Examining Roles, Support, and Experiences of Community Health Workers in the COVID-19 Response
Leveraging Community Health Workers to Address Health Crises
Community health workers (CHWs) have long been recognized as crucial frontline responders, bridging the gap between communities and formal health systems. This role has become especially critical during the COVID-19 pandemic, as CHWs have been tasked with amplifying public health messaging, supporting disease surveillance, and ensuring continued access to essential health services.
Across low- and middle-income countries, CHWs have adapted to rapidly evolving challenges, often with limited training and resources. Understanding their experiences, perspectives, and support needs is essential for strengthening community-based pandemic response efforts and leveraging CHWs to build more resilient health systems.
Drawing on recent studies from Bangladesh, Malawi, and Haiti, this article examines the diverse roles, support structures, and on-the-ground experiences of CHWs during the COVID-19 crisis. By highlighting both successes and challenges, it offers insights to policymakers, program managers, and global health practitioners on optimizing the contributions of this vital cadre.
Expanding Responsibilities Amid Disruptions
As the COVID-19 pandemic unfolded, CHWs found themselves tasked with a widening array of responsibilities, even as their routine work faced significant disruptions. A study of government-employed CHWs in Bangladesh revealed that the majority reported receiving training on COVID-19 prevention strategies from both government and non-governmental stakeholders.
“We went there and collect it without telling us what they want to do with the collected data. They just tell you a certain NGO wants it. Things like those are the ones I don’t like.”
– CHW in Zomba district, Malawi
Many CHWs took on new COVID-19-related duties, such as advising communities on symptoms and referring suspected cases for advanced care. However, they also experienced decreases in their regular health promotion and service delivery activities, especially early in the pandemic. As one CHW in Malawi explained, “These other activities consume much of our time and instead our normal duties do not bear results in good time as we are preoccupied with other duties.”
The study in Bangladesh found that government support and integration of CHWs into the COVID-19 response – particularly through training – helped mitigate disruptions and enhanced CHWs’ capacity to continue serving their communities. Regression analyses showed that CHWs who received COVID-19 training were more likely to effectively advise on symptoms and maintain routine service provision.
In Haiti, the Frontline Health project documented how CHWs, known locally as “agents de santé communautaire” (ASCs), took on a range of COVID-19-related responsibilities, including:
- Disseminating prevention messages
- Identifying and referring suspected cases
- Supporting contact tracing and follow-up
- Distributing hygiene kits and face masks
- Conducting community-based screening
However, ASCs also faced significant challenges, including limited personal protective equipment, inadequate training, and difficulties traveling due to pandemic-related restrictions. Many reported feeling overburdened by the competing demands of COVID-19 activities and their regular responsibilities.
Navigating Shifting Priorities and Competing Demands
The expansion of CHW roles during COVID-19 was not always a smooth transition. Studies across different country contexts revealed tensions between disease-specific priorities and CHWs’ broader community-based responsibilities.
In Malawi, for example, CHWs known as “Health Surveillance Assistants” (HSAs) described feeling overwhelmed by the proliferation of new tasks, which sometimes diverted them from their core duties in health promotion, disease surveillance, and facilitating community participation. As one HSA said, “We have a lot of jobs, so for you to become an expert at a particular job it becomes difficult because if you are to do a job you should put your heart into it, another one comes that you should do such, so we have a lot of jobs so that it becomes difficult to pick out one job that we are good that, the jobs are just too many.”
Policy-makers acknowledged that the influx of disease-specific programs, often supported by non-governmental organizations, had led to fragmented and uncoordinated demands on HSAs. One policymaker noted, “You find that some of the NGO they don’t do integration, they just want their programme to be done at that particular time…managers are biased towards their programme because everyone wants his programme to work. Yeah, so with that thing, it is like the HSAs now start losing focus to other activities which also they are supposed to implement.”
Similar dynamics emerged in Haiti, where ASCs reported struggling to balance COVID-19 activities with their regular responsibilities around maternal and child health, nutrition, and family planning. As one ASC shared, “Before COVID, we were responsible for many activities in the community. Now with COVID-19, we have a lot more to do – more trainings, more meetings, more supervision. We are overloaded.”
These findings underscore the importance of holistic, integrated approaches to community health programming, where CHWs are empowered to address a range of health priorities in a coordinated manner, rather than being pulled in multiple directions by disease-specific initiatives.
Fostering Supportive Ecosystems for CHWs
Effective community-based pandemic response requires robust support systems for CHWs. Across the studies, CHWs consistently highlighted the need for adequate training, supervision, supplies, and remuneration to fulfill their evolving roles.
In Bangladesh, access to infection prevention supplies varied significantly by CHW cadre, and perspectives on the provision of adequate supplies were mixed. Many CHWs in Malawi and Haiti reported inadequate training, particularly for the novel COVID-19-related tasks they were expected to carry out.
“We met different cases (diseases)…sometimes we fail to handle these just because of lack of knowledge or skills, and we also failed to help people even simple cases due to lack of knowledge.”
– CHW in Zomba district, Malawi
Fragmented supervision also emerged as a key challenge. In Malawi, HSAs reported having multiple, uncoordinated supervisors, which undermined their ability to prioritize tasks and receive consistent guidance. As one policymaker observed, “We are targeting the HSAs…these other cadres of their supervisor the Environmental Health Officer, the Assistant Environmental Health Officer; they are being left out…How can you supervise something you don’t know?”
Inadequate remuneration was another recurring concern, with many CHWs feeling that their compensation did not reflect the expanding scope of their responsibilities. As a Malawian HSA expressed, “Another thing that I see as a problem on our work is the abundance of the work which we receive to do, comparing to what they employed us for. So it seems we do a lot of work but we receive peanuts.”
To address these challenges, the studies highlighted the need for:
- Comprehensive, standardized training programs that equip CHWs with the knowledge and skills to fulfill evolving tasks
- Integrated supervision structures that coordinate support across different health programs and departments
- Reliable supplies of personal protective equipment, medicines, and other essential commodities
- Fair and commensurate remuneration to recognize CHWs’ critical contributions and prevent burnout
Strengthening these support systems is crucial for ensuring CHWs can continue serving as effective links between communities and the formal health system, even in the face of crises.
Leveraging CHWs for Resilient, Equitable Health Systems
The COVID-19 pandemic has underscored the vital role of CHWs in responding to public health emergencies and maintaining essential services. Their adaptability, community embeddedness, and frontline presence have proven invaluable assets, even as they have faced unprecedented challenges.
By documenting the experiences of CHWs in diverse contexts, these studies offer important insights for policymakers and program managers seeking to strengthen community-based pandemic preparedness and response. Key lessons include:
- Integrating CHWs into coordinated, multi-sectoral emergency response plans, with clear delineation of roles and responsibilities
- Ensuring comprehensive, continuous training to equip CHWs with the knowledge and skills to fulfill evolving tasks
- Establishing robust, integrated supervision structures to provide CHWs with consistent guidance and support
- Securing adequate supplies, commodities, and fair remuneration to sustain CHW motivation and productivity
- Balancing disease-specific priorities with CHWs’ broader mandate to address community health needs in a holistic manner
Ultimately, investing in the resilience and well-being of CHWs is crucial for building more equitable, responsive health systems – not just for weathering pandemics, but for promoting community health and well-being in the long term. By empowering this vital cadre, policymakers and global health practitioners can leverage CHWs’ unique strengths to tackle a wide range of challenges, from infectious diseases to chronic conditions to social determinants of health.
Strengthening the community health workforce is an essential component of realizing the vision of Health for All. The COVID-19 pandemic has underscored both the centrality and the fragility of this workforce. By heeding the lessons from CHWs’ experiences, we can chart a path toward more resilient, equitable, and people-centered health systems.
