Community health workers and Covid-19: Cross-country evidence on their roles, experiences, challenges and adaptive strategies

**Background:** Community health workers (CHWs) are a cornerstone of health service delivery in low- and middle-income countries (LMICs), particularly for reaching marginalised populations. During pandemics, their frontline position makes them critical for outbreak response. This paper synthesises evidence on CHWs' roles, support, challenges, and adaptive strategies during the COVID-19 pandemic across six countries: India, Bangladesh, Pakistan, Sierra Leone, Kenya, and Ethiopia. These countries face significant health system challenges, with skilled health worker densities ranging from 2.77 per 10,000 population in Ethiopia to 27.49 per 10,000 in India, all well below the WHO recommendation of 44.5 per 10,000.

**Methods:** The synthesis draws on 25 reports from 18 research projects conducted or supported by Oxford Policy Management over 2020–2021. Methods were primarily qualitative, including interviews, focus groups, and document reviews. A thematic framework was developed and used to code material using Taguette software. Coding was led by one researcher and discussed among the team. Findings were verified with original research teams to strengthen reliability. Most reports had been peer reviewed by senior staff and external researchers.

**Key Results:** CHWs took on new COVID-19 roles including case identification, contact tracing, community education, screening, and follow-up of patients. In India, CHWs also counselled returnee migrants. Support varied widely: training was provided in most countries, sometimes via mobile platforms (e.g., 53,000 CHWs in Kenya trained via the 'Leap' app), but gaps in smartphone access limited reach. PPE shortages were widespread—some health assistants in Bangladesh received only three PPE sets over the first year. In India, ASHAs were categorised as low-risk for PPE allocation despite conducting most screening, leading to feelings of disempowerment. Financial incentives were announced but often not received; in India, ASHAs were unaware of entitlements, and AWWs in some states went on strike due to lack of COVID-19 compensation. Supervision became less frequent and more task-focused. Challenges included increased workload—ASHAs in India described stress balancing household chores with contact tracing—disrupted supply chains, transport restrictions, and community fear leading to stigmatisation of CHWs as carriers or informers. CHWs adapted by using telemedicine, providing advance drug supplies, changing service locations, and using personal funds for PPE and transport. However, many described their situation as 'majboori' (helplessness), indicating coping rather than positive resilience.

**Clinical Implications:** CHWs are indispensable for pandemic response and routine service continuity, but their effectiveness and wellbeing depend on adequate systemic support. Ensuring reliable PPE, timely financial incentives, quality training and supervision, and mental health support is critical. Health system resilience should not rely on CHWs' personal sacrifice. Policymakers must address the structural issues—including gendered hierarchies and precarious employment—that undermine CHWs' capacity to respond to shocks. Strengthening CHW support at all stages of the policy cycle is essential for equitable and effective health emergency preparedness and response.