Health systems' resilience during the COVID-19 pandemic public health emergency: The role of existing community health structures in rural Malawi.

The emergence of the COVID-19 pandemic has put health systems under enormous pressure, pushing for health systems' resilience. Malawi, mostly rural with hard-to-reach areas, had their first case in April 2020, amidst political turmoil. So far, much has been documented on how health systems contained the COVID-19 pandemic. This paper describes the role of community health system structures in ensuring health systems' resilience during the COVID-19 pandemic in rural Malawi. To highlight the role of community health structures in the Malawian health system, we developed and applied a framework on health systems' resilience through the community health system structures in a rural district in Malawi. Our data collection and analysis were informed by a desk review of government documents and other publications. We drew on authors' expertise and experience in Malawi community health, and joint reflections on the role played by community health structures in ensuring access to essential health services during the COVID-19 pandemic in Malawi. The desk review and experts' reflections have highlighted the strong Malawi community health strategy with a clear chain of command from national to community levels. The community health surveillance assistants and volunteers have shown to be the backbone of community health structures and positive service delivery, contributing to health systems resilience during the COVID-19 pandemic. Countries' existing health system structures are a key determinant of response to pandemics -regardless of the available resources. Even though Malawi's health system is under-resourced, the existing community-based health structures have shown to contribute to the health systems' resilience during the COVID-19 pandemic. The proposed framework in this paper is a great tool in allowing countries to reflect on having pre-existing health system structures to strengthen the health systems' resilience during such pandemics. Therefore, having independent disease prevention and control structures from national to community levels, as done in Malawi, can help countries to absorb the shocks of health system emergencies and maintain essential health services, the core business of the health system.