COVID-19 has overwhelmed health systems worldwide, leading to worrisome drops in essential health services for preventable, yet deadly diseases. Many facilities in Kenya and Uganda are overstretched and understocked, and travel restrictions and fears of leaving home are keeping some from seeking essential preventative, routine and even urgent care. A recent review of government data in Kenya and Uganda revealed up to 35% declines in the number of people who sought facility-based care and treatments for common childhood diseases such as malaria, diarrhea and pneumonia due to COVID-19.
In contrast to these national trends, treatments for these same diseases in our direct operations have nearly doubled in areas where Living Goods supports government CHWs. These CHWs are surpassing expectations on many fronts, supported both by the strong community health platform Living Goods had in place pre-pandemic along with the numerous programmatic adjustments we made in response to it. Household demand for CHW services increased significantly due to the travel-restrictions, fear of facilities and economic hardship brought on by COVID-19, and several of the adjustments we designed were intended to drive more equitable care. CHWs, in turn, were able to fill vital gaps in essential health service delivery and meet the increased demand of neighbor families who felt safer visiting them and motivated by the free services and education CHWs were offering.
Here’s a sampling of the results achieved by CHWs in Living Goods’ direct operations in 2020:
As noted above, families increasingly turned to CHWs for health care during the crisis, both given their increased difficulties and fears around visiting facilities and because Living Goods removed some key barriers to care to ensure health service continuity. Key elements of our COVID-19 response included free essential medicines, a revised CHW compensation structure, remote supervision, and adjusted digital health workflows.
MALARIA: CHW treatments or referrals increased 99% in Kenya’s malaria-endemic areas and soared 138% in Uganda.
Malaria is also a pandemic and represented 16% of outpatient visits in Kenya and 34% in Uganda pre-COVID-19. Governments made massive strides in combatting malaria since 2000, but we feared the gains in malaria treatment might be undone by COVID-19, as modeled in The Lancet. Our analysis of DHIS2 data shows that in the areas where we work, malaria treatments at health facilities dropped 35% in Kenya and 1% in Uganda from 2019 to 2020. Some overtreatment of malaria was likely captured in Living Goods’ Uganda results due to a temporary policy of presumptive diagnosis for part of the year. This may account for about 30% of the increase in malaria cases recorded, but it has been accounted for in our lives saved estimate. We have since transitioned back to confirming the disease via mRDTs, in line with national COVID-19 protocols.
DIARRHEA: CHW treatments or referrals increased 46% in Uganda and 48% in Kenya in 2020.
Diarrheal disease is the second leading cause of deaths of children under age 5 (U5) globally, but is both highly preventable and treatable. CHWs play an essential role in reinforcing messages about hygiene and sanitation while simultaneously providing families with inexpensive, life-saving treatments like zinc and oral rehydration salts. DHIS2 data of facility care where we operate shows that diarrhea treatments fell 18% in Uganda and 25% in Kenya from 2019 to 2020.
PNEUMONIA: CHW treatments or referrals increased 62% in Uganda and 42% in Kenya.
Pneumonia is the single largest cause of infectious disease death for children worldwide and accounts for 15% of U5 mortality. Early detection and treatment of pneumonia is critical to saving lives. Some symptoms also mimic COVID-19, so assessing and treating pneumonia early helps ensure sick children receive the right treatment and reduces health system strain. Researchers estimated an additional 2.3 million childhood deaths from pneumonia and newborn sepsis would arise due to health system disruptions from COVID-19. In the areas where we work, our analysis of DHIS2 data found that facility-level pneumonia cases fell 27% in Uganda and 29% in Kenya from 2019 to 2020. We have long been able to treat pneumonia at the community level with amoxicillin in Uganda. Fortunately, at the end of 2020, the Kenyan government finally approved its use for treatment at the community level—it was previously only allowed in some counties—so we only expect treatment gains to further improve.
IMMUNIZATION: A greater number of children received life-saving vaccinations.
Within Living Goods-supported CHWs’ catchment areas, the number of children completing necessary immunizations increased 11% in Kenya and 3% in Uganda from 2019 to 2020; fully immunized children aged 9-23 months respectively increased 2% and 9%. We expected these numbers to decline during the crisis, but increases in immunization rates indicate that CHWs are successfully advocating for parents to take their children to health facilities for vaccinations. It also marks a significant achievement in driving down the incidence of future deadly and debilitating infectious diseases among children. Sustaining this momentum toward universal immunization is essential: Modeling commissioned by GAVI and published in The Lancet Global Health has shown that around 86 child lives would be saved in Kenya and Uganda for every potential one lost by continuing routine vaccinations during the pandemic.
FAMILY PLANNING: Couple-years protection (CYP) per CHW increased 39% in Uganda, averting 15,070 unwanted pregnancies in 2020.
Since family planning counseling is sensitive and often conducted within the home—which is restricted during COVID-19—we had not anticipated such strong results in Uganda. In Kenya, where we are still testing our protocols in a couple of sub-counties, we saw an 11% decrease in CYP, as during COVID-19 the government restricted CHWs from providing the popular three-month contraceptive injectable Sayana Press.
MATERNAL AND NEWBORN HEALTH: 94% of Kenyan women and 90% of Ugandan women supported by a CHW gave birth at a health facility.
Given the increased reluctance among clients to visit facilities, we believe that CHWs are making inroads in ensuring women still deliver their babies safely. Compared to the high rates of facility deliveries registered by CHWs, the national average for health facility deliveries is 61% in Kenya and 73% in Uganda. Pregnancy registrations and the rate of on-time postnatal care visits also remained on-target in both countries in 2020, despite some fluctuations.