The text below has been excerpted from pp. 5-6, 8-9, 32-33 of a 43-page document, Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic, published by the World Health Organization and the United Nations Children’s Fund (UNICEF) on May 5, 2020 (Licence: CC BY-NC-SA 3.0 IGO).
The original document outlines basic principles and practical recommendations that support decision-making to:
ensure the continuity of select essential services that can be delivered safely at the community level;
leverage and strengthen the community platform as an integral part of primary health care to ensure an effective COVID-19 response;
protect health workers and communities through infection prevention and control (IPC) measures.
The original document also contains sections addressing COVID-19 in the context of different life course phases and highlights disease-specific considerations for adapting community-level activities.
Note: This translation is provided with support from USAID’s Act to End NTDs | West program. The translation was not created by the World Health Organization (WHO) or the United Nations Children’s Fund (UNICEF). The original English edition shall be the binding and authentic edition.
WHO, UNICEF and USAID are not responsible for the content or accuracy of this translation. Further, the information provided in these excerpts and the original WHO/UNICEF document is not official U.S. Government information and does not represent the views or positions of the U.S. Agency for International Development or the U.S. Government.
The COVID-19 pandemic is challenging health systems across the world. Rapidly increasing demand for care of people with COVID-19 is compounded by fear, misinformation and limitations on the movement of people and supplies that disrupt the delivery of frontline health care for all people. When health systems are overwhelmed and people fail to access needed services, both direct mortality and indirect mortality from preventable and treatable conditions increase. Decision-makers will need to make difficult choices to ensure that COVID-19 and other urgent, ongoing public health problems are addressed while minimizing risks to health workers and communities. As established at the 2018 Astana Global Conference on Primary Health Care, the community level is an integral platform for primary health care, key to the delivery of services and essential public health functions, and to the engagement and empowerment of communities in relation to their health. This community-based platform, with its distinct capacities for health care delivery and social engagement, has a critical role to play in the response to COVID-19 and is essential to meeting people’s ongoing health needs, especially those of the most vulnerable.
Existing delivery approaches will need to be adapted as the risk−benefit analysis for any given activity changes in the context of a pandemic. Certain activities may need to be anticipated in areas where COVID-19 transmission has not yet begun, modified where an alternative mode of delivery is safe or temporarily suspended where the risk of COVID-19 transmission is high. Where appropriate, in-person encounters should be limited through the use of alternative delivery mechanisms, such as mobile phone applications, telemedicine and other digital platforms. Specific adapations will depend on the context, including the local overall disease burden, the COVID-19 transmission scenario, and the local capacity to deliver services safely and effectively.
Decisions should be aligned with relevant national and subnational policies and should be re-evaluated at regular intervals as the outbreak evolves. Taking a comprehensive and coordinated approach to community-based activities provides an opportunity to strengthen the resilience of the community-based platform into early recovery and beyond.
This guidance addresses the specific role of community-based health care in the pandemic context and outlines the adaptations needed to keep people safe, maintain continuity of essential services and ensure an effective response to COVID-19. It is intended for decision-makers and managers at the national and subnational levels and complements a range of other guidance, including that on priority public health interventions, facility-based care, and risk communication and community engagement in the setting of the COVID-19 pandemic. National policies and capacities for community health services vary widely. Some of the activities discussed in this guidance may require skills, equipment and supplies that are only available at primary care facilities in some settings. Adaptation of this guidance to resource context will be essential to avoid placing unrealistic expectations on local community health care teams.
Neglected tropical diseases
WHO recommends five main strategies to address the burden of neglected tropical diseases (NTDs): preventive chemotherapy, individual case management, integrated vector management, veterinary public health, and the water, sanitation and hygiene (WASH) framework. Several NTD interventions underlie each strategy and these use community-based approaches to deliver services to populations where NTDs are endemic (Table 2). Each activity has distinct risk-benefit considerations in the pandemic context.
In addition, community-based surveys for mapping or monitoring and evaluation purposes are core activities of NTD programmes and are comparable to community-based interventions in terms of logistics and the mobilization of health workers; therefore, they are also included in this guidance.
- Community-based surveys, mass treatment and active case finding should be temporarily suspended.
- Countries should monitor and re-evaluate at regular intervals the necessity for delaying these activities.
- Community-based vector control and veterinary public health interventions should continue with strict precautions (hand hygiene, respiratory etiquette, physical distancing) observed by all participants in areas where there is no community transmission of COVID-19.
- In areas with community transmission, only essential activities should be continued. For vector control, essential activities should be interpreted as source reduction of vector breeding sites in and around houses. In areas that are affected by dengue and under stay-at-home measures due to COVID-19, families could work together for 30 minutes every week to get rid of potential mosquito breeding sites, clean roof gutters and ensure that all water storage containers are covered. For veterinary public health, the maintenance of mass animal vaccination campaigns, where required, and euthanasia of rabid animals should be regarded as essential. When handling and caring for animals, basic hygiene measures should always be implemented; these include handwashing before and after handling animals, their food, or supplies.
- Community-based WASH activities should continue, with amendments to include key information about preventing COVID-19 in settings where there are no cases of COVID-19. In settings where COVID-19 transmission is occurring, WASH messages should be repurposed to focus on preventing COVID-19 transmission.
- Upon detection in a given geographical area of (a) a sudden increase in the incidence of NTD infections or
(b) a significant burden of disease, the decision to resume or commence active case finding or mass treatment campaigns, or both, will require a risk-benefit assessment on an event-by-event basis; the assessment must factor in the health system’s capacity to effectively conduct safe and high-quality health interventions in the context of the COVID-19 pandemic.
- This guidance does not cover ensuring access to diagnosis, treatment and care of NTDs for patients presenting to health care facilities, which should continue to the extent possible. In some settings, the only care for NTDs is through outreach initiatives and some adaptation of previous clinical pathways may be indicated. For example, for people being treated for leprosy, provision of sufficient medicine for 3 months instead of 1 month of treatment could be considered to reduce the number of attendances required.
Community Engagement and Communication
As outlined in the Astana 2018 document, systematic engagement and communication with individuals and communities are essential to maintain trust in the capacity of the health system to provide safe, high-quality essential services and to ensure appropriate care-seeking behavior and adherence to public health advice (7).1 Communication and engagement strategies for COVID-19 should include all dimensions of community-based health care and aim to facilitate optimal care-seeking, health behaviors and home care practices. Communities will rely on local health facilities, and trusted community actors, including local media, for information. It is important to ensure that they have up-to-date, accurate and contextualized information in the local language.
Communication should focus on building trust, reducing fear, strengthening collaboration and promoting the uptake of public health measures and essential services.
Key topics for communication include:
- COVID-19 transmission, public health actions to reduce the risk of transmission and risk factors associated with severe illness (8). Consider developing hotlines, implementing question and answer (Q & A) sessions and leveraging digital platforms where available to dispel harmful myths, curb the spread of misinformation, reduce stigma associated with COVID-19 and support the reintegration of recovered COVID-19 patients into the community;
- continued care-seeking for essential services, how care can be sought safely and any changes in service delivery settings or points of care;
- self-care and family care practices in the home, which should be provided to all members of the household to address their health needs and avoid reinforcing traditional gender roles;
- home care for people with mild to moderate COVID-19 symptoms, according to national guidance (9); share information about who to contact and where to seek care in case the patient has danger signs; 1 In this document, communication and community engagement encompass social and behavior-change communication strategies, as well as health promotion, health education, community mobilization and community engagement. This section complements guidance already published as Risk communication and community engagement (RCCE) action plan guidance: COVID-19 preparedness and response (7). Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic 9
- the role of the community health workforce as trusted actors in protecting the community;
- mental health and psychosocial well-being, addressing the increased risks of domestic violence against women (10), children, adolescents, persons with disabilities and older people, and providing information about accessible services. Community resources may help to identify trusted family, friends and neighbors who can keep in touch with and support persons subjected to violence.
The community health workforce and broader community support will become increasingly important in the COVID-19 context as stay-at-home measures have been reported to decrease care-seeking for essential services and to increase violence, the use of alcohol and other substances, addictive behaviors and stress related conditions.