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From Emergencies to Epidemics, Always Ready to Respond

Rakotondramasy Fidy Nirina Alexandre, a reference nurse in Ifanadiana, Madagascar

Community Health Workers (CHWs) are playing a pivotal role in fighting COVID-19, especially in countries with vulnerable health systems. Beyond the pandemic, CHWs can contribute to advancing universal health coverage, but only if they are set up for success—according to the Community Health Impact Coalition (CHIC) which is working to make professionalized community health workers a norm worldwide.

Working in over 30 countries, CHIC aims to catalyze high-impact community health systems design by identifying practices that lead to better quality health delivery and working with partners to adopt those practices. The Johnson & Johnson Center for Health Worker Innovation, with funding from Johnson & Johnson Foundation, is collaborating with CHIC on the #CHWAdvocates campaign to elevate stories of CHWs and equip them with the tools to be effective advocates.

Rakotondramasy Fidy Nirina Alexandre (“Alex”) is a reference nurse with PIVOT, a CHIC partner in Ifanadiana, Madagascar working together to strengthen the country’s health system. Alex has been a health worker for eight years and lives in Ifanadiana with his wife, a PIVOT hospital nurse, and their toddler son.

As a reference nurse, Alex starts his day at 7 a.m., or at 6 p.m. during night shifts. He is either in the call center referring patients to the area health center or hospitals, or in an ambulance transporting patients from the community to the health center or from the health center to hospitals when cases are escalated to the next level.

“When you transfer a patient from the health center to the district hospital and see that the patient’s condition has improved, you have succeeded in saving the patient’s life and that is very rewarding,” says Alex.

But in a poor community like Ifanadiana, it is not always easy, he adds. Many patients worry about hospital costs and do not want to be referred and that, Alex says, is the difficult part of his job. Lack of education, cultural misperceptions and traditional practices are also barriers that keep people from getting the help they need.

“A case that deeply marked me,” he recalls, “was a patient who was referred to the Fianarantsoa University Hospital who did not agree to be referred. After many negotiations, he finally accepted but unfortunately, he passed away along the way. Sometimes you feel a little unsettled because you wonder why people don't understand.”

Alex works closely with PIVOT’s social team and CHWs who work in communities to assess general health and raise community awareness about essential health services at the health center, including free medication and the reimbursement system.

In March, when the first cases of COVID-19 were diagnosed in Madagascar, Alex was assigned to the capital Antananarivo for three months. “At the beginning, I personally felt a huge fear because it was something new. I was also afraid for my family,” says Alex. Working in rotation as part of three reference teams, his work involved transporting patient samples from hospitals to the labs for testing, and in the evenings, transporting patients, which he describes as very intense.

“In majority of the cases, the patients preferred that we came late at night because they did not want their neighbors to see them being picked up by an ambulance. We transported at least four confirmed cases each night from their homes. Between patients we changed and disinfected. The work was very hard physically and psychologically, because we were in contact with confirmed cases every day and we worked for 24 hours at a stretch. We also had to reassure the patients during their transport to the hospital.”

Despite the challenges, Alex is grateful to be part of the work PIVOT and CHIC are doing in his community. He remembers always wanting to work in the health sector. “When I was a child, during role plays and sketches in our church for example, I often took the role of doctor. When I became a nurse, I really enjoyed it because I could help others. I take it as a vocation.”

Especially during times of crisis, wanting to help the community keeps him going, he adds. “As a referral team, we are always ready to respond during emergencies and epidemics. During the plague season, we were there, during the measles, we were there, and now with COVID, we are here.”