems likely CHWs will play an even bigger role in the Sustainable Development Goals (SDGs). As a recent editorial in the Lancet Global Health put it, CHWs seem to be emerging from the shadows (at last). The current SDG momentum around CHWs has a number of reasons. Among others, SDG target 3C explicitly asks governments “to increase health financing, and recruitment, development, training and retention of the health workforce”. CHWs also play a role with respect to other SDG goals and targets, not just the “health” SDG 3, and are already doing so in many settings. The deployment of CHWs is increasingly considered as a key strategy to respond to the scarcity of health personnel, particularly in low-income and middle-income countries (LMICs).  There is strong evidence that if appropriately and adequately trained and supported (and thus more or less part of the “formal” health system), CHWs can be effective in providing preventive, promotive and limited curative primary health care services  and improving health outcomes in LMICs, including in sub-Saharan Africa.

Almost 3,590 lives were lost during the 2014 Ebola outbreak in Sierra Leone. The epidemic devastated society, tearing apart families and communities with a health system ill-equipped to provide basic health services, let alone contain an epidemic of this scale. In such a situation, CHWs were fundamental to the activities undertaken to manage and contain the epidemic. Community health workers working with NGOs were deployed for contact tracing (defined as the identification and diagnosis of people who may have come into contact with an infected person), community sensitization, and promotion of epidemiologically and culturally appropriate protective practices, and data collection. They worked with community leaders, went house-to-house to provide information about Ebola, and search for active cases and contacts. They helped local religious leaders expand their education and outreach strategies, especially in efforts to minimize the risk of transmission during funerals and burials.

The Ebola outbreak presented a wake-up call on the implications of weak health systems, not just in poorer countries, but also for global health and the world at large. For Sierra Leone the epidemic was deadly with society still facing implications from the epidemic three years on. However, the epidemic also presented the country with some critical learnings, one of which being the recognition of the role played by CHWs during the crisis, and their fundamental contribution to a health system.

On February 2, 2017, Sierra Leone’s Ministry of Health and Sanitation (MOHS) launched the revised Community Health Worker (CHW) Policy, 2016-2020. The policy aims at formalizing the role of CHWs within the health system, and includes among others a shared CHW definition, selection criteria of new members, training, outlining the scope of their work, incentives and motivation. The 2017 presents a much clearer roadmap for CHWs as compared to the 2012 plan that was in place till now.

According to the 2017 plan, CHWs will focus on high-impact, cost-effective and evidence-based interventions that will reduce maternal and child morbidity and mortality, and improve maternal, newborn and child health outcomes. The plan expands the CHWs’ work to include the assessment and treatment of pneumonia, malaria, and diarrhea in children between the ages of two to 59 months and in adolescents. Additionally, CHWs are expected to practice infection prevention and control measures for their own safety and for the protection of their communities, with the scope to add more services under a particular program in a specific geographic area according to the context. In terms of remuneration, the new policy is clearer on the financial and non-financial incentives to CHWs, including those aimed at attracting new recruits. The 2017 policy on CHWs indicates that each CHW must receive Le100,000 per month (just over USD13) and monetary logistics support to reach areas where they have to work. Non-financial incentives, such as awards for an outstanding job, and opportunities to pursue career pathways in the health system for those who meet the minimum training requirements for other cadres, are also outlined.

The role of CHWs during the Ebola outbreak in Sierra Leone presents an interesting case on the scale-up of the position of CHWs in a health system. In Sierra Leone, the Ebola outbreak brought to light the importance of CHWs, and encouraged the health department to formalize their scope of work and remuneration. In other, similar low-resource settings, where health systems struggle to provide even basic care and face a chronic shortage of trained health workers, CHWs present a useful solution towards the provision of primary health care services, water and sanitation issues, behaviour change for health, etc. – particularly in the communities in remote areas.  CHWs can and do play a critical role in a health system, and it’s time that the international community focuses its attention on the formalization of CHWs. Slowly but gradually, that seems to be the case.

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ollister says:

Further implementation of the platform is foreseen in collaboration with the MoHS in Kambia district of Sierra Leone. This implementation will involve more than 800 CHWs spread over 68 PHUs and 7 Chiefdoms. The training content for the (Ebola) Disease Surveillance Outbreak Response module will be refined to ensure a better clarity of questions posed and also to enhance the probability that a greater degree of knowledge can be acquired or refreshed. This larger scale implementation will, as mentioned, be used to observe the effect of limiting the face-to-face time spent to explain the use of MOTS as well as the possible impact of the order in which trainings are delivered. This implementation also offers an opportunity to assess the cost component of a full-scale national roll-out should the local authorities wish to adopt the MOTS platform as an integral part of their health strengthening strategy. Research suggests that strong government ownership of this process is needed to scale-up interventions such as MOTS ( 10, 17 ).