Article Text

Original research
Continuity of community-based healthcare provision during COVID-19: a multicountry interrupted time series analysis
  1. Madeleine Ballard1,2,
  2. Helen E Olsen3,
  3. Anoushka Millear3,
  4. Jane Yang4,
  5. Caroline Whidden4,
  6. Amanda Yembrick3,
  7. Dianne Thakura5,
  8. Afra Nuwasiima6,
  9. Molly Christiansen5,
  10. Daniele J Ressler7,
  11. Wycliffe Okoth Omwanda7,
  12. Diego Lassala4,
  13. Daniel Palazuelos8,9,
  14. Carey Westgate10,
  15. Fabien Munyaneza11
  1. 1 Community Health Impact Coalition, London, UK
  2. 2 Department of Global Health and Health System Design, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  3. 3 Medic Mobile, San Francisco, California, USA
  4. 4 Muso, Bamako, Mali
  5. 5 Living Goods, Nairobi, Kenya
  6. 6 Living Goods, Kampala, Uganda
  7. 7 Lwala Community Alliance, Rongo, Kenya
  8. 8 Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
  9. 9 Partners In Health, Boston, Massachusetts, USA
  10. 10 Community Health Impact Coalition, New York, New York, USA
  11. 11 Partners In Health, Neno, Malawi
  1. Correspondence to Dr Madeleine Ballard; madeleine.ballard{at}


Background Pandemics often precipitate declines in essential health service utilisation, 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), that is, 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 27 districts across four countries in sub-Saharan Africa were extracted from CHW and facility reports for the period January 2018–June 2021. Descriptive analysis, null hypothesis testing, and segmented regression analysis were used to assess the presence and magnitude of a possible disruption in care utilisation after the earliest reported cases of COVID-19.

Results 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 each country. We found no disruptions to the coverage of proactive household visits or integrated community case management (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.

Conclusion 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 professionalising CHWs may be larger than previously estimated, particularly in light of the inevitability of future pandemics.

  • COVID-19
  • Health policy
  • Community child health

Data availability statement

No data are available. The data that support the findings of this study are available from Ministries of Health in Kenya, Malawi, Mali and Uganda. Restrictions apply to the availability of these data, which were used under licence for this study.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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Data availability statement

No data are available. The data that support the findings of this study are available from Ministries of Health in Kenya, Malawi, Mali and Uganda. Restrictions apply to the availability of these data, which were used under licence for this study.

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  • Contributors MB set up the collaborative network with vital early support from HEO and AY and serves as the guarantor. MB, HEO and AM designed the study with critical input from all authors. AM did the coding and ran the statistical analysis. MB, HEO and AM took the lead in interpretation of the results and drafting of the manuscript. AN, MC, DJR, WOO, DL, CWhidden, JY, DP, DT and FM led data collection and provided substantial contributions to interpretation of the results and drafting of the manuscript. CWhidden, CWestgate and JY made significant content contributions to the final draft of the report. All authors critically reviewed and approved the final version.

  • Funding This research was funded by Focusing Philanthropy (no grant number) and Patrick J McGovern Foundation (no grant number).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.