What impact can community health workers have?
Community health worker (CHW) programs have already transformed primary health care (PHC), improving 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.1 In Bangladesh, Brazil, and Nepal, CHWs have been a key factor in accelerating progress in reducing under-five mortality.2 And in a host of countries around the world, CHWs make modern long-term family planning available.3
The impact of CHWs
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.4
For example, a review of the effectiveness of CHWs in providing family planning services concluded that CHWs can safely provide birth control pills, condoms, and injectables, and effectively refer patients for other long-acting forms of contraception.5 6 An evaluation of Mozambique’s CHW program, which serves 1.1 million people, demonstrated a one-third reduction in the prevalence of childhood undernutrition.7 A review and meta-analysis of RCTs revealed the odds of exclusive breastfeeding was 5.6 times higher in women who had been exposed to CHW interventions, than women who had not.8 A review of studies of community case management carried out by CHWs concluded that the reduction in mortality could be as high as 70 percent for pneumonia.9 A study in rural Pakistan found that a package of community-based interventions delivered by the country’s Lady Health Workers led to improved home care practices and increased care-seeking behavior, reducing stillbirth and neonatal mortality rates by 35 percent and 28 percent, respectively, and increased deliveries by skilled birth attendants by 67 percent.10 A review and meta-analysis of RCTs of CHW-led women's groups practicing participatory learning and action in Bangladesh, Malawi, Nepal, and India demonstrated a 37 percent reduction in maternal mortality.11 Finally, an analysis published in 2017 estimated that if the 73 countries with the heaviest disease burdens adopted tailored CHW programming focused on providing a package of 30 common evidence-based interventions to half of their population, they could prevent three million maternal, neonatal and child deaths from 2016 to 2020.12 (For a list of service delivery areas on which there is published evidence of CHW effectiveness, see Annex 2 of the WHO Guideline on Health Policy and System Support to Optimize Community Health Worker Programmes.)
“In low-income countries, CHWs can make major improvements in health priority areas, including reducing childhood undernutrition, improving maternal and child health, expanding access to family planning services, and contributing to the control of HIV, malaria, and tuberculosis infections.”- Dr. Henry Perry, Johns Hopkins University13
The first large-scale community health worker (CHW) program was the 1920s Farmer Scholar program in Ding County, China. Dr. John B. Grant, of the Rockefeller Foundation, and Jimmy Yen, a Chinese community development specialist, trained local farmers to record births and deaths, vaccinate, provide first aid and health education to neighbors, and help communities keep their wells clean. In 1949, the program was expanded by China’s new communist government and became known as the “Barefoot Doctor” program. The national program trained roughly one million rural community members to work part-time, providing immunizations, preventive care, and health education to the nation's people, more than 80 percent of whom lived in the countryside far from hospitals and other health infrastructure.14
The first large-scale community health worker (CHW) program
Within two years of launch, the "barefoot doctors" had successfully vaccinated more than 512 million of China’s 600 million citizens against smallpox – allowing China to eradicate the disease 20 years before global eradication, and demonstrating the efficacy of using minimally trained community members to deliver critical preventive care.1
China’s Barefoot Doctor program inspired similar programs in many countries including Bangladesh, Honduras, India, Indonesia, Tanzania, the United States (e.g. Alaska’s Community Health Aide Program) and Venezuela.15
In 1978, community health worker programs garnered international attention at the International Conference on Primary Health Care at Alma-Ata. The conference, sponsored by the WHO and the United Nations Children’s Fund (UNICEF), was the first truly global health conference with attendees from virtually every country. The conference issued a declaration which positioned CHWs as important members of the primary health team, alongside physicians, nurses, midwifes and auxiliaries.16
As a result, more countries launched CHW programs. But just as national CHW efforts were gaining support, several factors in the 1980s - such as structural adjustment programs, implementation challenges in large-scale CHW programs, and changes in government priorities - reduced the funding available for primary health care and undermined governments' appetites for expanding staffing and programming. Soon, many CHW programs were dismantled.
Recently, as governments struggled with developing mechanisms for the effective long-term management of HIV and TB, interest in CHW programming again heightened. The Sustainable Development Goals, which include a call for universal access to primary health care as well as targets on reducing maternal and under-five mortality, also helped expand interest in CHWs as an effective and efficient tool for delivering PHC services to vulnerable and hard-to-reach populations, from urban informal settlements to remote villages.
In general, there is a dearth of information that helps countries forecast how much their CHW program will cost once they scale it. This makes it difficult for partners, donors, and governments to plan and ensure long-term sustainability. Furthermore, there is not a lot of information about cost-effectiveness, even for some of the largest and longest-running programs like the ones in Bangladesh or Brazil.17
A recent study conducted by the Financing Alliance for Health examined eight scaled CHW programs to understand cost structure and its relationship to key program features.
Varying costs of CHWs
As expected, rural-focused programs had higher costs than programs that included urban CHWs. In general, cost per person served decreased as the scale of programs increased. However, rural programs are typically more effective because they reach populations with poor access to health care.
Rural-focused programs experience relatively higher and more variable costs
As number of people increases, cost per person decreases
In terms of key cost components, the study revealed significant differences among programs. These differences could be attributable to program characteristics such as service package, level of scale and population served, as well as implementing agency (NGO vs. government). Annual salaries for CHWs ranged from $110.25 to $3,552.90 (8 percent to 329 percent of per capita GDP), with a median of $840. The share of total cost devoted to salaries averaged 17 percent, with a wide range across programs (two to 45 percent). The average share of costs devoted to supplies was nine percent (zero to 22 percent) and for training, the average was 11 percent (11 to 21 percent). While there is currently no data on the return on investment (ROI) for the CHW programs analyzed in this study, estimates indicate that investments in CHW programs, broadly, could achieve an ROI as high as 10 to one.18
Coming soon: Further data on costing for CHW programs in Exemplar countries
Hipgrave D. Communicable disease control in China: From Mao to now. J Glob Health. 2011;1(2):224–238. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3484775/pdf/jogh-01-224.pdf.
Rohde J, Cousens S, Chopra M, et al. 30 years after Alma-Ata: has primary health care worked in countries? Lancet 2008; 372(9,642): 950–61. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61405-1/fulltext.
Prata N, Gessessew A, Cartwright A, Fraser A. Provision of injectable contraceptives in Ethiopia through community-based reproductive health agents. Bulletin of the World Health Organization. 2011;89:556-564. https://doi.org/10.2471/BLT.11.086710.
Johnson AD, Thiero O, Whidden C, et al. Proactive community case management and child survival in periurban Mali. BMJ Global Health. 2018;3:e000634. https://gh.bmj.com/content/bmjgh/3/2/e000634.full.pdf.
Malarcher, et al. Provision of DMPA by community health workers: what the evidence shows. Contraception. 2011;83(6):495-503. https://doi.org/10.1016/j.contraception.2010.08.013.
Krueger, et al. Scaling Up Community Provision of Injectables through the Public Sector in Uganda. Stud Fam Plann. 2011;42(2):117-24. https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1728-4465.2011.00271.x.
Davis TP, Wetzel C, et al. Reducing child global undernutrition at scale in Sofala Province, Mozambique, using Care Group Volunteers to communicate health messages to mothers. Global Health: Science and Practice. 2013; 1(1):35-51; https://doi.org/10.9745/GHSP-D-12-00045.
Hall J. Effective community-based interventions to improve exclusive breast feeding at four to six months in low- and low-middle-income countries: a systematic review of randomised controlled trials. Midwifery. 2011 Aug;27(4):497-502. https://doi.org/10.1016/j.midw.2010.03.011.
Theodoratu E, Al-Jilaihawi S, et al. The effect of case management on childhood pneumonia mortality in developing countries. Int J Epidemiol. 2010;39 Suppl 1:i155-71. https://doi.org/10.1093/ije/dyq032.
Bhutta ZA, Memon ZA, Soofi S, Salat MS, Cousens S, Martines J. Implementing community-based perinatal care: results from a pilot study in rural Pakistan. Bull World Health Organ. 2008;86(6):452-459. https://doi.org/10.2471/blt.07.045849.
Prost A, Colbourn T, Seward N, et al. Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis [published correction appears in Lancet. 2014 May 24;383(9931):1806]. Lancet. 2013;381(9879):1736–1746. https://doi.org/10.1016/S0140-6736(13)60685-6.
Chou VB, Friberg IK, Christian M, Walker N, Perry HB. Expanding the population coverage of evidence-based interventions with community health workers to save the lives of mothers and children: an analysis of potential global impact using the Lives Saved Tool (LiST). J Glob Health. 2017;7(2):020401. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5592116/. Accessed January 30, 2019.
Perry HB, Zulliger R, Rogers MM. Community Health Workers in Low-, Middle-, and High-Income Countries: An Overview of Their History, Recent Evolution, and Current Effectiveness. Annual Review of Public Health. 2014;35:1, 399-421. https://www.annualreviews.org/doi/full/10.1146/annurev-publhealth-032013-182354.
World Health Organization. China’s village doctors take great strides. Bulletin of the World Health Organization. 2008;86:909-988. https://www.who.int/bulletin/volumes/86/12/08-021208/en/.
Perry H. A Brief History of Community Health Worker Programs. Draft December 2013. https://www.mchip.net/sites/default/files/mchipfiles/02_CHW_History.pdf.
WHO, UNICEF. Declaration of Alma-Ata: International Conference on Primary Health Care. Almaty, Kazakhstan: September 6–12, 1978. http://www.who.int/publications/almaata_declaration_en.pdf. Accessed January 4, 2013.
Frankel S. Overview. In: Frankel S, ed. The Community Health Worker: Effective Programmes for Developing Countries. Oxford, England: Oxford University Press; 1992: 1– 61.
Dahn B, Woldemariam A, Perry H, et al. Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations. World Health Organization; 2015. https://www.chwcentral.org/sites/default/files/CHW-Financing-FINAL-July-15-2015.pdf.