Ebola and community health worker services in Kenema District, Sierra Leone: please mind the gap!

Setting: All community health workers (CHWs) in rural Kenema District, Sierra Leone. Objective: CHW programmes provide basic health services to fill gaps in human health resources. We compared trends in the reporting and management of childhood malaria, diarrhoea and pneumonia by CHWs before, during and after the Ebola outbreak (2014-2016). Design: Retrospective cross-sectional study using programme data. Results: CHW reporting increased from 59% pre-outbreak to 95% during the outbreak (P < 0.001), and was sustained at 98% post-outbreak. CHWs stopped using rapid diagnostic tests for malaria mid-outbreak, and their use had not resumed post-outbreak. The average monthly number of presumptive treatments for malaria increased from 2931 pre-outbreak to 5013 during and 5331 post-outbreak (P < 0.001). The average number of monthly treatments for diarrhoea and pneumonia decreased from respectively 1063 and 511 pre-outbreak to 547 and 352 during the outbreak (P = 0.01 and P = 0.04). Post-outbreak pneumonia treatments increased (mean 1126 compared to pre-outbreak, P = 0.003), and treatments for diarrhoea returned to pre-outbreak levels (P = 0.2). Conclusion: The CHW programme demonstrated vulnerability, but also resilience, during and in the early period after the Ebola outbreak. Investment in CHWs is required to strengthen the health care system, as they can cover pre-existing gaps in facility-based health care and those created by outbreaks.