key: cord-252843-vd81pftu
authors: Doherty, Tanya; Kroon, Max; Reynolds, Louis; Fawcus, Sue; Lake, Lori; Solanki, Geetesh
title: Building back from the ground up: the vital role of communities
date: 2020-10-07
journal: BMJ Glob Health
DOI: 10.1136/bmjgh-2020-003928
sha: 
doc_id: 252843
cord_uid: vd81pftu

nan

Globally the COVID-19 pandemic has destabilised health systems and communities. Governments in low-and middle-income countries (LMICs) followed the approaches adopted by the Global North and advocated by international bodies such as the WHO, and instituted varying degrees of nationwide stay at home orders (lockdowns) from strict restrictions (such as in South Africa, India and Zimbabwe) to weakly enforced lockdown as in Brazil. 1 Many have questioned the appropriateness of these measures in LMIC contexts 2 where key preventive behaviours such as social distancing and frequent hand washing are impossible to implement in densely populated informal housing settlements. People rely on crowded public transport to get to work, households are cramped and lack easy access to water and sanitation; loss of income leads to food insecurity and hunger as well as high levels of stress and violence. In such conditions viral spread is impossible to control and economic devastation is inevitable. In this commentary we examine (1) some of the unintended impacts of this approach for LMICs and (2) the steps that need to be taken in the short-term and longer-term to mitigate these impacts and the vital role of civil society and communities in this recovery process.

The response from LMIC governments to contain the COVID-19 pandemic aimed primarily to limit virus spread. The unintended consequences of the instituted measures are wide reaching. UNICEF reports from the early months of the COVID-19 pandemic suggest a 30% reduction in the coverage of essential nutrition services in LMICs and declines of 75% to 100% under lockdown contexts. 3 A preliminary assessment by the UN Food and Agricultural Organization suggests the pandemic may add between 83 and 132 million people globally to the total number of undernourished in 2020 as a result of loss of income and livelihoods. 4 In terms of health service access, a WHO survey reported that 55% of essential health services were at least partially disrupted in the African region in response to the pandemic. Family planning services were disrupted in 68% of countries, 53% of countries reported partial disruptions in antenatal care services and 32% in facility-based birth services. 5 Despite WHO and country guidance to the contrary, mother-newborn separation has occurred in many LMICs. Research from Nepal has described a 3.5% decline in breast feeding within 1 hour of birth during lockdown, from an already low rate of 46%. 6 Disruption or suspension of outreach immunisation services was reported by 86% of countries in the African region and disruption of immunisation services at health facilities for 44% of countries. 7 Lockdowns exacerbated the silent pandemic of gender-based and intimate partner violence in countries with already high levels.

Research undertaken during the lockdown in Bangladesh found significantly increased Summary box ► The medicalised response to COVID-19 in low-and middle-income countries has had unintended and far-reaching consequences. ► Communities, non-governmental organisations and civil society organised themselves from the 'groundup' to alleviate the economic, social and health impacts of COVID-19. ► Urgent intersectoral mitigation strategies required for COVID-19 recovery will not be fulfilled through state services alone. ► Investing in community cadres and organisations has the potential to build social solidarity, mitigate the impact of COVID-19 and strengthen intersectoral collaboration and safety nets for future crises.

BMJ Global Health levels of emotional, physical and sexual violence among women living with their husbands. 8 In South Africa, data collected from the government gender-based violence and femicide command centre revealed more than 120 000 victims in the first 3 weeks of lockdown. 9 As a result of these unintended impacts, there is a high probability that COVID-19 will deliver us into the next set of crises in the form of increasing inequality, poverty and food insecurity, outbreaks of vaccine preventable diseases, unintended pregnancies and rising child malnutrition which will be felt for generations to come.

While LMIC governments have focussed almost exclusively on reducing COVID-19 case numbers, many communities organised themselves with 'ground-up' mitigation measures to address the worsening unintended effects. Examples have emerged from many LMICs of neighbourhood initiatives to support vulnerable families.

In India, the health focussed non-governmental organisation (NGO) Swasti brought together a group of NGOs to found the COVID-19 Action Collaborative. Its 150 member organisations are now coordinating efforts and sharing knowledge to provide integrated health, nutrition, social protection, livelihood and financing support to over 2 million vulnerable people across 15 states. 10 Women's empowerment groups in Kerala helped to map where older people live to ensure they had access to medicine and food while social distancing. 11 In South Africa, a movement of self-organising, neighbourhoodlevel community action networks (CANs) has contributed significantly to the community-based response to COVID-19. Without any financial support from the government these CANs have initiated community support activities such as establishing community kitchens, developing communication materials, distributing clothing and skills upliftment training. 12 Concerted civil mobilisation also led to a court case 13 brought by civil society organisations Breast feeding Potential for declines due to mother-infant separation and health worker fears of COVID-19 transmission.

Rapidly disseminate strong messages through community-based organisations and CHWs about the importance of breast feeding in the context of COVID-19, and the harmful consequences of separating mothers and newborns.

Declines in routine immunisation due to health service disruptions, reallocation of staff to COVID-19 and fears of mothers to attend health facilities.

Visits by CHWs to all households with children under 5 years of age to check immunisation status.

Catch up immunisation campaigns in schools and Early Child Development centres.

Chronic medication Disruptions to chronic medication distribution leading to gaps in adherence.

Establish community distribution points CHWs supporting medication distribution to households with elderly or ill.

Weak community platform with too few CHWs to augment public sector response to crises CHWs re-assigned to COVID-19 unable to perform their usual household visits and functions.

Strengthen community delivery platforms with increased numbers of CHWs. High coverage of households to undertake detailed assessments of COVID-19 recovery needs.

Civil society actions to support COVID-19 were implemented in parallel to government actions with little/no co-ordination or community consultation on the appropriateness of government solutions.

Policy mandated forums for community consultation and accountability mechanisms to ensure feedback and progress tracking.

Prioritisation of domestic spending COVID-19 stimulus packages risk deepening inequity by prioritising large companies and leaving behind small business and community enterprises.

Embark on a transparent, participatory prioritisation process to inform the allocation of COVID-19 stimulus funding with a focus on growing 'township' economies.

CHWs, community health workers.

and school governing bodies to have the national school nutrition programme which provides a daily meal to roughly nine million children, reinstated 4 months after school closures. The intense lockdown periods and burden of COVID-19-related illness have revealed the inadequacies of strained, under-resourced public health facilities, and in some instances inept LMIC governments' responses to crises; and the critical role of resilient, mobilised community structures. The urgent intersectoral mitigation strategies required for COVID-19 recovery will not be fulfilled through state services alone. The efforts already being led by NGOs and civil society need to be supported and harnessed, both to develop context-specific solutions and to implement them.

Several areas will require short-term and long-term mitigation measures implemented through strong primary healthcare systems and community participation. Some specific illustrative examples are given in table 1. An important community cadre that has the potential to play a critical role in mitigation strategies in LMICs are community health workers (CHWs). CHWs have been at the forefront of efforts to screen and trace individuals as part of the COVID-19 response in many LMICs including South Africa, 14 India 15 and Brazil. 16 However, this additional work has meant neglect of their usual functions of providing health promotion, prevention and care to vulnerable families. Long-term COVID-19 mitigation strategies should prioritise increasing the number of CHWs to ensure an optimal ratio of workers to households to cope with the more intensive COVID-19 recovery period. Through home visits CHWs can assess and identify household needs such as catch up immunisation, family planning, antenatal care, growth monitoring, birth registration, HIV, tuberculosis and chronic disease management and mental health.

Increasing the numbers of female CHWs serves not only to improve coverage of care for households and thus a return on investment due to a healthier population, but there are other important societal benefits. Modelling based on the South African situation estimated that increasing the number of CHWs to 96 000 (from 60 000) and paying the minimum wage would cumulatively, over 3 years, contribute an additional R13.6 billion (South African rand) to the economy (equivalent to 0.3% of GDP (gross domestic product)) given that the employed women would spend this salary primarily on the health, education and nutrition of their children thus also benefitting their local community economies. 17 Appropriately funded community cadres and organisations have the potential to build social solidarity that would enable a more rapid intersectoral response for future crises. The recovery process and accompanying investments (domestic or multilateral) are an opportunity to embark on open and transparent prioritisation processes to determine how best to use resources with a pro-equity focus. Given the enormous constraints facing LMIC governments in the COVID-19 aftermath, it is only through the active participation of communities and civil society in designing and implementing solutions, that lasting sustainable societal improvements will be realised.

The challenges highlighted by the COVID-19 epidemic in LMICs are in many respects an acute manifestation of long-standing chronic problems and the recovery phase should address them. The resource constraints faced by Governments in LMICs (sometimes compounded by inappropriate decision-making and undermined by corrupt disbursement of COVID-19 funding) and the generally weak public healthcare systems of these countries means that they cannot be solely relied on to address such crises. The COVID-19 experience has further demonstrated the contributions communities and civil society can make and the critical need to incorporate them into efforts to mitigate the health, social and economic effects of COVID-19. This is the only way to move towards sustainable positive change that better builds resilience for the inevitable future crises.

COVID-19 in Brazil

An appeal for practical social justice in the COVID-19 global response in low-income and middleincome countries

Situation tracking for COVID-19 socioeconomic impacts

Food and Agricultural Organization of the United Nations. The state of food security and nutrition in the world

Pulse survey on continuity of essential health services during the COVID-19 pandemic

Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study

Immediate impact of stayat-home orders to control COVID-19 transmission on socioeconomic conditions, food insecurity, mental health, and intimate partner violence in Bangladeshi women and their families: an interrupted time series

Shocking STATs on gender-based violence during lockdown revealed Sowetan Live

Philanthropy's distinct role in India's COVID-19 response.Devex

COVID-19 care in India: the course to self-reliance

What is COVID-19 teaching us about community health systems? A reflection from a rapid Community-Led mutual aid response in Cape town, South Africa

Judgement in the matter between equal education, the school governing body of Vhulaudzi secondary school, the school governing body of Mashao high school and the Minister of basic education. high Court of South Africa

Community-Based screening and testing for coronavirus in Cape town, South Africa: short report

India's first line of defense against the coronavirus is an army of 900,000 women without masks or hand sanitizer Buzfeed News

Community health workers reveal COVID-19 disaster in Brazil

Saving lives, saving costs: investment case for community health workers in South Africa. Cape Town: South African Medical Research Council


