Continuity of Community-Based Healthcare Provision During COVID-19: A Multi-Country Interrupted Time Series Analysis

Background: Pandemics often precipitate declines in essential health service utilization, which can ultimately kill more people than the disease outbreak itself. There is some evidence, however, that the presence of adequately-supported community health workers (CHWs), i.e.  financially remunerated, trained, supplied, and supervised in line with WHO guidelines, may blunt the impact of health system shocks. Yet, adequate support for CHWs is often missing or uneven across countries. This study assesses whether adequately-supported CHWs can maintain the continuity of essential community-based health service provision during the COVID-19 pandemic.  Methods: Interrupted time series analysis. Monthly routine data from twenty-seven districts across four countries in sub-Saharan Africa were extracted from CHW and facility reports for the period January 2018 to September 2020. Descriptive analysis, null hypothesis testing, and segmented regression analysis were used to assess the presence and magnitude of a possible disruption in care utilization after the earliest reported cases of COVID-19.  Findings: CHWs across all sites were supported in line with the WHO Guideline and received COVID-19 adapted protocols, training and personal protective equipment within 45 days after the first case in country. We found no disruptions to the coverage of proactive household visits or iCCM assessments provided by these prepared and protected CHWs, as well as no disruptions to the speed with which iCCM was received, pregnancies were registered, or postnatal care received. We found that coverage of facilities-based deliveries was disrupted following the pandemic.   Interpretation: CHWs who were equipped and prepared for the pandemic were able to maintain speed and coverage of community-delivered care during the pandemic period. Given that the majority of CHWs globally remain unpaid and largely unsupported, this paper suggests that the opportunity cost of not professionalizing CHWs may be larger than previously estimated, particularly in light of the inevitability of future pandemics. Funding Statement: None to declare. Declaration of Interests: None to declare. Ethics Approval Statement: The study team received an IRB exemption from the University of Washington’s Human Subjects Division.