Going further with Community Health Workers

Community health workers (CHWs) are the backbone of the health workforce across sub-Saharan Africa. They play a crucial role in addressing health inequities and achieving Health for All.

They are health workers who are based in their own or neighbouring communities, who have received some training (up to two years) but are not considered health professionals. 

CHWs are an effective way to bring health services to disadvantaged or marginalised groups who may face barriers to accessing health services through the formal health system. They are usually the first line of response and key link between community members and health facilities.

They have the knowledge, experience and access to these groups of people – including women and girls, the poor, people with limited literacy/education, and people living in rural/remote regions – which means they can deliver the health services that these groups might otherwise go without.

Yet, approximately 86% of CHWs receive little to no compensation for their work. Malawi has committed to providing payment to and training CHWs. CHWs in Ethiopia, Kenya and now Zambia are remunerated although this context varies within each country, for example in Kenya's devolved system, not all counties fund CHWs.

The study: Researching the Effectiveness and Accessibility of Community Health Workers in Low and Middle-Income Countries (REACH)

We know from monitoring and evidence from CHW programmes that disadvantaged groups receive as much or more care from CHWs than more advantaged groups, yet in many communities they continued to have poorer health. What we didn’t know – and wanted to find out – was how CHWs can be a catalytic force to change this.

The REACH Study (Durham University, 2021) was commissioned by Save the Children UK and supported by CARE International and Amref Health Africa, as part of the GSK-funded Community Health Worker portfolio. It sought to provide recommendations for how CHW programmes in low- and middle-income countries could go further; how they could play a role in transforming social, political and health systems.

CHWs are a health powerhouse

CHWs can play a pivotal role in bringing about change in the health system—and wider in society. They are too often seen as a ‘band-aid’ solution in programmes to reach disadvantaged groups; their potential goes much further beyond this. 

CHW programmes create qualified employment opportunities for community members. They can take action in their communities on the forces and factors that influence health in daily life, and they can both generate expertise and collate information on communities’ health that can be used to improve health policy and programme planning.

Towards a paradigm shift

Governments and NGOs should carefully consider CHW programme design to realise this potential. CHW programming and investment as an intersectoral approach can address the structural drivers of disadvantage, social inequities, and health access barriers. With this paradigm shift, CHW programmes can have greater impact on health inequities.  

Implications for our work

There is a projected shortage of more than six million health workers in Africa by 2030, including two million CHWs.

The REACH study reinforces the need for a 'whole-of-society' approach to address this shortage as well as multisector partnerships to address factors that impact the effectiveness of CHWs. We know that there are educational, livelihoods, infrastructure and transport, gender, religious, or cultural barriers that restrict people's access to health services.

Solutions must therefore be integrated to address these social and structural determinants of health. We need a multisector approach including governments, the private sector and CSOs. No sector can do this alone.

Recommendations

To maximise the effectiveness of CHW interventions it is important (1) to have a whole-of-society approach when developing programmes and (2) for CHWs to be formalised within health systems; to be remunerated and treated fairly for the value that they bring to health programmes.

By Dr Aneesa Ahmed, Head of Programmes and Strategic Partnerships, Amref UK and Diana Mukami, Programme Operations Director, Amref Health Africa