Community Health Workers
QUICK FACTS ON COMMUNITY HEALTH WORKERS
Community health worker (CHW) programs can be a powerful tool for improving primary health care by…
extending the reach of primary health care systems, by working in marginalized communities
addressing constraints in access to health care, by ensuring patients receive simple curative care and evidence-based interventions in their own communities
boosting health-seeking behavior and promoting demand for care, including simple cost-effective preventive care
Community health workers (CHWs) are health care workers that extend the reach of primary health care (PHC) systems to communities otherwise underserved or unserved by formal health systems.
CHWs accomplish this by delivering a comprehensive set of PHC services, including preventive and curative care and health education in homes, community institutions, or peripheral health posts. CHWs are typically selected from, serve in, and answer to the communities where they live and work.
There are many CHW program models, each with its own standards for CHW training, supervision, place of service, remuneration, and service package. Training for CHWs can range from a few weeks to up to two years. Remuneration can range from the standard salary for an entry-level government employee, to pay based on performance and incentives, and can also be volunteer-based. Place of service also varies by model, with some programs calling for the delivery of services in patients’ own homes (see Brazil), in community settings (see Liberia), or in health posts, while other models rely on mixed approaches (see Bangladesh and Ethiopia). Supervision of CHWs and opportunities for career advancement also vary by program, with some CHWs being supervised by clinicians like nurses, and others being supervised by high-performing peer CHWs.
Community health worker (CHW) programs have already transformed primary health care (PHC) and improved health outcomes across a number of countries.
The evidence from programs at national scale is still varied, but there is growing global consensus based on evidence from several countries, that CHW programs have made vital contributions to rapid progress in improving health.
In China, the forebearer of all CHW programs, CHWs helped the country achieve the eradication of smallpox, and double life expectancy. In Bangladesh, Brazil, and Nepal, CHWs have been key in accelerating progress to reduce under-five mortality. And, in a host of countries around the world, CHWs make modern long-term family planning available.
There is already a significant body of evidence that well-trained, well-equipped, and well-supervised CHWs, as part of integrated primary health care teams, can have significant impact on nutrition, under-five mortality, and maternal mortality, by delivering evidence-based interventions.
Community health worker (CHW) programs remain an underutilized tool, despite decades of research demonstrating their potential for providing universal primary health care (PHC) and improving health outcomes.
These are among the key challenges to effective CHW programs at scale:
LONG-TERM FINANCING CHALLENGES
Despite the evidence that CHWs can deliver interventions in a cost-effective way, compared to strictly facility-based PHC, CHW programs remain a significant cost to the PHC system.
FRAGMENTATION IN IMPLEMENTATION
Often, countries have a patchwork of CHW programs managed by various NGOs, each focused on its own narrow list of health challenges, and each with different remuneration, training, and performance standards. Such inefficient fragmentation scatters limited resources and creates both redundancies and gaps in PHC.
CHALLENGES WITH PROGRAM DESIGN
There is no one-size-fits-all model that would be effective in any geography. And, despite multiple studies and recent WHO guidelines, there is still not precise information on how to best design critical program elements to optimize impact, scalability, and sustainability.
CHALLENGES TO IMPLEMENTATION AT SCALE
While there exist many examples of high-performing, small-scale CHW programming, there are still few examples of high-performing large-scale CHW programming.
A critical shortage of health workers remains a significant challenge to achieving universal health coverage, and reducing both under-five and maternal mortality.
In order to achieve Sustainable Development Goal 3 - ensure healthy lives and promote well-being for all at all ages - urgent action is needed to address the PHC access crisis.
As such, the WHO is advocating for the adoption and expansion of CHW programs, alongside the expansion of programs that train doctors and nurses and place them in geographies where they can serve vulnerable populations.
In 2018, the WHO released guidelines to optimize program design and implementation to help expedite the adaptation and adoption of effective CHW programming. In response to the new guidelines, during the May 2019 World Health Assembly, member states supported a resolution recognizing community health workers as a key health system component in providing primary health care services.