The role of a structured community health worker network in achieving malaria elimination goals in the Dominican Republic: an impact evaluation amid COVID-19 disruptions

Community health workers (CHWs) can play a key role in malaria elimination through expanding access to malaria testing and treatment. The Dominican Republic, a low endemic country committed to eliminate malaria by 2025, implemented a structured malaria CHW network in the three main urban foci of Greater Santo Domingo. This research quantifies the networks contributions towards malaria elimination from its implementation in 2019 until 2022. The study highlights the impact of COVID-19 disruptions on CHWs performance and explores the networks ability to bounce back from health systems shocks. The performance of a malaria CHW network in Greater Santo Domingo, Dominican Republic was evaluated using weekly data collected from CHWs and routinely collected surveillance data from the Ministry of Public Health (MoH). We assess performance of CHWs by analyzing key variables such as (1) reporting compliance, (2) household visitation rates, (3) malaria rapid diagnostic tests performed, (4) malaria cases detected, and (5) time between symptom onset and malaria diagnosis. To evaluate the impact of COVID-19 on the network, CHWs performance indicators are evaluated across three time periods (prior to, during, and after COVID-19 interruptions). Results showed that over the evaluation period, reported malaria cases in study foci decreased from 1,243 cases in 2019 to 5 cases in 2023. CHWs diagnosed and treated over 43% of malaria cases in study foci before COVID-19 interruptions and 14% during interruptions. 83% of cases detected by CHWs were detected through active case detection, with 17% detected passively. CHWs detected malaria cases and initiated treatment 1.5 days earlier than health facilities and MoH personnel performing active case detection. This evaluation provides evidence that a structured CHW network with clearly defined responsibilities and management protocol can assume a large proportion of malaria case management service provision, contribute to early malaria case detection, and help curb local malaria transmission. It adds to a growing body of research on the feasibility and benefits of CHW-led proactive household visitation. Despite interruptions such as the COVID-19 pandemic, concerted investment can sustain CHW program gains.