Community Health Workers

The early childhood workforce has played an important role in providing healthcare services to young children and their families during COVID-19. Community Health Workers (CHWs) who act as a critical link between their communities and primary healthcare services, play an important role in preventing the spread of the virus in their communities. However, despite the increased reliance on this workforce during the pandemic, CHWs face a number of obstacles, such as insufficient personal protective equipment (PPE), limited training, and a lack of professional development opportunities, which have made it challenging for them to carry out their roles and responsibilities.

The COVID-19 Home Visiting Workforce Platform was developed to provide policymakers and program managers with resources that can be used to support the home visiting workforce in their countries during times of crises. Informed by desk reviews and key informant interviews (KIIs) with experts in the field (e.g., program directors, public health officials, CHWs), the platform highlights ten different approaches that have been used to support the home visiting workforce during COVID-19. A few of the promising approaches are highlighted below:

1. Providing the home visiting workforce with high-quality PPE ensures that they are protected as they carry out their roles and responsibilities.

CHWs are often the only source of essential services in many remote and marginalized communities. During the pandemic, these workers are in close contact with young children and their families to ensure that they have access to important health information and services. Despite this close contact, CHWs often lack the Personal Protective Equipment (PPE) needed to protect themselves against the virus and maintain the delivery of essential services.

To address this problem, the COVID-19 Action Fund for Africa (CAF-Africa) was created to supply CHWs in 24 African countries with essential PPE items (e.g., surgical masks, gloves, face shields). CAF-Africa works closely with the Ministry of Health (MOH) and one supporting non-governmental health partner to determine the PPE needs of CHWs and establish a plan for distributing these items to workers. Between August 2020 and June 2021, CAF-Africa had provided 81.6 million units of PPE to CHWs in 18 countries, thereby helping to fill a critical gap that has plagued CHWs since the beginning of COVID-19. The PPE has not only allowed these workers to protect themselves against the virus but to also continue delivering essential health services to their community.

2. Providing the home visiting workforce with reliable training, ongoing professional support, and up-to-date information on COVID-19 ensures that they can continue gaining important knowledge and skills during the pandemic.

Social distancing guidelines triggered by the virus have made it challenging for CHWs to receive consistent training and ongoing professional development support that was previously delivered in-person. Providing CHWs with COVID-19 training and professional development opportunities in a flexible and user friendly format (e.g., radio, mobile phone applications) mitigates challenges (e.g., limited internet connectivity) they may face when working in resource-constrained settings and helps ensure that they are equipped with the knowledge needed to address the virus in their communities.

One example of a program that is working to provide members of the workforce with flexible training is Health Care on Air, a distance education program for primary healthcare (PHC) nurses that is being implemented in six countries in the Pacific (Fiji, the Solomon Islands, Tongo, Tuvalu, the Federated States of Micronesia, and Vanuatu). The program uses radio to cover topics (e.g. how to use PPE, how to cope with stress during the pandemic) that allow these workers to continue providing essential services to member of their community, including children, during the pandemic

After listening to each episode, PHC nurses can receive credits that go toward the renewal of their annual nursing license. PHC nurses who received the training noted that it had helped increase their confidence in managing suspected COVID-19 cases in their communities and protecting themselves against the virus.

3. Equipping the home visiting workforce with Mobile Health (mHealth) can help inform data-driven decision-making aimed at preventing the spread of the virus

Equipping CHWs with mobile health (mHealth) technology (e.g., phone applications) allows them to contribute to the prevention, early detection, screening, and treatment of COVID-19 cases in their communities. mHealth can also be used to ensure that the information collected at the community level is used to inform regional and national COVID-19 response efforts.

In Siaya County, Kenya, for example, mDharura, an application that is used to facilitate the early detection and real-time reporting of public health threats at the community level, is being used to assist community health volunteers (CHVs) in responding to COVID-19. Under mDharura, CHVs use SMS messaging to rapidly report suspected COVID-19 cases to their supervisors, who then review and verify the reported cases. They can subsequently escalate them to the appropriate sub-county team for investigation and follow-up if warranted. The information that is gathered is then used to inform data-driven decision-making related to responding to COVID-19 at the sub-national and national levels.

Moving Forward

Although the pandemic has presented a unique set of challenges for CHWs, numerous efforts have been made to support these workers as they carry out their roles and responsibilities.  The promising approaches highlighted in the COVID-19 Home Visiting Workforce Platform offer important insights for policymakers and program managers interested in further supporting the workforce in their countries. Providing CHWs with high-quality PPE, training and on-going professional support, and mHealth technology are a few examples of how resources can be deployed to support these workers and mitigate the effects of the virus in their communities. As the home visiting workforce continues to provide critical health services to young children and their families during the pandemic, we look forward to learning about approaches being implemented to support them across the globe.

To learn more about the other promising approaches, please visit the COVID-19 Home Visiting Workforce Platform’s webpage.

Kavita Hatipoglu, Results for Development

Time and again, we’ve seen that setting policy is often the easier part of reform, with implementing policy being the real nut to crack. And when challenges loom large, sometimes it’s hard to see the progress you have made and determine the way forward. However, the South African government has taken some key early steps towards supporting young children and their families in a more systematic and comprehensive way, including through the recent National Integrated Early Childhood Development Policy (NIECDP; 2015) which laid out goals to be achieved in the coming years. Notably, the NIECDP also set out to strengthen parenting and family support at the community level, identifying Community Health Workers (CHWs) as the key personnel to deliver what are commonly called  First 1000 Days Services.

As part of the Early Childhood Workforce Initiative (ECWI), Results for Development, along with Ilifa Labantwana and researchers from the University of Pretoria, recently studied the NIECDP and its early implementation in two provinces, KwaZulu-Natal and Western Cape, looking particularly at the capacity of CHWs in South Africa to deliver these expanded First 1000 Days services. Reflecting on our work, we’re sharing four key lessons on the implementation process in South Africa.   

1. Clarity, Communication, and Coordination are essential 

While nearly everyone we spoke with responded positively to expanding First 1000 Days Services, it was apparent that not everyone knew about the NIECDP or that those services were likely to be delivered through the existing CHW workforce. Even among those familiar, it was hard to pin down which services we were talking about because as of yet, there is no defined service package. Discussions with the provinces reflected that, without clarity from the top – about the detailed services or how their performance will be measured - implementation often stalls. 

Further challenges arise when there isn’t enough communication between the line department responsible for developing the service package and the department tasked with delivering it.  The Child, Youth, and School Health directorate within the NDoH recently led the overhaul of the Road to Health Booklet (RtHB), and commendably, the tool is organized around the five key pillars of care – Nutrition, Love, Protection, Healthcare, and Early Care, and aligned with the Nurturing Care Framework. However, CHWs are managed by a separate directorate – Primary Health Care – and it is not readily apparent how committed they are to (re)training the CHWs and other health personnel to maximize RtHB’s potential. Communication and coordination will need to be the name of the game to see any services comprehensively delivered and outcomes for young children and families changed.

2. More data is always a good place to start

While you don’t want to collect data for the sake of collecting data, more information about the baseline situation often aids implementation. And despite significant variation in the way services are organized and delivered among the provinces, we consistently heard about the need for more data. There is relatively little understanding, at the provincial or national level, about what the current CHW workforce looks like or what they precisely do. Past estimates suggest up to 72,000 paraprofessionals with differing levels of training and education, experience, and subject-matter expertise -- a vestige of a health system organized around tackling specific diseases.[1] Furthermore, little is known about the exact package of services CHWs currently provide, the visit length different services require, or their relative quality. This type of information could assist provinces to plan for, cost, and evaluate any service changes. Importantly, this would also help ensure that the needs of vulnerable populations are addressed. The need for data is not uncommon, and in fact, is something we heard repeatedly through interviews conducted with stakeholders across the globe, and part of the reason that the ECWI is setting out to develop a tool to help policymakers identify gaps in and strengthen their workforces.

3. Additional Training and Support will be essential if services are to be implemented and sustained

Policymakers in South Africa are aware of the need for enhanced training and are striving to develop it, yet there is simultaneous effort to simplify existing trainings. As CHW Coordinators and NDoH officials noted, there are currently 645 topics within Phase 1 and 2 of the CHW training and a clear need to streamline and update the content, ensuring better alignment with CHWs’ capacity, education, and working conditions. Efforts to simplify training while building out capacity for First 1000 Days Services aren’t necessarily at odds, but it merits close attention and suggests power struggles may be ahead.  Wherever they end up, if providers are to deliver new services, they will need a host of training and upskilling opportunities, as well as continued mentoring and in-service support. However, frontline staff aren’t the only ones in need of training, supervisors and other health professionals do as well, if they are to support, monitor, and reinforce the new services. Current supervisors suggested that supervision was primarily compliance-based and focused on service delivery planning, as opposed to an opportunity to aid, support, or enhance the skills of CHWs. They also noted a lack of training on how to be a manager or provide any type of reflective supervision.  As many First 1000 Days Services also encompass parenting support and coaching on developmental activities, it will be essential for supervisors to also understand the value of these services and be able to provide continuous support to ensure quality delivery.

4. Innovation can be sourced from within

In South Africa, policy is set at the national level and the nine provinces have a greater level of autonomy to determine the implementation service model that best fits their needs. For example, Western Cape primarily contracts NGOs to deliver community-based services, whereas KwaZulu-Natal has a well-developed and extensive system of Community Care Givers (CCGs) who have smaller caseloads but larger teams. CCGs are also employed on a contract-basis through the Provincial Department of Health. The Western Cape has also created a branded initiative, The First 1000 Days Initiative, to bring partners together and raise awareness of the importance of these early days for children and families. The variation among provinces presents an excellent chance to learn from the challenges and opportunities these differing workforce models present, and suggests a context ripe for innovation and adaptation. It would be highly beneficial to create more structured learning opportunities between the provinces on the road to full implementation.  

Pushing ahead

The road to implementing integrated ECD policies is almost always messy. It requires bringing people, sectors, and roles, under one house and aligning them in new and different ways. From what we saw, South Africa continues to grapple with many of the same challenges that we often talk about in relation to the global early childhood workforce: they are an underpaid, undervalued, and undertrained system of professionals, para-professionals, and volunteers who, though dedicated to their work, require additional support to more effectively care for young children and their families. However, in South Africa, there are many indications -- like the adoption of the NIECDP and the recent creation of Mother-Child Think Tanks at the Department of Health -- that suggest that the country is up for tackling these challenges and that the momentum around the First 1000 Days will only increase. Their efforts tie into the growing global consensus around the Nurturing Care Framework, and our work at ECWI, where we are eager to continue learning alongside countries and support them with tools and resources as they crack that implementation nut!

Read the Country Study, Supporting the Early Childhood Workforce at Scale: Community Health Workers and the Expansion of First 1000 Days Services in South Africa.

[1]An audit of CHWs by the Department of Health in 2011 identified about 72,000 CHWs, the figure still quoted in planning documents for the 2015 ECD policy. Nearly 50,000 of these CHWs were identified as home-based carers (HBC) or community care givers (CCGs) while others include lay and adherence counsellors, DOTS supporters, peer educators, further highlighting the diversity of this workforce (National Department of Health, 2012. Annexure B1. Human resource requirements for re-engineering primary health care in South Africa.)

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