Brazil has more than 286,000 community health workers integrated into the national primary healthcare program. These professionals form a broad network serving 75% of the population, especially low-income families who lack medical insurance and are the most adversely affected by the COVID-19 pandemic.
“Back in March, researchers at Imperial College London noted Brazil’s network of community health workers as a valuable asset that could assure an effective response to the pandemic. According to the article, the service they provide sets an example to be followed by other countries. But the response was not effective, there was no national plan, and the service provided by community health workers wasn’t considered essential to control the disease until July.
They weren’t even considered health professionals and so weren’t given personal protective equipment [PPE], just to take one example,” said Gabriela Lotta, a professor at Getúlio Vargas Foundation (FGV). Lotta is affiliated with the Center for Metropolitan Studies (CEM) , one of the Research, Innovation and Dissemination Centers (RIDCs) funded by São Paulo Research Foundation – FAPESP.
In collaboration with researchers at Oswaldo Cruz Foundation (Fiocruz, a leading public health research institution linked to the Brazilian Ministry of Health), the University of York (UK) and the London School of Economics, Lotta authored an article published in the Comment section of The Lancet warning that community health workers in Brazil were being treated with neglect during the pandemic.
“Several countries have community health workers, but the researchers at Imperial College London focused on Brazil’s advantage in this respect because it was one of the first countries to create such a network as an integral part of primary care and the national health system [in Brazil, Sistema Único de Saúde, SUS]. In most countries community health workers aren’t part of the official health system but belong to NGOs or civic associations,” Lotta told.
Thanks to this structural feature, she added, Brazil’s community health workers would have been able to perform important functions during the pandemic, “provided they had PPE, training, the backing of governmental policy, support, and recognition of their significance”.
Three tiers of government
For Lotta, neglect of community health workers exemplifies the effect on cities of the lack of a national plan to combat the pandemic: although the service they provide is run by local authorities, the federal government is responsible for funding and other support mechanisms.
“There are huge disparities among Brazilian cities,” Lotta said. “Municipalities find their hands are tied if they lack the funding and other resources to determine a strategy on their own. There has to be a national plan, with substantial transfers from the federal government to fund community health workers. It’s up to local government to execute. Of course, if a city has resources it can use them, but the federal government should shoulder most of the burden and set the policy. That includes defining whether community health workers are health professionals or not and whether they should get hazard pay. All these decisions have to apply to the entire national health service.”
During the first four months of the pandemic, Lotta continued, community health workers received neither training nor PPE. They were at last classed as key workers only on July 21, 2020, when President Bolsonaro signed Law 14,023/2020.
“Because there was no national plan and they weren’t even classed as health professionals, only 9% received infection control training and PPE. Their union says some 100 have died from COVID-19, but the actual number may be three times higher,” Lotta said.
Brazil has one of the world’s highest death tolls of nurses, nursing assistants, and nurse technicians affected by COVID-19, according to the International Council of Nurses (ICN). In its last update, Brazil’s Federal Nursing Council (COFEN) pointed to 441 deaths. The number of physicians who died from the disease had reached 244 by September, according to the São Paulo Physicians Union.
“The law is positive, although it has yet to be implemented,” Lotta said. “Better late than never. At least there’s a legal measure that says community health workers are entitled not to go out to work if they aren’t given PPE. They had no such right before. They were very vulnerable.”
Nevertheless, she added, the law does not automatically solve the problems of community health workers or ensure they play an effective role in combating the pandemic. “It’s an important contribution, but it won’t necessarily translate into better policy,” she said. “Even with this law in place, local governments lack the means to prioritize community health workers in fighting the pandemic until a strategic plan and a funding scheme are established.”
Key functions, key workers
Among the functions that could be performed by community health workers during the pandemic, Lotta highlighted key activities such as tracing contacts of infected people, combating fake news by disseminating trustworthy information, and monitoring social isolation in confirmed cases.
“They already act as health educators. They live in the communities where they work and are seen as trustworthy and legitimate,” she said. “Keeping their neighbors well-informed about personal hygiene, and the importance of face covering and social isolation is an effective way to neutralize fake news. A few cities have community health workers circulating in cars with loudspeakers to give out this kind of information.”
Contact tracing would not be a problem for them, Lotta argued. “They already did something very similar to contact tracing when they monitored people’s healthcare requirements. In the few Brazilian cities that have had contact tracing it’s been done by community health workers,” she said.
They could staff telephone banks to call patients with the disease who are isolated at home and assess their need for hospitalization if local authorities supplied thermometers and pulse oximeters, she added.
They could also man the roadblocks set up at the entrances to many cities. “The disease was transmitted to many small and medium towns by visitors who were infected but had no symptoms, especially if the locality was a tourist attraction,” Lotta said. “Some local authorities installed roadblocks manned by community health workers, who took people’s temperature as they arrived by car and told them about the measures in place to deal with the pandemic. Of course, in this case, they will have had to supply PPE and support of other kinds. We have the structure, and if such apparently simple but crucial measures were universally applied they would have a positive impact in terms of containing transmission of the virus.”