Living Goods is committed to maintaining essential health services at the community level in order to avoid preventable deaths during the COVID-19 pandemic. This is urgent, as we know that the burden of preventable deaths from easily treatable disease can easily exceed the toll taken by the pandemic itself—given the excessive strain on already limited health systems. As a member of the Community Health Impact Coalition, our priorities for the global COVID-19 response are further outlined in this position paper. In consultation with the Ministries of Health of Uganda and Kenya, WHO and UNICEF, and other technical experts and partners, we have adapted our delivery of health services under adjusted “no and low-touch” protocols.

We are working to strike the right balance so that CHWs can continue effectively delivering lifesaving core health services safely in the face of COVID-19, and also play a meaningful role in that response. There are synergies between these two imperatives. For example, we are leveraging our digital infrastructure and relationships to educate and assess people for COVID-19 and have been able to transition a majority of maternal and child health services to virtual telemedicine engagements. But, some of these traditionally face-to-face efforts are harder to transition. For example, alongside our Kenya MOH colleagues, we are grappling with the best way to continue the uninterrupted treatment of malaria during the pandemic, since rapid malaria tests (mRDTs) cannot be done remotely. Our adjusted no/low-touch protocols aim to mitigate some of these tensions.

As COVID-19 spreads in the communities where we work, we have adopted these no and low touch protocols as guidelines for the safe delivery of health services during the pandemic. We determine which protocols to apply based on the local disease burden and guidelines, the extent of COVID-19 transmission, and the level of personal protective equipment (PPE) we can ensure for the CHWs we support. We have also launched remote supervision protocols to make sure that CHWs receive frequent check-ins from their supervisors over the phone; rolled out daily symptom checking for staff, CHWs, and their families; and are sensitizing communities via SMS to call CHWs when services are needed. Our goal is to ensure CHW protection, minimize transmission of the disease, and, most importantly, to ensure that essential health services continue to be delivered at the community level by CHWs.

Since rolling out these adjusted protocols in April 2020, Living Goods-supported CHWs are largely providing phone-based support to their communities. CHWs begin all health activities and assessments by screening the individual and household for COVID-19-related symptoms. If a patient comes to a CHW’s home, the assessment is conducted outside at a minimum distance of six feet and all essential medicines are delivered for free using a “contactless” protocol to the client. High-risk CHWs are given the option to do only no-touch and phone-based protocols or to opt out completely.

Specific health services protocols that are being adapted include:

• Integrated community case management (iCCM): Malaria is assessed either using an mRDT under a low-touch protocol or presumptively without an mRDT under a no-touch or “distanced iCCM” protocol. Pneumonia is assessed based on observation of rapid breathing at a distance. Diarrhea diagnoses and treatments remain unchanged. All newborns and children with danger signs are referred to the health facility. Essential medicines are being provided for free during COVID-19.
• Pregnancies/Newborn: Pregnancy registrations, newborn visits, and related education are conducted via phone. Pregnant mothers and newborns with danger signs are automatically referred to health facilities.
• Family Planning: CHWs provide oral contraceptives and condoms and refer for other family planning methods. In Uganda, where CHWs have sufficient PPE, they can continue to provide the popular contraceptive injectable Sayana Press. Living Goods is also testing Sayana Press client self-injection in Uganda to reduce transmission risk while continuing to provide essential family planning services.
• Immunization: CHWs are able to continue defaulter tracking and referrals for immunization completion remotely.

Depending on the status of COVID-19 in each country and through an ongoing close review of our results, we will adjust our approach to ensure continued high-quality service delivery that keeps CHWs safe. For example, we will assess the how many households each CHW can safely visit and may encourage more proactive community work—e.g. CHWs still going door-to-door while staying outside at a distance to ensure we are seeing and sufficiently fulfilling our duty to pregnant women and newborns. Given the dynamic nature of the pandemic, each country context, and emerging data and evidence, we will review and adapt these protocols over time.

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