“If there’s one message, it’s health systems need to be resilient, agile, and equitable,” said Uzma Alam, a researcher at the Africa Institute for Health Policy Foundation and Senior Program Officer of the Africa Academy of Sciences. “No one person, no one community, no one minority can be left behind. After all, your health system is as agile, as resilient as your weakest link.” She spoke at a recent Wilson Center event co-sponsored with the Population Institute, “Lessons from Africa: Building Resilience through Community-Based Health Systems.” The event focused on how locally led interventions improved the resilience and responsiveness of health systems in sub-Saharan Africa. 

Community health workers have played a fundamental role in the COVID-19 response, said Juliet Nabyonga-Orem, Team Lead of Health Financing and Investment in the Universal Health Coverage/Life Course Cluster of the World Health Organization (WHO). In Ethiopia, community health workers have been critical in risk communication, contact tracing, transporting supplies, and ensuring the continuity of essential services, she said, much as they did in the Marburg response in Uganda and the Ebola response in the Democratic Republic of Congo.

Creating Resilient Health Systems

Community health workers serve as the link between the community and the response team, which is important to building trust and encouraging the uptake of health interventions, said Nabyonga-Orem.

A recent study found that communities trust their health workers to give them accurate information about public health events, said Dr. Mohammed Abdulaziz, Head of Division for Disease Control and Prevention at Africa Centres for Disease Control and Prevention (Africa CDC). Community health workers are the first source of information for most people in rural villages in Africa and an important part of an effective response to emerging infectious disease crises like COVID-19, said Abdulaziz.   

As we have learned from the Ebola epidemic, the root of resilient health systems is investing in people closest to the problem, said Dr. Raj Panjabi, CEO of Last Mile Health and Assistant Professor of Medicine at Harvard Medical School and the Division of Global Health Equity at Brigham & Women’s Hospital. “The second thing we learned from the West Africa Ebola epidemic, and what we’re learning now from COVID, is that epidemics don’t only threaten our immune systems, they can devastate our health systems,” he said.

Making a Difference 

But it doesn’t have to be this way. In the first month of the pandemic, South Africa retrained 27,000 HIV and TB community health workers who went on to screen more than 11 million people, or about 20 percent of the population, for COVID-19, said Panjabi. Meanwhile, workers from Ethiopia’s Health Extension Program traced tens of thousands of people to ensure that they were connected with rapid response teams, said Panjabi. As a result, Ethiopia has largely avoided the worst of the pandemic thanks to its community-led response.

Speakers agreed that hiring community health workers is also a smart, cost-effective approach to crisis responses. According to Abdulaziz, governments in some Nigerian states recruited epidemiologists for their initial COVID-19 responses, paying upwards of US$3,000 for contact tracing and other activities. Now Africa CDC is supporting the hiring of community health workers in Nigeria instead. They earn $100 per month, the national compensation rate for community health workers, and assist in detecting suspected cases, contact tracing, and community advocacy, he said.  

Undervalued Workers 

We need to shift from the idea that community health workers, most of whom are women and from poor communities, should work without pay, said Panjabi. Underrecognizing and undervaluing these workers can have devastating results, whereas paying and supporting them with the necessary supervision yields better health results and better protects livelihoods during times of crisis, he said.

Back in 2017, a head of state in the African Union said that Africa requires another 2 million community health workers to ensure sustainable health for all on the continent, said Abdulaziz. With community health workers, countries can ensure their health systems can mount a sustainable public health response when crises arise, he said.

Investing in community health workers is not just the right thing to do, said Panjabi. “It’s a smart thing to do.” Community health workers can be part of an everyday system that can surge at times of crisis, he said. Investing a few billion dollars in community health workers could prevent trillions of dollars of economic losses, since every dollar invested in community health workers brings returns to the economy in the form of outbreak prevention and improved health and longevity, he said. Moreover, it’s also one of the fastest ways to create jobs for young people on the continent.

When Leaders Do the Right Thing

While health systems around the world have struggled to contain the spread of the coronavirus, Africa has seen notably fewer COVID-related deaths. Africa’s younger population, pre-existing immunity, and other explanations are commonly cited, but they don’t explain the whole picture, said Alam. “How about Africa leadership got it right?” she said. African leaders saw COVID-19 for what it was: a public health emergency. Hence, they acted on it, and did all the right things fast, said Alam.

“And what happens when leadership steps up? Communities step up,” she said. African communities are resilient and innovative. Their social capital and social networks kicked in and have positively impacted management, economics, and health care, said Alam. The African concept of social capital (also known as “Ubuntu,” “Undugu,” and “Ujamaa”) emphasizes interconnectedness and a shared sense of responsibility. This has strongly shaped the Eritrean government’s COVID-19 response as it engaged communities on the frontline as risk communicators and advocates for social distancing measures.

Despite these successes, challenges to Africa’s health systems persist, particularly regarding women’s and children’s health: The COVID-19 pandemic has disrupted essential healthcare services. In low- and middle-income countries, many of which are in Africa, weakened health systems could cause maternal and neonatal deaths and stillbirths to increase by approximately 31 percent. “There’s a lot more that needs to be done in this area,” said Panjabi. 

Some countries have successfully maintained maternal and reproductive health services during the COVID-19 pandemic, said Panjabi, citing Liberia’s continued provision of sexual and reproductive health services. Rather than halting essential health services during disease outbreaks, the country adapted its systems to continue providing care to women, he said. In Liberia, workers were given the personal protective equipment they needed, he said. However, such cases are still exemplars and exceptions, whereas they need to be absolutes and universal, said Panjabi.

Governments must understand that without health, we cannot talk about education, economic prosperity, and empowering women, said Ambassador Deborah Malac, former U.S. Ambassador to Uganda and Liberia, Career Foreign Service Officer at the U.S. Department of State, and Senior Fellow at the Population Institute. Investing in areas like women and girls’ education requires investments in health systems that are robust and resilient, and this must begin at the community level. After all, communities are the ones that are directly impacted and can be the most effective tools for ensuring that everybody has an equal chance in life, said Malac.