While COVID-19 vaccine shipments and supply have increased in recent months, there are currently not enough health workers in low- and middle-income countries, or LMICs, to vaccinate populations equitably against the coronavirus and other common illnesses.
In fact, the World Health Organization estimates that 18 million more health workers are needed by 2030, primarily in LMICs. Africa’s COVID-19 vaccination rate, meanwhile, must increase to six times the current level if it is to meet the 70% immunization goal this year — a stark reminder that much more work still needs to be done to achieve global vaccine equity.
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While immunizations are widely known to be one of the most important public health interventions, WHO reports that coverage of routine immunizations has stagnated over the past 10 years, and this pattern will likely continue due to interruptions from COVID-19. In particular, populations facing physical, cultural, or socioeconomic barriers to getting vaccinated are still being left behind.
As trained, trusted members of their local communities, community health workers are in a unique position to fill this health workforce gap and boost COVID-19 vaccination rates in LMICs. CHWs have better access to rural and vulnerable populations, and they can serve as a powerful bridge between remote populations and the primary health care system.
There is evidence that CHWs can be successfully trained to administer injectable medication, and they already administer injectable contraception in many countries. However, CHWs are not legally permitted to give vaccines in a number of nations. If countries were to shift how vaccinations are provided and leverage CHWs as vaccinators, they could significantly expand the immunization capacity of the strained global health care workforce.
CHWs can and should have a more active role in vaccinating populations and reaching immunization coverage goals. Governments, global health funders, and policymakers should rethink CHWs’ current role as mere promoters of immunization services and consider them viable providers of immunization services.
Instead of national health systems relying on a small pool of overstretched nurses and facility-based staff members to vaccinate their populations, how can we train larger numbers of CHWs to take on this task?
We turn to Malawi for answers. The country is facing a severe shortage of doctors and nurses, causing difficult working conditions for many health care professionals. With approximately 1 physician and 15 nurses and midwives for every 53,000 people in the country, there is a clear need for CHWs.
For decades, Malawi has relied on its cadre of around 10,000 CHWs, known as health surveillance assistants, to vaccinate its national population against all kinds of preventable diseases. HSAs make up more than a third of the health workforce in Malawi and undergo a 12-week training course, allowing them to perform secondary tasks meant for health assistants and nurses, according to the Ministry of Health.
Perhaps not coincidentally, Malawi’s routine immunization coverage rates are some of the highest in Africa, despite ranking as one of the world’s lowest-income nations. Malawi has been successful in vaccinating high proportions of rural people who otherwise have poor access to health care, ultimately increasing vaccine equity. HSAs have the advantage of being able to proactively reach out into their communities to bring vaccines closer to them — often arriving in hard-to-reach villages by bicycle, by canoe, or on foot.
Globally, CHWs have played a critical role in the COVID-19 pandemic response through educating populations, early detection, community surveillance, and contact tracing — but not in vaccinating communities, because current country policies and global guidance do not encourage it.
We propose a paradigm shift, whereby the task of vaccinating populations can be moved to CHWs, taking the burden off of other health care workers. By shifting the task of vaccine administration down to the level of CHWs, valuable nurses and health technicians’ time is freed up to tend to patients with more urgent clinical needs.
Because they hail from the communities in which they work and understand community perceptions and beliefs, CHWs possess another invaluable asset: local trust. This makes them ideally placed to combat vaccine hesitancy and misinformation and to encourage their peers to get vaccinated. By working within the existing social structures of a community, CHWs have the opportunity to increase vaccine uptake through engagement, education, and myth-busting.
The untapped potential of CHWs in vaccination efforts is increasingly being recognized by development groups. In 2019, health organizations in over 40 countries joined to form the Community Health Impact Coalition, with the goal of making CHW professionalization a norm worldwide. Last year, the coalition joined UNICEF and WHO in co-authoring the first guidance on the role of CHWs in COVID-19 vaccination.
The world needs innovative solutions that shift health care delivery from the status quo to reach more people quickly and equitably. In countries with health workforce shortages, extending CHW responsibilities to include vaccination can bring health care closer to communities and save more lives.
About the author
Rebecca Alban
As a senior manager of health systems, Rebecca Alban leads the health workforce development at VillageReach, a global health organization that works with governments, the private sector, partners, and communities to build responsive primary health care systems that deliver health products and services to the most underreached. Rebecca has co-authored multiple research publications related to the role of CHWs as vaccinators and is an active participant on the Community Health Impact Coalition. She has lived and worked in Africa, South America, the U.S., and currently resides in Spain.
