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Community health workers key to containing Ebola
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IN sub-Saharan Africa, any child with a fever should receive immediate medical care to prevent death from malaria or pneumonia. But, as panic about the spread of Ebola grips Liberia — as well as Sierra Leone, Guinea, and Nigeria — people there are increasingly associating clinicians and health-care facilities with exposure to the disease.
Ensuring that they continue to seek care when they need it requires improvements to front-line clinics and investment in locally hired community health workers (CHWs) to reach the vulnerable in their homes.
To be sure, the shortcomings of Liberia’s health-care system long preceded the Ebola outbreak, with roughly 28 percent of the country’s 4 million citizens lacking access to adequate facilities. With very few qualified health-care professionals, repairing the health-care system demands more than building new hospitals and clinics across Liberia’s densely rain-forested countryside. Fortunately, the government, like others in sub-Saharan Africa, recognizes the need to invest in training CHWs in rural counties to treat diarrhea, pneumonia, and malaria — the three major causes of death in children under 5 years old.
By definition, CHWs have deep relationships with their communities, including traditional healers, which enables them to help the formal health-care system calibrate its approach. At the same time, mobile technologies facilitate quality control and supervision.
In March, Liberia’s health ministry, in collaboration with UN agencies, the US Agency for International Development, local and international NGOs and private companies, created a comprehensive scale-up plan for the country’s community-health program. But Ebola struck soon after, shifting attention to clinics, quarantines and reports of cures.
The World Health Organization has played a central role in coordinating the international response along with national governments, aid groups like Doctors Without Borders, and the US Centers for Disease Control and Prevention (CDC).
With the epidemic still growing, the public-health community is attempting to mount an effective response, using a US$100 million funding boost to deploy clinicians, epidemiologists and other experts.
To put this in context, the Liberian plan unveiled in March estimated that a national CHW network would cost some US$20 million annually. To be sure, investments in CHWs should not come at the expense of critical public-health measures to slow the spread of Ebola or support for front-line clinics. But without continued investment in CHWs, whose costs are modest compared to those of traditional health-care systems, it will be difficult for the international community and national governments to stop the spread, and prevent the recurrence, of Ebola and other devastating epidemics.
There are two basic approaches to building a health-care system. One has hospitals at the center and clinics radiating outward; the other is founded on social networks and mobilized by CHWs. If the first is too rigid, diseases and their social context evolve beyond its means. If the second is too flexible, the ability to carry out technically complex work is compromised.
Striking the right balance is particularly challenging in areas where access is limited or trust is lacking.
As a CDC expert explained, CHWs are the key to stopping Ebola, because anybody who shows symptoms of the disease becomes a “suspected patient,” all of whose contacts must be followed for another three weeks. “Every day, except Sunday, the workers report their findings to a supervisor.”
One organization, Last Mile Health, has built a network of 300 CHWs that serves 30,000 patients, providing access to basic clinics even in places like hard-to-reach Konobo, Liberia. The organization’s hybrid structure is capable of addressing regular challenges, while retaining the flexibility to respond to extraordinary developments.
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