Ebola and community health worker services in Kenema District, Sierra Leone: please mind the gap!

Abstract

All community health workers (CHWs) in rural Kenema District, Sierra Leone. CHW programmes provide basic health services to fill gaps in human health resources. We compared trends in the reporting and management of childhood malaria, diarrhoea and pneumonia by CHWs before, during and after the Ebola outbreak (2014-2016). Retrospective cross-sectional study using programme data. CHW reporting increased from 59% pre-outbreak to 95% during the outbreak ( < 0.001), and was sustained at 98% post-outbreak. CHWs stopped using rapid diagnostic tests for malaria mid-outbreak, and their use had not resumed post-outbreak. The average monthly number of presumptive treatments for malaria increased from 2931 pre-outbreak to 5013 during and 5331 post-outbreak ( < 0.001). The average number of monthly treatments for diarrhoea and pneumonia decreased from respectively 1063 and 511 pre-outbreak to 547 and 352 during the outbreak ( = 0.01 and = 0.04). Post-outbreak pneumonia treatments increased (mean 1126 compared to pre-outbreak, = 0.003), and treatments for diarrhoea returned to pre-outbreak levels ( = 0.2). The CHW programme demonstrated vulnerability, but also resilience, during and in the early period after the Ebola outbreak. Investment in CHWs is required to strengthen the health care system, as they can cover pre-existing gaps in facility-based health care and those created by outbreaks.

Community Health Workers and Pandemic Preparedness: Current and Prospective Roles

“…The disproportionate effects of outbreaks on healthcare workers-as seen in the 2003 SARS (15) and 2014 Ebola outbreaks (16)-are likely to rapidly decimate the healthcare workforce resulting in a reluctance to work and in high rates of absenteeism (17). CHWs are not exempt from this trend (18). Still, medical tasks are fundamentally different from other essential response tasks-the former require technical proficiencies, whereas the latter can rely on social competencies, communication skills, and local-level knowledge (19).…”

“…This role is of great importance should healthcare workforces be depleted by an outbreak response. Scholars have noted that sustained political and financial investment in CHW programs could create a solid foundation for CHWs to close sudden or unexpected health system gaps and improve the resilience of health systems (18). Box 2 | Selected community health worker roles that promote adaptive resilience.…”

What was the effect of the West African Ebola outbreak on health programme performance, and did programmes recover?

“…22 Nevertheless, improved and sustained coverage of the population's health care needs will only be possible when the dramatic workforce gap is addressed, as shown by a Sierra Leone study. 15 The operational research performed demonstrates the importance of studying the effect of the EVD outbreak on health system performance, and how adaptive approaches may improve the utilisation and provision of health services. Moreover, the results of these studies may inform priorities for the allocation of scarce resources.…”

“…In Sierra Leone, community health workers stopped using rapid diagnostic tests for suspected malaria cases and treated clients based on symptoms. 15 Another Liberian study illustrated the feasibility of using a checklist to monitor infection prevention and control measures and thus guide safe health care delivery. 21 Output from scarce human resources may also increase when appropriate motivation is present.…”

“…6 Sixteen studies were conducted, and are assembled here for this special issue. [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Through the study of routine data the performance of a wide range of programmes was assessed before, during and after the outbreak. These studies present data from mother and child health care services, the human immunodeficiency virus (HIV), tuberculosis, vaccination, malaria, malnutrition and non-communicable diseases programmes.…”