Donna Edwards is one of the community health workers (CHW) who have been instrumental in providing primary health care services to communities at risk of COVID-19 in Dominica’s Roseau Health District.

“I decided to be trained to become a Community Health Aide because I have a love for my community and other communities. During the pandemic, we have been able to teach hand-washing techniques, proper wearing of masks and social distancing,” said Donna.

The group of CHWs received initial training in people- and community-centred health care from September 2018 to March 2019, with the Community Health Aide Programme. This was part of a larger primary health care (PHC) and health systems strengthening programme supported by PAHO/WHO and funded by the UHC Partnership, one of WHO’s largest initiatives on international cooperation for UHC.

On 30 January 2020, Tedros Adhanom Ghebreyesus, WHO Director-General, declared the COVID-19 outbreak “a public health emergency of international concern” under the International Health Regulations (IHR) (2005). Just over a month later, on 1 March 2020, the first cases of COVID-19 were recorded in the Caribbean. Dominica recorded its first case of COVID-19 on 24 March 2020. Dominica remains proactive in its public health response to prevent community transmission and CHWs are playing a key role.

Dominica has shown its commitment to the implementation, strengthening and capacity building of both its International Health Regulations (IHR 2005) and pandemic preparedness by completing the State Party Self-Assessment Annual Reporting Tool (SPAR) in 2018 and 2019. SPAR consists of 24 indicators needed to detect, assess, notify report and respond to public health risks of domestic and international concern, such as COVID-19.

Why do Community Health Workers matter?

The urgent need for community health workers (CHW) became clear in 2017, when hurricane Maria devasted the island of Dominica and inflicted major damage on the health system. Nurses left the island and the remaining health staff became overwhelmed. A thorough post-hurricane assessment of the health system and its needs was conducted by PAHO/WHO with the aim to strengthen and rebuild. The training of CHWs was one of the many recommendations, and the Community Health Aide programme was initiated with the support of the Ministry of Health, Wellness and New Health Investment of Dominica in partnership with PAHO /WHO and the UHC Partnership.  

Dominica has a long history in primary health care, with a focus on providing local health and social services to communities based on their needs. The UHC Partnership has allowed Dominica to strengthen and intensify this approach, and implement important changes within the system that places primary health care at the centre of the country’s drive to improve health and well being.

The UHC Partnership works in 115 countries through funding provided by the European Union (EU), the Grand Duchy of Luxembourg, Irish Aid, the Government of Japan, the French Ministry for Europe and Foreign Affairs, the United Kingdom – Foreign, Commonwealth & Development Office and Belgium.

When COVID-19 struck in early 2020, CHWs were recognized for their important role in the national emergency response and in delivering essential health services to the community. The Minister of Health, Wellness and New Health Investment, Dr Irving McIntyre, acknowledged the invaluable role of the CHWs at the first level of care in Dominica.

“The training received during the Community Health Aide Programme proved adequate and instrumental in Dominica’s response to COVID-19. The CHWs played a significant role in contact tracing,” Dr McIntyre said.

PAHO/WHO Representative for Barbados and the Eastern Caribbean Countries, Dr Yitades Gebre said, “CHWs represent an important health resource to the country at the time of this global pandemic and increasing demand to provide wide range of health services.”

The assistance provided by the UHC Partnership came just in time to help Dominica strengthen its health system and make it more resilient. In addition to the training of CHWs, the assistance provided will continue to develop policies to strengthen human resources for health, PHC, health systems governance and the prevention and control of non-communicable diseases.

Health workers facing COVID-19 with confidence

Dominica was among the first countries to introduce CHWs in the late 1970s as part of the Alma Ata declaration, but in recent years, there has been an attrition of health care workers, including CHWs. The re-introduction of the CHW training programme in 2018 as a part of a comprehensive health systems strengthening initiative was timely, and the 27 graduates of the programme have now become invaluable in the fight against COVID-19 in Dominica.

The trained CHWs has are now confident health professionals capable of flexibility during a health emergency. Living within the communities they serve make the CHWs effective in engendering trust and communicating critical COVID-19 health information. Their added skillsets as CHWs helped enhance contact tracing and testing services in the communities and helped increase compliance with quarantine and other public health measures.

Mrs Terrillia Ravaliere, Principal Nursing Officer with the Ministry of Health, who managed the training of the CHWs, described the programme as one which produced graduates that are making a significant transformation in the health care system, particularly in primary health care services.

“They are using their initiative and volunteer willingly, so they are heavily utilized at the quarantine facilities, assisting with community testing and contact tracing. I would really like to commend them for their effort during this time. This is just the beginning of their contribution to the health care system in Dominica and I really wish them all the best. I also wish to thank PAHO/WHO for their remarkable technical and financial support,” said Nurse Terrillia Ravaliere.

“As it relates to the COVID-19 pandemic, the Community Health Aides’ contribution has been excellent, and they could not have come at a better time: it was a time when our nursing staff was stretched. The Community Health Aides are assisting with community education, contact tracing and our educational sessions on social distancing and hand hygiene. They go to the homes of persons in quarantine to take their temperatures and make sure they maintain the quarantine – they are very efficient. Having a male Community Health Aide has encouraged more males to access health services,” said Eva Vigiland, Community Health Nurse.

The strengthening of the Dominica’s health system with the training of CHWs has proven so beneficial that a second CHWs training programme began in October 2020, again with the support of UHC Partnership and PAHO/WHO.

“In view of the ongoing pandemic, we saw it necessary to train a second cohort, which was possible thanks to the support provided by the UHC Partnership,” said Dr Irving McIntyre, Minister of Health, Wellness and New Health Investment.

Community health workers working with pride

The CHWs, who normally work from health centres based within the communities in which they live, provide outreach health services as part of a health team. They visit homes of elderly, people in confinement for physical or mental illness, and others in need of health care in hard-to-reach areas of Dominica. This experience in community-based care at the household level has equipped them to fight against COVID-19. Like all health workers on the front line, the CHWs are taking personal risks to provide crucial health services during this pandemic—a role they proudly accepted—and volunteering their services beyond the call of duty.

“The UHC Partnership gave me the opportunity to bring health education to the community. When the first case of COVID-19 came to Dominica, schools were still open and we had to go into schools to speak to the Grade 6 pupils. We also went into the community, to the bars, restaurants, shops, to inform people about what they are supposed to do, the protocols and hygiene practices. There is a need for us Community Health Aides as we are frontline agents and there is definitely a need for more of us,” said Paulette Joseph-St Ville, Community Health Aide.

“My motivation for becoming a Community Health Aide is my mother, the Community Health Nurse for the La Plaine District. I have not regretted one minute of this opportunity. During the COVID-19 pandemic, there was one instance when I went with the group to do contact tracing. I was a bit skeptical but at the end of the day I had at the back of my mind, I am helping people who helped me. It is a cycle, so I have to put my best foot forward and I want to help the doctors and the nurses. I was with them when we did rapid testing. It was a bit sad because those being tested were scared, but my approach is to crack a joke and let them see we are handling it and there is a light at the end of the tunnel,” said Kireem Vigilant, Community Health Aide.

The importance of primary health care

The COVID-19 pandemic has put a strain on Dominica’s already fragile health system, but by revitalizing a primary health care approach and providing support to other health workers through CHWs, the country is in a better position to respond to the crisis. A strong and resilient health system is essential for effective public health measures of testing, tracing, isolating and treating persons with COVID-19 to slow the spread and prevent community transmission. So far, Dominica has managed to prevent community transmission through its effective public health measures, including the actions and support of the CHWs who continue to be at the heart of the COVID-19 response.