Community health worker programmes after the 2013-2016 Ebola outbreak.

Abstract

The 2013-2016 Ebola virus disease outbreak in West Africa exposed an urgent need to strengthen health surveillance and health systems in low-income countries, not only to improve the health of populations served by these health systems but also to promote global health security. (1) Chronically fragile and under-resourced health systems (2) enabled the initial outbreak in Guinea to spiral into an epidemic of over 28 616 cases and 11310 deaths (as of 5 May 2016) (3) in Guinea, Liberia and Sierra Leone, requiring an unprecedented global response that is still ongoing. Control efforts were hindered by gaps in the formal health system and by resistance from the community, fuelled by fear and poor communication. Lessons learnt from this Ebola outbreak have raised the question of how the affected countries, and other low-income countries with similarly weak health systems, can build stronger health systems and surveillance mechanisms to prevent future outbreaks from escalating. (4) Factors that were important in the growth and persistence of the Ebola virus outbreak were lack of trust in the health system at the community level, the spread of misinformation, deeply embedded cultural practices conducive to transmission (e.g. burial customs), inadequate reporting of health events and the public's lack of access to health services. (1) Community health workers are in a unique position to mitigate these factors through surveillance for danger signs and mobilization of communities when an outbreak has been identified. In this paper we make the case for investing in robust national community health worker programmes as one of the strategies for improving global health security, for preventing future catastrophic infectious disease outbreaks and for strengthening health systems. Community health workers provide health education, gather information and deliver basic curative and preventive services at the community and household levels. They were first deployed in China nearly a century ago and have been deployed by both nongovernmental organizations (NGOs) and national governments over the past half-century. (5) Although community health workers play diverse roles, they share common features: they receive limited formal training and are recruited from and work in their own communities. (6) They are therefore uniquely positioned to promote healthy household practices and appropriate health-care-seeking behaviours. Large-scale national community health worker programmes are the cornerstones of primary health-care systems in many countries that have been pacesetters in improving the health of their populations, such as Brazil, Ethiopia, Malawi, Nepal and Rwanda. (7) Yet the failure of several national community health worker programmes in the 1970s and 1980s resulted in a loss of momentum for the movement. As a result of the growing success of the current programmes, (5,7) there is renewed global interest in using community health workers to strengthen primary health-care systems towards the goals of achieving universal health coverage and ending preventable child and maternal deaths. During the most recent Ebola outbreak, community health workers played several important roles. They worked with community leaders, going house to house to provide important information about Ebola and searching for active cases and contacts, (8) and they helped local religious leaders to expand their education and outreach strategies, especially in efforts to reduce transmission during funerals and burials. Many community-based agents, including community health workers working with NGOs, were deployed for contact tracing, community sensitization, promotion of epidemiologically and culturally appropriate protective practices, and data collection. (8) Networks of community health workers played key roles in limiting the spread of Ebola virus infection within Nigeria in July 2014. (9) Community health workers who were normally engaged in polio eradication initiatives were rapidly redeployed to detect patients with Ebola virus and trace their contacts. …