Building back from the ground up: the vital role of communities.

The medicalised response to COVID-19 in low- and middle-income countries has had unintended and far-reaching consequences.

Communities, non-governmental organisations and civil society organised themselves from the ‘ground-up’ to alleviate the economic, social and health impacts of COVID-19.

Urgent intersectoral mitigation strategies required for COVID-19 recovery will not be fulfilled through state services alone.

Investing in community cadres and organisations has the potential to build social solidarity, mitigate the impact of COVID-19 and strengthen intersectoral collaboration and safety nets for future crises.

Introduction

Globally the COVID-19 pandemic has destabilised health systems and communities. Governments in low- and middle-income countries (LMICs) followed the approaches adopted by the Global North and advocated by international bodies such as the WHO, and instituted varying degrees of nationwide stay at home orders (lockdowns) from strict restrictions (such as in South Africa, India and Zimbabwe) to weakly enforced lockdown as in Brazil.1 Many have questioned the appropriateness of these measures in LMIC contexts2 where key preventive behaviours such as social distancing and frequent hand washing are impossible to implement in densely populated informal housing settlements. People rely on crowded public transport to get to work, households are cramped and lack easy access to water and sanitation; loss of income leads to food insecurity and hunger as well as high levels of stress and violence. In such conditions viral spread is impossible to control and economic devastation is inevitable. In this commentary we examine (1) some of the unintended impacts of this approach for LMICs and (2) the steps that need to be taken in the short-term and longer-term to mitigate these impacts and the vital role of civil society and communities in this recovery process.

COVID-19 unintended impacts

The response from LMIC governments to contain the COVID-19 pandemic aimed primarily to limit virus spread. The unintended consequences of the instituted measures are wide reaching. UNICEF reports from the early months of the COVID-19 pandemic suggest a 30% reduction in the coverage of essential nutrition services in LMICs and declines of 75% to 100% under lockdown contexts.3 A preliminary assessment by the UN Food and Agricultural Organization suggests the pandemic may add between 83 and 132 million people globally to the total number of undernourished in 2020 as a result of loss of income and livelihoods.4

In terms of health service access, a WHO survey reported that 55% of essential health services were at least partially disrupted in the African region in response to the pandemic. Family planning services were disrupted in 68% of countries, 53% of countries reported partial disruptions in antenatal care services and 32% in facility-based birth services.5 Despite WHO and country guidance to the contrary, mother–newborn separation has occurred in many LMICs. Research from Nepal has described a 3.5% decline in breast feeding within 1 hour of birth during lockdown, from an already low rate of 46%.6 Disruption or suspension of outreach immunisation services was reported by 86% of countries in the African region and disruption of immunisation services at health facilities for 44% of countries.7

Lockdowns exacerbated the silent pandemic of gender-based and intimate partner violence in countries with already high levels. Research undertaken during the lockdown in Bangladesh found significantly increased levels of emotional, physical and sexual violence among women living with their husbands.8 In South Africa, data collected from the government gender-based violence and femicide command centre revealed more than 120 000 victims in the first 3 weeks of lockdown.9

As a result of these unintended impacts, there is a high probability that COVID-19 will deliver us into the next set of crises in the form of increasing inequality, poverty and food insecurity, outbreaks of vaccine preventable diseases, unintended pregnancies and rising child malnutrition which will be felt for generations to come.

Mitigation measures and equity-focussed recovery

While LMIC governments have focussed almost exclusively on reducing COVID-19 case numbers, many communities organised themselves with ‘ground-up’ mitigation measures to address the worsening unintended effects. Examples have emerged from many LMICs of neighbourhood initiatives to support vulnerable families. In India, the health focussed non-governmental organisation (NGO) Swasti brought together a group of NGOs to found the COVID-19 Action Collaborative. Its 150 member organisations are now coordinating efforts and sharing knowledge to provide integrated health, nutrition, social protection, livelihood and financing support to over 2 million vulnerable people across 15 states.10 Women’s empowerment groups in Kerala helped to map where older people live to ensure they had access to medicine and food while social distancing.11 In South Africa, a movement of self-organising, neighbourhood-level community action networks (CANs) has contributed significantly to the community-based response to COVID-19. Without any financial support from the government these CANs have initiated community support activities such as establishing community kitchens, developing communication materials, distributing clothing and skills upliftment training.12 Concerted civil mobilisation also led to a court case13 brought by civil society organisations and school governing bodies to have the national school nutrition programme which provides a daily meal to roughly nine million children, reinstated 4 months after school closures.

The intense lockdown periods and burden of COVID-19-related illness have revealed the inadequacies of strained, under-resourced public health facilities, and in some instances inept LMIC governments’ responses to crises; and the critical role of resilient, mobilised community structures. The urgent intersectoral mitigation strategies required for COVID-19 recovery will not be fulfilled through state services alone. The efforts already being led by NGOs and civil society need to be supported and harnessed, both to develop context-specific solutions and to implement them.

Several areas will require short-term and long-term mitigation measures implemented through strong primary healthcare systems and community participation. Some specific illustrative examples are given in table 1. An important community cadre that has the potential to play a critical role in mitigation strategies in LMICs are community health workers (CHWs). CHWs have been at the forefront of efforts to screen and trace individuals as part of the COVID-19 response in many LMICs including South Africa,14 India15 and Brazil.16 However, this additional work has meant neglect of their usual functions of providing health promotion, prevention and care to vulnerable families. Long-term COVID-19 mitigation strategies should prioritise increasing the number of CHWs to ensure an optimal ratio of workers to households to cope with the more intensive COVID-19 recovery period. Through home visits CHWs can assess and identify household needs such as catch up immunisation, family planning, antenatal care, growth monitoring, birth registration, HIV, tuberculosis and chronic disease management and mental health.

Table 1

Illustrative examples of areas indirectly affected by COVID-19 requiring mitigation measures

Issue	COVID-19 impact	Mitigation measures
Short- term measures
Birth registration	Birth registration stopped during country lockdowns. Sustainable Development Goal target 16.9 aims to achieve universal registration of all births by 2030.	Temporary processing of birth certificates at health facilities to catch up infants not registered at birth.Visits by CHWs to all households with children under 1 year to check birth registration status.
Breast feeding	Potential for declines due to mother-infant separation and health worker fears of COVID-19 transmission.	Rapidly disseminate strong messages through community-based organisations and CHWs about the importance of breast feeding in the context of COVID-19, and the harmful consequences of separating mothers and newborns.
Immunisation	Declines in routine immunisation due to health service disruptions, reallocation of staff to COVID-19 and fears of mothers to attend health facilities.	Visits by CHWs to all households with children under 5 years of age to check immunisation status.Catch up immunisation campaigns in schools and Early Child Development centres.
Chronic medication	Disruptions to chronic medication distribution leading to gaps in adherence.	Establish community distribution pointsCHWs supporting medication distribution to households with elderly or ill.
Long-term measures
Weak community platform with too few CHWs to augment public sector response to crises	CHWs re-assigned to COVID-19 unable to perform their usual household visits and functions.	Strengthen community delivery platforms with increased numbers of CHWs.High coverage of households to undertake detailed assessments of COVID-19 recovery needs.
Lack of forums for communities/civil society in decision-making	Civil society actions to support COVID-19 were implemented in parallel to government actions with little/no co-ordination or community consultation on the appropriateness of government solutions.	Policy mandated forums for community consultation and accountability mechanisms to ensure feedback and progress tracking.
Prioritisation of domestic spending	COVID-19 stimulus packages risk deepening inequity by prioritising large companies and leaving behind small business and community enterprises.	Embark on a transparent, participatory prioritisation process to inform the allocation of COVID-19 stimulus funding with a focus on growing ‘township’ economies.

CHWs, community health workers.

Increasing the numbers of female CHWs serves not only to improve coverage of care for households and thus a return on investment due to a healthier population, but there are other important societal benefits. Modelling based on the South African situation estimated that increasing the number of CHWs to 96 000 (from 60 000) and paying the minimum wage would cumulatively, over 3 years, contribute an additional R13.6 billion (South African rand) to the economy (equivalent to 0.3% of GDP (gross domestic product)) given that the employed women would spend this salary primarily on the health, education and nutrition of their children thus also benefitting their local community economies.17

Appropriately funded community cadres and organisations have the potential to build social solidarity that would enable a more rapid intersectoral response for future crises. The recovery process and accompanying investments (domestic or multilateral) are an opportunity to embark on open and transparent prioritisation processes to determine how best to use resources with a pro-equity focus. Given the enormous constraints facing LMIC governments in the COVID-19 aftermath, it is only through the active participation of communities and civil society in designing and implementing solutions, that lasting sustainable societal improvements will be realised.

Conclusion

The challenges highlighted by the COVID-19 epidemic in LMICs are in many respects an acute manifestation of long-standing chronic problems and the recovery phase should address them. The resource constraints faced by Governments in LMICs (sometimes compounded by inappropriate decision-making and undermined by corrupt disbursement of COVID-19 funding) and the generally weak public healthcare systems of these countries means that they cannot be solely relied on to address such crises. The COVID-19 experience has further demonstrated the contributions communities and civil society can make and the critical need to incorporate them into efforts to mitigate the health, social and economic effects of COVID-19. This is the only way to move towards sustainable positive change that better builds resilience for the inevitable future crises.