Community Health Workers

Community health workers:
What do we know about them?

The state of the evidence on programmes,
activities, costs and impact on health outcomes of
using community health workers
A report by Uta Lehmann and David Sanders
School of Public Health
University of the Western Cape
Evidence and Information for Policy, Department of Human Resources for Health
Geneva, January 2007
Content
Executive summary ...........................................................................................................v
Abbreviations ................................................................................................................... vii
Acknowledgements.......................................................................................................... vii
Introduction ........................................................................................................................1
Methodology ......................................................................................................................2
The state of the evidence ..................................................................................................2
Defining community health workers...................................................................................3
The history of community health worker programmes.......................................................5
Profiling community health workers ...................................................................................6
Who are they? ...............................................................................................................6
Roles and activities........................................................................................................8
Performance ....................................................................................................................13
Health worker performance .........................................................................................14
Use ..............................................................................................................................14
Retention/attrition.........................................................................................................14
Impact effectiveness ....................................................................................................15
Cost-effectiveness of CHW programmes ....................................................................16
Managing CHW programmes ..........................................................................................17
Recruitment and selection ...........................................................................................18
Initial and continuing training .......................................................................................19
Supervision and support ..............................................................................................20
Governance, ownership and accountability .....................................................................21
Community participation ..............................................................................................21
Relationships with the formal health services..............................................................23
Incentives.....................................................................................................................24
Summary of lessons learnt ..............................................................................................26
References ......................................................................................................................28
Community health workers: what do we know about them? Page iii
Community health workers: what do we know about them? Page iv
Executive summary
The use of community health workers has been identified as one strategy to address the growing shortage
of health workers, particularly in low-income countries. Using community members to render certain basic
health services to the communities they come from is a concept that has been around for at least 50 years.
There have been innumerable experiences throughout the world with programmes ranging from largescale, national programmes to small-scale, community-based initiatives.
This review paper revisits questions regarding the feasibility and effectiveness of community health
worker programmes. It was commissioned by the World Health Organization as a follow-up to the World
health report 2006: working together for health, which identified as a research priority the feasibility of
successfully engaging community health workers. This review aims to assess the presently existing
evidence. It constitutes a desktop review, very broad in scope, as is evident from the title, which draws
together and assesses the evidence as it can be found in the published and selected grey literature since
the late 1970s.
The umbrella term community health worker (CHW) embraces a variety of community health aides
selected, trained and working in the communities from which they come. Generalizations about the profile
of community health workers internationally are difficult. While there are some broad trends, CHWs can
be men or women, young or old, literate or illiterate. More important is an acknowledgement that the
definition of CHWs must respond to local societal and cultural norms and customs to ensure community
acceptance and ownership.
The roles and activities of community health workers are enormously diverse throughout their history,
within and across countries and across programmes. While in some cases CHWs perform a wide range of
different tasks that can be preventive, curative and/or developmental, in other cases CHWs are appointed
for very specific interventions.
While it is difficult, given the extensiveness of the topic and the diversity of the literature informing the
review, to make generalizations about experiences with CHW programmes or answer the question of what
makes a good CHW programme, there is consensus in the literature on a number of issues:
First, CHWs can make a valuable contribution to community development and, more specifically, can
improve access to and coverage of communities with basic health services. There is robust evidence that
CHWs can undertake actions that lead to improved health outcomes, especially, but not exclusively, in the
field of child health. However, although they can implement effective interventions, they do not
consistently provide services likely to have substantial health impact, and the quality of services they
provide is sometimes poor.
Second, for CHWs to be able to make an effective contribution, they must be carefully selected,
appropriately trained and very important adequately and continuously supported. Large-scale CHW
systems require substantial increases in support for training, management, supervision and logistics.
Third, CHW programmes are therefore neither the panacea for weak health systems nor a cheap option to
provide access to health care for underserved populations. Numerous programmes have failed in the past
because of unrealistic expectations, poor planning and an underestimation of the effort and input required
to make them work. This has unnecessarily undermined and damaged the credibility of the CHW concept.
Fourth, by their very nature CHW programmes are vulnerable unless they are driven, owned by and firmly
embedded in communities themselves. Where this is not the case, they exist on the geographical and
organizational periphery of the formal health system, exposed to the moods of policy swings without the
wherewithal to lobby and advocate their cause, and thus are often fragile and unsustainable. However, the
concept of community ownership and participation is often ill-conceived and poorly understood as a byproduct of programmes initiated from the centre. Evidence suggests that CHW programmes thrive in
mobilized communities but struggle where they are given the responsibility of galvanizing and mobilizing
communities.
Community health workers: what do we know about them? Page v
Examples of successful programmes can thus be found in the wake of community mobilization efforts,
either as part of large-scale political transformation, such as in Brazil or China; or through local
mobilization, often facilitated by nongovernmental, community-based or faith-based organizations. In
many cases programmes last through the lifespan of the mobilization effort and wither or collapse entirely
as the momentum of mobilization is lost. The rhythms and dynamics of community participation lie
outside the scope of this review, yet are crucial to better understanding and discussing the future of CHW
programmes.
A key challenge lies in institutionalizing and mainstreaming community participation. To date, the largest
and most successful programme in this regard is the Brazilian Family Health Programme, which has
integrated CHWs into its health services and institutionalized community health committees as part of
municipal health services to sustain social participation. This means that community participation does not
become an alternative, but an integral part of the states responsibility for health care delivery.
Fifth, the question of whether CHWs should be volunteers or remunerated in some form remains
controversial. There exists virtually no evidence that volunteerism can be sustained for long periods: as a
rule, community health workers are poor and expect and require an income. Although in many
programmes they are expected to spend only a small amount of time on their health-related duties, leaving
time for other breadwinning activities, community demand often requires full-time performance. The
reality is that CHWs as a rule and by their very nature provide services in environments where formal
health services are inaccessible and people are poor. This also complicates the issue of community
financing, which is rarely successful unless institutionalized, as in China. Most of the evidence reflects
failures of community financing schemes, leading to high drop-out rates and the ultimate collapse of
programmes.
Given present pressures on health systems and their proven inability to respond adequately, the existing
evidence overwhelmingly suggests that particularly in poor countries, CHW programmes are not a cheap
or easy, but remain a good investment, since the alternative in reality is no care at all for the poor living in
geographically peripheral areas. While there is a lot to learn, there is a lot we do know about making
programmes work better: appropriate selection, continuing education, involvement and reorientation of
health service staff and curricula, improvement supervision and support are non-negotiable requirements.
These need political leadership and substantial and consistent provision of resources. We need to learn
from examples of large-scale successful programmes in this regard, particularly providing longitudinal
evidence of what works and what does not work. This presently constitutes the biggest knowledge gap.
CHW programmes have been revered as a panacea and decried as a delusion in the past. A sober view
reveals today, as it did in the late 1980s, that with political will, however, governments can adopt more
flexible approaches by planning CHW programmes within the context of overall health sector activities,
rather than as a separate activity. Weaknesses in training, task allocation and supervision need to be
addressed immediately. CHWs represent an important health resource whose potential in providing and
extending a reasonable level of health care to undeserved populations must be fully tapped (Gilson et al.,
1989).
Community health workers: what do we know about them? Page vi
Abbreviations
ARI
acute respiratory infection
CBD
community-based distributor
CHW
community health worker
DOTS
directly observed treatment support
FBO
faith-based organization
HAART
highly active antiretroviral treatment
IMCI
integrated management of childhood illnesses
LGA
local government area
LHW
lay health worker
MoH
Ministry of Health
NGO
nongovernmental organization
ORS
oral rehydration solution
PLWHA
people living with HIV/AIDS
RTC
randomized controlled trial
TB
tuberculosis
TBA
traditional birth attendant
VHC
village health committee
VHW
village health worker
WHO
World Health Organization
Acknowledgements
The authors would like to thank the World Health Organization for entrusting them with this important
piece of research and the Department for International Development, United Kingdom of Great Britain
and Northern Ireland, for providing financial support.
They would further like to thank Carmen Dolea, WHO Department of Human Resources for Health, who
accompanied the research and writing process, and Irwin Friedman, formerly of the SEED Trust and now
Research Director of the Health Systems Trust, who was co-author of a previous study on community
health workers in Africa and whose insight and expertise have always been much valued, for collaboration
on an earlier paper that provided some of the basis for this review.
Community health workers: what do we know about them? Page vii
Introduction
The most recent World health report focuses the worlds attention on human resources as the key
ingredient to successful health systems functioning and it highlights the growing human resource crisis,
particularly in low-income countries. In its foreword the late Director-General of WHO argues that:
there is a chronic shortage of well-trained health workers. The shortage is global, but most acutely
felt in the countries that need them most. For a variety of reasons, such as the migration, illness or
death of health workers, countries are unable to educate and sustain the health workforce that
could improve peoples chances of survival and their well-being (WHO, 2006).
The World health report is a culmination of initiatives acknowledging the significance of human resources
that began with the Joint Learning Initiative (JLI, 2004) on health human resources in 2003.
Shortages of skilled health workers, particularly in underserved areas, have been identified as a key facet
of the growing human resource crisis. These shortages are driven by a number of factors: the dramatic
increase in demand for health workers in high-income countries that has created a tremendous pull of
health workers into these countries; increasing morbidity, mortality and absenteeism rates, coupled with
increasing workloads due to the impact of the HIV/AIDS pandemic; and inadequately funded and poorly
managed and performing health systems, which lead to deteriorating working conditions in many
underserved areas, creating a strong push factor.
While the multifaceted crisis must be addressed through multiple measures, one strategy identified by both
the JLI report and the World health report is so-called task-shifting a review and subsequent
delegation of tasks to the lowest category that can perform them successfully. It is in the context of taskshifting that the concept of using community members to render certain basic health services to their
communities has gained currency again.
This review paper revisits questions regarding the feasibility and effectiveness of community health
worker programmes. It was commissioned by WHO as a follow-up to the World health report, which
identified as a research priority the feasibility of successfully engaging community health workers (WHO,
2006). This review aims to assess the presently existing evidence and has the following objectives:
to review the existent evidence on community health workers and their impact on health outcomes;
to identify gaps in knowledge and evidence on the use of CHWs to deliver basic health care services;
to provide policy recommendations on the use of CHWs in response to acute shortages of health
workers, particularly in areas with significant shortages of health workers, such as sub-Saharan Africa,
Latin America and Asia.
The paper constitutes a desktop review, very broad in scope, as is evident from the title, which draws
together and assesses the evidence as it can be found in the published and selected grey literature since
the late 1970s. Given the volume and diversity of the literature, it draws particularly heavily on reviews
conducted over the years.
After a brief discussion of the methodology of the review and the state of the evidence, the subsequent two
chapters define the concept of the community health worker and give a short overview of the history of
CHW programmes.
Chapters 6 to 9 then review different aspects of CHW programmes, starting with a profile of CHWs,
analysing the different facets making up performance of CHW programmes and then examining different
components of CHW programme management. Chapter 9 considers the role of community participation
and other aspects of governance and accountability. Chapter 10 summarizes the lessons learnt.
Methodology
The authors drew on previous work conducted by themselves in this area (Lehmann, 2004). We then
searched a number of databases (PubMed, POPLINE, Healthstar, Omni, SOSIG), of which PubMed
proved by far the most productive.
The search terms initially used were the following:
CHWs
LHWs
VHWs
lay health workers
lady health workers
volunteer health workers
voluntary health workers
community health workers
community health distributors
community health surveyors
community health assistants
community health promoters
promotoras de salud.
These were later supplemented with the following:
community health agents (agentes de sade)
rural health auxiliaries (used primarily in the 1970s)
traditional midwives
TBAs
traditional birth attendants
health promoters.
The criteria for inclusion were a focus on developing countries and publication in a peer-reviewed
publication, a published book or a formal evaluation report.
The review takes a narrative inductive approach.
The state of the evidence

The literature discussing community health workers and their numerous permutations is both voluminous
and diverse. Our various searches, as discussed above, generated well over 650 titles, of which about 250
were retained in our data base. Discussions in academic journals and books were particularly lively
throughout the 1980s, as CHW programmes mushroomed in the aftermath of the Alma Ata Declaration.
Interest then waned in the 1990s, only to pick up again during the past two to three years, in response to
increasing service needs, primarily due to the impact of the HIV/AIDS pandemic and the increasing
shortages of professional health workers.
Community health workers: what do we know about them? Page 2
The available literature is quite varied in character. A great number of the early publications are
programmatic rather than academic in character, narrating experiences with CHW programmes and
making the case for their importance, rather than providing rigorous scientific evaluations and analyses.
However, there are also a substantial number of systematic evaluations, some of them making use of
controlled or intervention trials, others using a range of qualitative and quantitative evaluation methods.
Furthermore, there are a number of large evaluation reports that were commissioned by either
governments, NGOs or multilateral organizations. While we have no sense as to how many such reports
exist, we were able to gain access to a small number of them through personal contacts.
There now are a number of web sites that report on mostly small CHW programmes in different parts of
the world. As a rule, these do not contain any element of evaluation, but are meant to inform about and
advocate specific programmes.
In this review we have considered and included the first three categories of publications. We very
consciously did not limit this review to controlled trials and similarly rigorous evaluations, as a great deal
of very rich evidence would then remain unexplored.
A great gap remains nevertheless, as it is very evident from personal experiences and communication that
many experiences with CHW programmes in the developing world are not appropriately documented or
not documented at all. While some experiences may have found their way into publications and
unpublished reports, much remains undocumented.
Finally, given the long interest in CHW programmes, it is not surprising that over the years a number of
researchers have summarized the evidence on various subtopics. We have found at least eight such
summaries and reviews: Gilroy & Winch, 2006; Bhattacharyya et al., 2001; Ofosu-Amaah, 1983; Gilson et
al., 1989; Walt, 1992; Parlato & Favin, 1982; Lehmann, Friedman & Sanders, 2004; Haines et al.,
forthcoming. And while we worked through and summarized about 250 publications to establish a sound
knowledge base, the text below, where appropriate, draws heavily on these summaries to answer the
overarching question of this review: CHWs what do we know about them?
Defining community health workers

The umbrella term community health worker (CHW) embraces a variety of community health aides
selected, trained and working in the communities from which they come. A widely accepted definition
was proposed by a WHO Study Group (WHO 1989):
Community health workers should be members of the communities where they work, should be
selected by the communities, should be answerable to the communities for their activities, should
be supported by the health system but not necessarily a part of its organization, and have shorter
training than professional workers.
Internationally, CHWs had and have a large number of different titles. Bhattacharyya et al. and Gilroy &
Winch list altogether 36 different terms by which CHWs are known in different countries, which is not
exhaustive and which does not include a range of lay health workers who now render different forms of
services for people living with HIV and AIDS (PLWHA) (Bhattacharyya et al., 2001; Gilroy & Winch,
2006).
Table 1. Alternative titles for CHWs
Title
Country
Activista
Mozambique
Agente comunitario de salud
Peru
Agente comunitrio de sade
Brazil
Anganwadi
India
Animatrice
Haiti
Title
Country
Barangay health worker
Phillippines
Basic health worker
India
Brigadista
Nicaragua
Colaborador voluntario
Guatemala
Community drug distributor
Uganda
Community health agent
Ethiopia
Community health promoter
various countries
Community health representative
various countries
Community health volunteer
Malawi
Community health worker
various countries
Community nutrition worker
India
Community resource person
Uganda
Female community health volunteer
Nepal
Female multipurpose health worker
Nepal
Health promoter
various countries
Kader
Indonesia
Lady health worker
Pakistan
Maternal and child health worker
Nepal
Monitora
Honduras
Mother coordinator
Ethiopia
Outreach educator
various countries
Paramedical worker
India
Promotora
Honduras
Rural health motivator
Swaziland
Shastho shebika
Bangladesh
Shastho karmis (leaders of shastho shebika)
Bangladesh
Sevika
Nepal
Traditional birth attendant
various countries
Village drug-kit manager
Mali
Village health helper
Kenya
Village health worker
various countries
Source: Bhattacharyya et al., 2001; Gilroy & Winch, 2006
All these types of CHWs carry out one or more functions related to health care delivery and are trained in
some way for the interventions they are expected to perform. Not included, for example, are formally
trained nurse aides, medical assistants, physician assistants, paramedical workers in emergency and fire
services and others who are auxiliaries, mid-level workers and self-defined health professionals or health
paraprofessionals. CHWs may receive training, which is recognized by the health services and national
certification authority, but this training does not form part of a tertiary education certificate.
Some would include in this group traditional, faith and complementary healers as well as traditional birth
attendants, whom we will not deal with in this review, as these important groups warrant separate and
quite detailed treatment in their own right.
For the purposes of this review we follow the definition used by Lewin et al. in their Cochrane review
(Lewin et al., 2005): any health worker carrying out functions related to health care delivery; trained in
some way in the context of the intervention; and having no formal professional or paraprofessional
certificated or degreed tertiary education.
The history of community health worker programmes

The concept of using community members to render certain basic health services to the communities from
which they come has a 50-year history at least. The Chinese barefoot doctor programme is the best known
of the early programmes, although Thailand, for example, has also made use of village health volunteers
and communicators since the early 1950s (Kauffman & Myers, 1997; Sringernyuang, Hongvivatana &
Pradabmuk, 1995).
Barefoot doctors were health auxiliaries who began to emerge from the mid-1950s and became a
nationwide programme from the mid-1960s, ensuring basic health care at the brigade (production unit)
level (Zhu et al., 1989; see also Hsiao, 1984; Sidel, 1972; Shi, 1993). Partly in response to the successes of
this movement and partly in response to the inability of conventional allopathic health services to deliver
basic health care, a number of countries subsequently began to experiment with the village health worker
concept (Sanders, 1985).
The early literature emphasizes the role of the village health workers (VHWs), which was the term most
commonly used at the time, as not only (and possibly not even primarily) a health care provider, but also
as an advocate for the community and an agent of social change, functioning as a community mouthpiece
to fight against inequities and advocate community rights and needs to government structures: in David
Werners famous words, the health worker as liberator rather than lackey (Werner, 1981). This view is
reflected in the Alma Ata Declaration, which identified CHWs as one of the cornerstones of
comprehensive primary health care.
Examples of VHW initiatives in Africa driven by this rationale include Tanzanias and Zimbabwes VHW
programmes in their early phase. Both were set in the political context of wholesale systemic
transformation (decolonization and the Ujamaa movement in Tanzania, and the liberation struggle in
Zimbabwe), and both focused on self-reliance, rural development and the eradication of poverty and
societal inequities.
Then came the economic recession of the 1980s, which seriously jeopardized particularly the economies
of developing countries, and brought shifts in the policy environment as the focus on liberation,
decolonization, democratization, self-reliance and the basic needs approach to development was
replaced by World Bank-driven policies of structural adjustment and its successors. CHW programmes
were the first to fall victim to new economic stringencies and most large-scale, national programmes
collapsed (although numerous nongovernmental organizations (NGOs) and faith-based organizations
(FBOs) continued to invest in mostly small, community-based health care). The collapse was further
facilitated by the fact that many large-scale programmes had suffered from a number of conceptual and
implementation problems such as unrealistic expectations, poor initial planning, problems of
sustainability, and the difficulties of maintaining quality (Gilson et al., 1989).
While many policy-makers turned their attention away from CHWs altogether, others, wanting to rescue
the concept and practice, suggested subtle shifts, as the following quote from a WHO publication on
CHWs illustrates:
CHW programs have a role to play that can be fulfilled neither by formal health services nor by
communities alone. Ideally, the CHW combines service functions and developmental/promotional
functions that are, also ideally, not just in the field of health.Perhaps the most important
developmental or promotional role of the CHW is to act as a bridge between the community and
the formal health services in all aspects of health development.the bridging activities of CHWs
may provide opportunities to increase both the effectiveness of curative and preventive services
and, perhaps more importantly, community management and ownership of health-related
programs CHWs may be the only feasible and acceptable link between the health sector and the
community that can be developed to meet the goal of improved health in the near term (Kahssay,
Taylor & Berman, 1998).
Although this concept of CHWs continues to focus on their role in community development and bridging
the gap between communities and formal health services, their role as advocates for social change has
been replaced by a predominantly technical and community management function. Over the years, and
within the prevailing political climate, this pragmatic approach to CHWs has gained currency, and
undoubtedly today constitutes the dominant approach, although the fundamental tension between their
roles as extension worker and change agent remains and will be discussed below.
Examples of CHW programmes implemented as part of wider health sector reform processes, aiming to
enhance accessibility and affordability of health services to rural and poor communities within a PHC
approach, can be found in numerous low-income countries in the 1970s and 1980s, three of which are
sketched below.
Indonesia restructured its health system in 1982, with a focus on district health development. Village
health volunteers, selected and paid by local communities, became part of health posts set up within each
district. Their activities included family planning, health education, growth monitoring, nutrition support,
immunization and treatment, particularly of diarrhoeal diseases. Initial reports showed remarkable results.
Yahya reports that the dramatic increase in village health posts led to significant health status
achievements: infant mortality dropped by 30% within seven years and immunization coverage improved
many-fold (Yahya, 1990).
In Ghana, the Ministry of Health introduced substantial numbers of community or village health workers
in the late 1970s as part of a substantial review and reorganization of MoH activities aimed at
implementing PHC strategies (Morrow, 1983). The initiative was driven by the MoH and integrated into
the national health service structure, with the MoH providing training, technical supervision and necessary
supplies.
In Niger, CHW programmes evolved from the work of volunteer health workers whose work started in the
late 1960s in the primarily agricultural Maradi Department, along the Nigerian frontier, with a population
of 730 000 people (Fournier & Djermakoye, 1975). Since 1963 Niger had a rural extension service
(animation rurale), which promoted community development schemes characterized by voluntary
participation. In the Ministry of Health, a 10-year plan from 1965 to 1974 set out the principles governing
the training of village health workers and traditional birth attendants.
While emphasizing community ownership and participation, all these projects were initiated and driven by
central government. Unfortunately, we could not find any literature on lifespan or impact of these
programmes.
Another source of CHW initiatives is faith-based organizations, which, over the decades, have combined
missionary with practical work to improve the health, education and social conditions of communities. By
their very nature, these initiatives are driven by a different rationale, and the challenges they confront are
often somewhat different.
Todays renewed focus on the use of CHWs has its rationale primarily in a recognition that service needs,
particularly in remote and underprivileged communities, are not met by existing health services,
particularly given increased needs created by HIV/AIDS in many countries and worsening health worker
shortages. CHWs are used primarily to render basic, mostly curative health services within homes and
communities and to assist health professionals with their tasks.
Profiling community health workers

Who are they?
The question of who CHWs were and are in terms of gender, age, status, etc., finds many different
answers in the literature that reflect the diversity of CHW programmes. There is agreement on two factors,
though: in virtually all cases in the literature, CHWs come from the communities they serve and they have
little or no secondary and no tertiary education.
With regard to gender, the majority of articles do not

comment specifically on whether CHWs were male or
female. In 17 articles that do specify gender, female
CHWs dominate (Briend et al., 1989; Fauveau et al.,
1991; Hailu & Kebede, 1994; Iyun, 1989; Odebiyi &
Ondolo, 1993; Ratnaike & Chinner, 1992; Ronsmans et
al., 1997; Shah, Pratinidhi & Bhatlawande, 1984; Taha,
1997; Yunus et al., 1996; Zeighami et al., 1977; Bang
et al., 2005; Brown et al., 2006; Douthwaite & Ward,
2005; Knowles, 1995; Majumdar, Amarsi & Carpio,
1997; Tumwine, 1993).
Gender of CHWs (n = 17 articles)
male & female

18%
male
12%
female
70%
It is interesting to note that especially articles on CHW programmes in Bangladesh and Pakistan mention
the sex of their health workers, while articles on programmes in Latin America and Africa in most cases
do not. Clearly, the gender issue is to a very large extent influenced by wider societal practices and beliefs,
and gender relations more generally. This is borne out by a Somali case example.
In the Somali VHW programme, where most VHWs were male, an interesting gender problem emerged in
that (male) CHWs had little contact with women.
When children had diarrhoea, frequently it was the husband who came to the centre to collect
medicine. Oral rehydration salts were provided, but apparently little information transfer was
occurring from husband to wife. The CHW had no direct contact with the mother so as to be able
to advise and help. In a new strategy, each community elected a woman helper. This person
became the key informant for the CHW in that community. She was trained in the use of oral
rehydration therapy and preparation of oral rehydration salts and in the importance and methods of
preventing anaemia in pregnancy. This woman, who was often also the TBA, was supplied with
ORS, iron and chloroquine by the CHW (Bentley, 1989).
In Peru, on the other hand, the fact that the vast majority of health promoters and indeed traditional birth
attendants and traditional healers are male appears problematic only because they dramatically skew
gender equality in community leadership positions. Resistance from husbands was identified as a key
barrier to the participation of women in the programme (Brown et al., 2006).
Comments on age are even less frequent in the literature, although mature age (between 20 and 45 years)
and often married status are reported to be a criterion in a number of cases (Ofosu-Amaah, 1983).
Examples are the Church of the Brethren initiative in Nigeria (Hilton, 1983), the Somalia and Kenya
VHW programmes (Kaseje et al., 1987a; Bentley, 1989), and a Safe Motherhood initiative in Uganda
(Kasolo, 1993). In the case of a Peruvian project, the age of health promoters ranged from 19 to 57, with
an average age of 29, whereas TBAs were considerably older by comparison (52) (Brown et al., 2006).
A great deal of variation exists in required qualifications. Many, but not all, programmes require certain
levels of literacy. In the Democratic Republic of the Congo, Peru, Somalia and Uganda, for example,
literacy was a prerequisite (Kasolo, 1993; Bentley, 1989; Brown et al., 2006; Delacollette et al., 1996),
while the Tanzanian VHW programme and Kenyan AMREF programmes required seven years of primary
education (Johnson et al., 1989; Chagula & Tarimo, 1975). The Church of the Brethren project in Eastern
Nigeria (Hilton, 1983) required the ability to read and write in Hausa, the local language, as well as good
communication skills. In Quechua, Peru, as well, knowledge of the local language was identified as
crucial, together with a certain amount of schooling (Brown et al., 2006). However, in the community selfhelp health development programme in Sarididi, Kenya, literacy was not considered a selection criterion
(Kaseje et al., 1987a). Bhattacharyya et al. comment that literacy requirements often affect the age of the
selected CHWs: literate people tend to be younger. There is some evidence, on the other hand, that older
CHWs are more respected in their communities (Bhattacharyya et al., 2001).
It is evident that generalizations about the profile of community health workers internationally are
difficult. While there are some broad trends, CHWs can be men or women, young or old, literate or
illiterate. More important is an acknowledgement that who and what CHWs are has to respond to local
societal and cultural norms and customs to ensure community acceptance and ownership.
Roles and activities

There is a wide range of different community health workers, performing an even wider range of tasks. A
typology is therefore not easy. One simple distinction, however, is that between generalist and specialist
CHWs.
Generalist
Generalist village health workers have been working in developing country health programmes from
before the Alma Ata declaration; some in large national programmes, such as, most prominently, the
Chinese barefoot doctor programme, but also programmes in India, Indonesia and a number of African
and Latin American countries; others in innumerable smaller programmes run by nongovernmental, faithbased and community-based organizations. Some of these programmes and models have been described in
books such as Health by the people (Newell, 1975) and Practising health for all (Morley, Rohde &
Williams, 1983).
Ofosu-Amaah, in her extensive 1983 review of CHW programmes based in 46 countries, wrote:
the CHW is expected to perform a wide range of functions, which according to country reports
generally include: home visits, environmental sanitation, provision of water supply, first aid and
treatment of simple and common ailments, health education, nutrition and surveillance, maternal
and child health and family planning activities, communicable disease control, community
development activities, referrals, record-keeping, and collection of data on vital events (OfosuAmaah, 1983).
There has been a long and unresolved debate about the question how many functions one CHW can
effectively perform, considering the potential scope of activities (Ofosu-Amaah, 1983; Bhattacharyya et
al., 2001; Gilroy & Winch, 2006. Coupled with concerns about how many tasks a CHW can realistically
perform are questions about the primary role of CHWs. Gilson et al., in their 1989 assessment of three
large national CHW programmes, found that while CHWs had been set up to be change agents in
communities, in reality they were functioning as extensions of formal health services as auxiliaries rather
than independent agents, even then.
This finding highlights a key tension in the conceptualization of CHWs in the post-Alma Ata period.
While developmental and educational activities are considered important, curative services are demanded
by communities that do not have access to these services. There is substantial evidence in several countries
that CHW programmes floundered due to disappointment among the community about the range of health
services the CHWs could provide. One such example is documented in Burkina Faso (Sauerborn,
Nougtara & Diesfeld, 1989). The authors report that two thirds of ailments had to be referred to the next
level of care, rendering CHWs largely ineffectual. Sanders argues that equipping VHWs with curative
skills does not simply provide health care to more people, more quickly and more cheaply, but it also gives
the VHW greater credibility in the eyes of the community (Sanders, 1985). This needs to be weighed
against other stakeholders expectations and a realistic assessment of CHWs capacity, given their
training, other commitments and the size of the population they are expected to serve.
It is impossible to comprehensively assess the full scope and depth of these programmes. Instead we have
chosen to present two recent large CHW programmes as case examples.
Case study: Brazil

One example of a recent, large-scale, government-initiated and -driven CHW programme can be found in Brazil in the
Programa Agente Comunitrio de Sude. This programme started in the mid-1980s in the north-eastern state of
Cear (Cufino Svitone et al., 2000), but was integrated into the national Family Health Programme (Programa Suda
da Famlia) in 1994 (Gilroy & Winch, 2006; Lobato & Burlandy, 2000; McGuire, 2002).
McGuire summarizes the Cear programme as follows:
When a drought hit the region in 1987, Cear's state government began to hire community health agents,
mostly women, as part of a job-creation programme. Each of the new health agents was given three months'
training and assigned to make monthly visits to 50-250 households to provide prenatal care, vaccinations,
and checkups, as well as to promote breastfeeding and oral rehydration. By 1992, 7,300 community health
agents had been hired, along with 235 half-time nurse supervisors. These health workers served 65 percent
of Cear's population at a cost of less than US $8,000,000 per year, or about $1.50 for each person served
(McGuire, 2002).
The agents were paid about USD 112 per month (double the amount of a rural worker) and supervised by local nurses
who also provided continuing training in regular meetings (Cufino Svitone et al., 2000).
The programme led to a 32% drop in infant mortality within five years and a substantial increase in exclusive
breastfeeding (Cufino Svitone et al., 2000). By 1994 the national government adopted the Cear programme and
integrated it into the newly developed Family Health Programme.
The Family Health Program (Programa Suda da Famlia or PSF in Portuguese) can be considered the main
government effort to improve primary health care in Brazil. The PSF provides a broad range of primary health care
services delivered by a team composed of one physician, one nurse, a nurse assistant, and (usually) four or more
community health workers. In some places, the team also includes dental and social work professionals.
Each team is assigned to a geographical area and is then responsible for enrolling and monitoring the health status of
the population living in this area, providing primary care services, and making referrals to other levels of care as
required. Each team is responsible for an average of 3450 and a maximum of 4500 people. Physicians and nurses
typically deliver services at health facilities placed within the community, while community agents provide health
promotion and education services during household visits.
As of 2004, the programme covered about 66 million people [nationally] nearly 40% of the entire population. The
results showed that PSF expansion, along with other socioeconomic developments, were consistently associated with
reductions in infant mortality. The policy implication is that a broad based approach to improving child health, with
primary health care at its core, can make considerable improvements in outcomes (Macinko et al., 2006).
By early 2006, 60% of the population was looked after by 25 000 health teams. In areas covered by family health
teams, hospitalization has dropped from 52 to 38 per 10 000 in the past three years (information gleaned from
presentations at 3rd National Conference on HRH in Brasilia, March 2006).
Several features make this programme different from most others. First, its sheer scale appears unrivalled, as roughly
50 million people are served by the programme at the moment. Second, Brazil took the bold decision to fully integrate
CHWs into their PHC services, making them paid members of the Family Health Teams. The issue of local ownership
has been and is challenging, and is addressed in the following way: first, with decentralization, municipalities are
responsible for delivery of services at primary level. Municipalities are to actively ensure the existence of community
health committees. Public service regulations regarding the national advertising of civil service posts were amended to
ensure that health agents came from and served their own communities (input and discussion at 3rd National
Conference on HRH in Brazilia, March 2006).
India case study

India has a long and rich history of small and large CHW programmes. A large national CHW scheme was established
in the late 1970s that aimed to provide one CHW for every 1000 population in order to provide adequate health care
to rural people and to educate them in matters of preventive and promotive health care (Chatterjee, 1993; Bose,
1983).
However, the programme ran into problems virtually from the start: resistance from the medical profession, demands
for payment and vacillating government policies with regard to funding meant that the scheme collapsed in most states
within a few years. Furthermore, it would appear that the scheme was not well anchored in and owned by communities
and there was role confusion between CHWs and multipurpose health workers. Interestingly also, CHWs were trained
for a very limited scope of curative tasks, to the exclusion of any preventive or promotive work, leading to frustration
and demotivation among themselves and the communities they served (Chatterjee, 1993; Bose, 1983).
While the government considered CHWs volunteers who were appointed by and accountable to the communities they
served, they themselves, their communities and the health services considered them government employees, leading
to demands for higher salaries rather than small honoraria. By the late 1980s, although there were large numbers of
CHWs registered, few of them functioned effectively.
On a smaller scale of NGOs, India, like so many other countries, has seen a number of successful projects.
Kaithathara reports of a project called MOTT (mobile orientation and training team) which set up CHW projects in a
number of villages in the Indian state of Orissa. Here, community participation was central to the programme:
communities decided and planned whether and when they wanted a health care programme, and what kind:
the cost, type and location of the health centres. They chose the women who were to be trained from among
women in their community. They also formed a small committee of seven to ten people, women and men, to
help the health workers in their day-to-day problems (Kaithathara, 1990).
Training and supervision was done in circular fashion, on a continuing basis, involving health centre staff. Kaithathara
points out that in addition to health workers, there must be other agents of change in villages, so that a
comprehensive approach can accelerate the peoples awakening, enabling them, by cooperative effort, to build their
own future together. Unfortunately, as in so many cases, we have neither a systematic evaluation of the project, nor
any firm figures regarding impact on health status, nor a sense of the lifespan of the project. The reported time span
lies between 1968 and 1985.
Very recently another large-scale programme called the mitanin programme was initiated by the government in the
Indian state of Chhattisgarh in 2002. The programme is seen to be following the long tradition of Indian CHW
programmes and was preceded by intensive studies of these previous experiences (SOCHARA, 2005). The
programme was evaluated by the Society for Community Health Awareness, Research and Action (SOCHARA) at the
request of the Chhattisgarh government in early 2005. This summary is based on their evaluation report (SOCHARA,
2005).
Chhattisgarh is a new state, formed in 2000 after the separation of two others. It has a population of 20 million and all
the characteristics of a rural, underserved community, with low health and education indicators. The creation of the
new state was seen as an opportunity to strengthen measures to improve health and health care.
The core idea was to have a mitanin (trained community health worker) for every one of the 54 000 majra
tolas/paras (hamlets) in the state. There was political commitment and pressure from the highest level, with
the Chief Minister taking personal interest in its launch and progress (SOCHARA, 2005).
The programme initiation was a collaborative effort between the state, NGOs and funders, who set up a dedicated
structure the State Health Resource Centre (SHRC) which was charged with operationalizing and managing the
programme.
Mitanin are women, selected from their communities, who receive altogether 20 days of training and who work closely
with primary health staff. Training was organized as follows:
The Block Medical Officer (BMO) would organize the training programmes for Mitanins and the cost would be
borne by government. The first stage of training would consist of six rounds and was expected to be
institutional based. The second stage of training would be mainly refresher training at regular intervals and at
cluster and panchayat level. The first stage of training would include preparation, and building of certain basic
attitudes, knowledge, and skills. She would be expected to perform the following tasks after training: blood
smear preparation, anemia detection, antenatal care, weighing children, malnutrition detection and care, ARI
(Acute Respiratory Infection) treatment, chloroquine treatment for fever, early detection and referral,
treatment of dehydration, health education for specific groups.
After training they were expected to work for two to three hours per day for two to three days per week, thus leaving
time for farming or other breadwinning activities.
In contrast to the Brazilian programme, it was decided that compensation (in cash or kind) should be the responsibility
of communities, while government would guarantee training and retraining; integration of the mitanins work with
government services, and supply free medicines and material.
The SOCHARA evaluation summarized their findings of the early implementation of the programme as follows:
The team found that the Mitanin programme has covered all areas, and there are Mitanins in almost all
places. Supportive institutional mechanisms have been established at state level with the SHRC advisory
committee, and at district and block level with district RCH [reproductive and child health] Societies and a
variety of arrangements. However the programme is struggling at the field level on several fronts including
Mitanins demand for drugs, remuneration, training, and referral support; non payment of BRP-DRPs [block
respource person-district resource persons] for long periods; relative indifference of the health system, and
lack of adequate meaningful community participation at several stages (in selection, implementation). The
knowledge level of Mitanins, their home visits, provision of primary medical care, referral, cooperation with
ANM-AWW [auxiliary nurse midwife/Aganwadi Worker], Panchayat connection, gender-rights etc are
presently at low levels. Their training, follow-up and support systems need considerable strengthening. The
document search suggests thoughtful planning with potential problems considered and options weighed. Due
to several reasons spanning design, strategy and implementation, the programme is performing below
expectations. Despite good efforts on some fronts like preparation of good training booklets, separate support
system for Mitanins, picture symbols on the tablet-packs, kalajathas to generate enthusiasm and
community awareness and ensuring a Mitanin everywhere, the programme faces serious challenges.
Continuing the process of learning by doing with technical, training, supervisory and referral support at block
and district level () could help to make the difference.
Several aspects stand out in the Chhattisgarh mitanin programme:
First, the programme very explicitly sees itself as continuing a tradition of CHW programmes in India, and the
programme initiators took great care to study and learn from previous programmes.
Second, as in Brazil, the programme was initiated during a time of political transformation, by a government that
seriously endeavours to address issues of inequity in health service delivery. There is considerable political leadership
in the process of initiating and implementing the programme. Of particular interest and well worth studying in greater
detail is the decision to establish a dedicated structure tasked with the operationalization of the programme, as well as
the fact that three years into the programme it had seen one internal and one external evaluation, indicating an
awareness that this was not an easy process and a willingness to learn from experience. This is also reflected in the
language of the evaluation report.
The findings of the evaluation raise challenges entirely common to CHW programmes throughout the world: problems
with community ownership, demands for training, remuneration and supplies, lack of supervision and negative
attitudes from the formal health services. However, rather than abandoning the programme, there appears to be great
resolve to view and address these challenges in the context of broader human resource and systems development.
Specialist CHWs
While in some programmes the lines between generalist and specialist CHWs are blurred, many
programmes established in the past 20 years make use of CHWs to address specific health issues.
This is often, but not only, true for programmes run by NGOs, which frequently have a programmespecific focus. Specialization may also be a response to the difficulty experienced in finding the optimal
mix of CHW functions and tasks and the right balance between breadth and depth of tasks (Bhattacharyya
et al., 2001).
Key areas in which the use of specialist CHWs is reported frequently in the literature are the following:
Maternal and child health, including reproductive health and family planning (Cesar et al., 2002;
Goldhaber-Fiebert et al., 2005; Kelly et al., 2001; Majumdar, Amarsi & Carpio, 1997; Haider et al.,
2002; Integration, 1990; Bairagi, Islam & Barua, 2000; Kasolo, 1993; Haspel, 1994; Kamanzi,
Avutsekubwimana & Hakiruwizera, 1990; African Alternatives, 1995; Miller, 1998; Maro, 1988;
Leite et al., 2005; Morrison et al., 2005; Jacobson, 1991; De Francisco, 1994; Ogunfowora & Daniel,
2006; Velema et al., 1991; Kuhn & Zwarenstein, 1990; Yach, Hoogendoorn & Von Schirnding, 1987;
Cesar et al., 2005; Bang et al., 2005; Jokhio, Winter & Cheng, 2005; Douthwaite & Ward, 2005;
James, Howat & Binns, 1998; Nougtara et al., 1989; Paul & Singh, 2004).
TB care (Barker, Millard & Nthangeni, 2002; Chopra & Wilkinson, 1997; Chowdhury et al., 1997;
Connolly, Davies & Wilkinson, 1999; Daniels et al., 2005; Dudley et al., 2003; Kironde &
Kahirimbanyi, 2002; Lwilla et al., 2003; Sinanovic et al., 2003; Tanser & Wilkinson, 1999; Wilkinson
1999a, 1999b; Zwarenstein et al., 2000; Floyd et al., 2003; Islam et al., 2002; Khan et al., 2002;
Nganda et al., 2003; Okello et al., 2003).
Malaria control (Ghebreyesus et al., 2000; Ghebreyesus et al., 1996; Delacollette, Van der Stuyft &
Molima, 1996; Allen et al., 1990; Bell et al., 2005; Cho Min & Gatton, 2002; Greenwood et al., 1988;
Sirima et al., 2003).
HIV/AIDS care (Howard, 1995; Schneider et al., 2006; Shah, Rollins & Bland, 2005; Koenig, Leandre
& Farmer, 2004; Wendo, 2003; Kipp, Kabagambe & Konde-Lule, 2002; Farmer et al., 2001).
Treatment of acute respiratory infections (ARIs) (Kallander et al., 2006; Winch et al., 2005; Mehnaz et
al., 1997; Charleston, Johnson & Tam, 1994; Brewster et al., 1993; Zeitz et al., 1993; Pandey et al.,
1991; Rai & Tatochenko, 1988).
Less frequent reports can be found about the use of CHWs in food security and nutrition, immunization,
community rehabilitation, diarrhoea management, environmental health and sanitation, treatment of skin
diseases and the collection of basic health information in communities, including recordkeeping.
Of 86 articles discussing the use of specialized
CHWs in developing countries, 30 focused on
maternal and child health (including reproductive
health and family planning), 19 on the treatment
of TB, 9 on malaria control, 8 on ARIs, 7 on
HIV/AIDS, 13 on other intervention areas.
Use of specialist CHWs as reported in the

literature
Other
15%
0%
MCH
36%
HIV
8%
ARIs
9%
Malaria
10%
TB
22%
It would be impossible to comprehensively summarize or even represent the range of activities of

specialist health workers. Instead, a few case studies below aim to give an impression of the scope and
character of roles and activities.
By far the most comprehensive review of the use of CHWs in a specific area, with a strong clinical
perspective, can be found in Management of sick children by community health workers (Gilroy & Winch,
2006). Based on an extensive literature review, the authors identified seven intervention models, which
they categorized according to according to a number of factors (see table below).
Source: Gilroy & Winch, 2006
The role of CHWs in child survival has also been reviewed in a forthcoming article by Haines et al.
(forthcoming). They found that in a number of trials, reductions in child mortality through the use of
CHWs could be proven. They warn, however, that:
CHWs are not a panacea for weak health systems and will require focussed tasks, adequate
remuneration, training, supervision, and the active involvement of the communities in which they
work. The introduction of large-scale CHW programmes requires evaluation research to document
the impact on child survival and cost effectiveness as well as to elucidate factors associated with
success and sustainability (Haines et al., forthcoming).
The potential for using CHWs to administer treatment of malaria was evaluated in the Katana health zone
in the Democratic Republic of the Congo (Delacollette, Van der Stuyft & Molima, 1996). In each of the 12
villages of the intervention area, a CHW selected by the village was trained for two weeks in the use of a
simple fever management algorithm. After training, the CHWs started their activities. Since they were also
local farmers, they were, in principle, always accessible to the villagers, who had been motivated through
health education to consult the CHW for any fever episodes.
The CHWs performed their services under the supervision of the nurse in charge of the area's health centre
and attended monthly meetings. They received only a symbolic monetary award, as well as increased
standing in the community. Nevertheless, no CHW dropped out of the programme.
Malaria morbidity and mortality trends were monitored over two years in area A (the project area) and in
an ecologically comparable control area (area B), where malaria treatment continued to be available at the
health centre only. Health care behaviours changed dramatically in the intervention area, and by the end of
the observation period 65% of malaria episodes were treated at the community level. Malaria morbidity
declined 50% in area A but remained stable in the control area. Malaria-specific mortality rates remained,
however, at essentially the same levels in both areas.
Key problems in the project revolved around the limited scope of the CHWs practice and their ambiguous
role within the health care system. More specifically, Delacotte et al. observed that CHWs wanted to be
more than symbolically remunerated for their services; they were eager to receive further training so as to
expand their scope of practice, and they wanted to become a formal part of the health structure.
Furthermore, the project management and supervision placed an increased burden on health centre staff,
and communities became increasingly disenchanted with the limited scope of services delivered by the
CHWs. This, in the authors' opinion, would in the long term compromise the sustainability of the project.
One of the fastest-developing areas for the use of CHWs is HIV/AIDS prevention and care. Today CHWs
are widely used as lay counsellors (Kipp, Kabagambe & Konde-Lule, 2002), and a number of countries,
particularly Haiti, have explored the use of CHWs in treatment support (Farmer et al., 2001; Koenig,
Leandre & Farmer, 2004). In addition there is a proliferation of community-, church- and NGO-initiated
activities, particularly in countries with high HIV prevalence, which make use of lay personnel for a wide
range of prevention, support and care activities (Johnson & Khanna, 2004). These are often unregulated
(Chaava, 2005), not well documented and, as Schneider et al. point out, their potential for addressing the
overwhelming human resource challenges in HIV care is inadequately understood (Schneider et al., 2006).
A systematic assessment of these programmes and activities is an urgent research requirement.
Having discussed the range of CHW profiles, their roles and activities, we will now turn to questions of
performance of programmes and how this is affected by issues of management and governance. Given the
diversity of programmes, generalizations must be approached with caution, but trends are discernable.
Performance
Performance is made up of different but closely interlinked elements: individual health worker
performance, use of services, impact effectiveness and financial performance or cost-effectiveness. All of
these will in turn be discussed below.
Health worker performance

Individual health worker performance, while an important element, is somewhat difficult to discuss as a
stand-alone issue, as it depends on all aspects of management, as discussed below: selection, training,
supervision and support. Two studies that explicitly explore the performance of CHWs illustrate this.
Evaluations of CHW performance in 1998, 1999, and 2001 in Siaya, Kenya (Kelly et al., 2001) found that
key reasons for the deficiencies [in performance] appear to be guideline complexity and inadequate
clinical supervision.
An assessment of health worker performance in the management of children with acute respiratory
infections (ARI) in two local government areas (LGAs) in Nigeria found that:
many of the health workers had not attended a continuing education programme in the previous
two years and supervision which could have provided on-the-spot training was irregular.
Improvements in ARI case management will require attention to policy, logistics, training
(including in-service education) and supervision (Fagbule & Kalu, 1995).
Use
Low use of CHW programmes is a commonly expressed concern in the literature (De Francisco et al.,
1994; Sringernyuang, Hongvivatana & Pradabmuk, 1995; Develay, Sauerborn & Diesfeld, 1996; Nougtara
et al., 1989; SOCHARA, 2005; Sauerborn, Nougtara & Diesfeld, 1989; Menon, 1991).
As a rule, use is seen to be linked to poor community introduction of the programme, which often, as in
the case of a CHW initiative in Burkina Faso, then leads to political tensions between traditional
hierarchies and the structures set up under the new regime (Sauerborn, Nougtara & Diesfeld, 1989) or to a
preference for formal, established health services.
In Thailand it was found that use of well-established programmes was dropping (Kauffman & Myers,
1997; Sringernyuang, Hongvivatana & Pradabmuk, 1995):
Many of the once rural villages of Thailand have greater access to secondary and tertiary services
located in larger cities and communities. Consequently, more and more people self-refer into this
level of care, based on information they receive from radio or television.
They suggest a context-sensitive adjustment of existing CHW programmes.
Like CHW performance, use is clearly context-sensitive and linked to a number of factors internal and
external to the programme. That use can be influenced and improved is convincingly shown by Curtale et
al. (1995). They report that the implementation of a specific intervention in Nepal that improved training,
support and supervision of CHWs not only improved their performance, but also led to a significant
increase in usage rates and improved rates in choice of CHWs as first stop providers.
Retention/attrition
High attrition rates have been reported in many CHW programmes, as summarized by Bhattacharyya et al.
(2001):
Attrition rates for CHWs of 3.2 percent to 77 percent are reported in the literature, with higher
rates generally associated with volunteers. One review (Parlato & Favin, 1982) found attrition
rates of 30 percent over nine months in Senegal and 50 percent over two years in Nigeria. CHWs
who depend on community financing have twice the attrition rate as those who receive a
government salary. In the Solomon Islands, attrition was attributed to multiple causes in addition
to inadequate pay, including family reasons, lack of community support, and upgrading of health
posts (Chevalier et al., 1993). High attrition rates cause several problems. Frequent turnover of
CHWs means a lack of continuity in the relationships established among a CHW, community, and
health system. Considerable investment is made in each CHW, and programme costs for
identifying, screening, selecting, and training the CHW rise with high attrition rates. When CHWs
leave their posts, the opportunity is lost to build on their experience and further develop their skills
over time through refresher training. The very effectiveness of CHW work usually depends on
retention.
These points are elaborated in several studies.
In a study in the Solomon Islands, training before the age of 20 and irregularity in remuneration were
found to be the main factors explaining why village health workers leave their posts (Chevalier et al.,
1993):
Attrition occurred when VHWs were trained before they reached age 20 and when their
remuneration was irregular; only 58% of VHWs surveyed had been paid regularly, and 66 of the
non working VHWs surveyed had quit because of pay-related reasons. () Many of the younger
workers abandoned the job of VHW when they married and sought other employment to support
their families or had children to tend. For others, the VHW post was a steppingstone to becoming
a nurse. In the Solomon Islands, local communities try to have their VHW posts upgraded to that
of nurse's aid. If this practice were restricted, more VHWs would drop out.
In Bangladeshs BRAC programme CHWs discontinued their work due to lack of time, lack of profit,
and family's disapproval. The effects of the dropouts were decreased achievement of targets, and a loss of
money in the amount of $24 (U.S.) per dropout [CHW] for their training and supervision (Khan et al.,
1998).
Ofosu-Amaah (1983) found in her study of the literature available in 1983 that turn-over of CHWs is
high for a number of reasons, the most important being poor selection and low remuneration. Another
frequently cited reason was movement upwards to higher positions in the health system, marriage or
family matters, and finding better positions in other fields.
The cost of high attrition rates is also discussed by Gilson et al., who found that, although volunteer
programmes were cheaper in terms of salaries, very high attrition rates mean not only that frequent
training of new volunteers is required, but also that it is difficult to keep track of volunteers and to judge
their usefulness (Gilson et al., 1989).
Hence, retention is affected by central concerns with governance and management, such as sources of
financing, community ownership and selection practices. It stands to reason that retention can and should
be addressed as part of a broader package of management interventions.
Impact effectiveness
When discussing the impact effectiveness of CHW programmes, the question needs to be asked: impact on
what?
Lewin et al. conducted a Cochrane review to assess the effects of LHW interventions in primary and
community health care on health care behaviors, patients' health and wellbeing, and patients' satisfaction
with care (Lewin et al., 2005).
Based on 43 RTCs included in the study they concluded that:
LHWs show promising benefits in promoting immunization uptake and improving outcomes for
acute respiratory infections and malaria, when compared to usual care. For other health issues,
evidence is insufficient to justify recommendations for policy and practice. There is also
insufficient evidence to assess which LHW training or intervention strategies are likely to be most
effective.
The already quoted review of evidence for the management of sick children by CHWs (Winch et al., 2005)
found that of seven intervention models, that of CHW pneumonia case management has the strongest
evidence for an impact on mortality.
Numerous programmes may have impacts on communities, such as social mobilization, building of trust,
etc., that are difficult to quantify, yet may be of great importance (see below) (Walker & Jan, 2005).
In a study of rural Nepal, Curtale et al. report a general improvement of CHW skills and utilization as a
result of a specific intervention that brought with it improvements in training, supervision and supplies
(Curtale et al., 1995).
Therefore, while impact effectiveness is clearly a crucial benchmark for programme planners and
managers, it is important to note that it cannot be discussed in general, but needs specific definition not
only regarding impact on what, but also impact over what time period. The literature discusses
effectiveness in relation to a range of impacts, of which mortality and morbidity rank prominently, not
only due to their obvious importance, but also because they are quantifiable much more easily than
measures such as client satisfaction or community mobilization and are also mostly relatively short-term,
i.e. over one- to five-year periods. Within these parameters, most studies indicate some degree of impact
effectiveness. Below is one example.
The strategy of the Planned Parenthood Association of Ghana (PPAG) for helping poor communities, which includes
concrete and practical health education; community involvement; encouragement of voluntary activities; use of the
skills of the community; and self-reliance, including family planning, has gained wide acceptance. The practice rate of
family planning among nine intervention villages ranged from 24.6% to 43.6%, far higher than the national average of
5.2%. And while immunization coverage rates for nine villages range from 74.7% to 87.0%, nearby villages have
coverage rates of about 30%. Furthermore, village women have themselves begun promoting maternal and child
health and family planning. As the results indicate, the community health project has been successful in improving the
living conditions of the villagers by mobilizing local resources (Integration, 1990).
Cost-effectiveness of CHW programmes

Services provided by community health workers are expected to be more appropriate to the health needs of
populations than those of clinic-based services, to be less expensive and to foster self-reliance and local
participation. Furthermore, because CHWs are more accessible and acceptable to clients in their
communities, they are expected to improve the overall coverage of services as well as equity, i.e. increased
service use by poorer individuals and households (Berman, 1984). In short, these programmes are
expected to improve the cost-effectiveness of health care systems by reaching large numbers of previously
underserved people with high-impact basic services at low cost (Berman, Gwatkin & Burger, 1987).
However, there is a dearth of data on the cost-effectiveness of CHW programmes to confirm these views.
The limited studies available suggest that CHWs increase the coverage and equity of health service
delivery compared with alternative modes of service organization (Walker & Jan, 2005). But most
studies, while useful and necessary for decision-makers, miss key elements of CHW programmes that do
not lend themselves to economic analysis: institutional factors such as altruism, volunteerism, community
norms, reciprocity and duty and these tend not to be reflected well in estimates of cost effectiveness.
Hence cost-effectiveness analyses are insensitive to a range of social benefits (including community
mobilization), which often constitute the strength of CHW programmes.
A number of studies have examined the cost-effectiveness of specific programmes. One of the first papers
to evaluate the value for money of CHW programmes was published by Wangombe (1984). The study
reports on a project in two locations in Kenyas Western Province. CHWs were trained for 12 weeks and
deployed as providers of basic health care and promoters of selected health, sanitation and nutrition
practices. A cost-benefit analysis was performed using the willingness-to-pay approach to compare the
costs and benefits of the project. The evaluation illustrated a large net present value and a benefit-cost ratio
of between 9.36 and 9.85, depending on the choice of discount rate. The author concluded that the results
were strongly in favour of decentralization of primary health care on similar lines in the rest of the
country (Wang'ombe, 1984).
A study of five CHW programmes delivering primary health care services and one CHW training centre in
South Africa found that the CHW unit costs were comparable to those of other health services, although
the comparison failed to account for differences in disease severity and professional training (Makan &
Bachman, 1997). Unfortunately, a failure to assess the effectiveness of the programmes did not allow for
an assessment of cost-effectiveness.
A number of studies have compared the cost and cost-effectiveness of community-based TB care versus
other strategies. One study illustrated that the cost to both health service and patient can be substantially
reduced by using community-based directly observed therapy (short-course) (DOTS) for tuberculosis (TB)
in South Africa. It found that this strategy was more cost-effective than hospitalization or sanatorium care
(Wilkinson, Floyd & Gilks, 1997). Similar findings have been reported from a number of other developing
countries: Bangladesh (Islam et al., 2002), Kenya (Nganda et al., 2003), Malawi (Floyd et al., 2003),
Pakistan (Khan et al., 2002), South Africa (Clarke, Dick & Bogg, 2006) and Uganda (Okello et al., 2003).
For example, a recent paper compared the cost-effectiveness of an NGO TB control programme that uses
CHWs with the governments programme, which does not. The cost per patient cured was USD 64 in the
NGO area compared to USD 96 in the government area, suggesting that the involvement of CHWs
represents a more cost-effective use of resources in rural Bangladesh (Islam et al., 2002).
Similarly, an economic study was conducted alongside a clinical trial at three sites in Pakistan to establish
the cost-effectiveness of different strategies for implementing DOTS (Khan et al., 2002). Patients were
randomly allocated to one of three arms: DOTS with direct observation by health workers (at health
centres or by CHWs); DOTS with direct observation by family members; and DOTS without direct
observation. The clinical trial found no statistically significant difference in cure rate for the different
arms. However, the economic analysis found that direct observation by health centre-based health workers
(the model recommended by WHO and the International Union against Tuberculosis and Lung Disease)
was the least cost-effective of the strategies tested (USD 310 per case cured). The self-administered group
came out as most cost-effective (USD 164 per case cured). However, the CHW subgroup achieved the
highest cure rates (67%), with a cost per case only slightly higher than the self-administered group (USD
172 per case cured). The authors concluded that this approach should be investigated further, along with
other approaches to improving patient compliance.
In a recent review of the effects and costs of expanding the coverage of immunization services in
developing countries, one of the interventions with the highest impact on full coverage was CHWs
(Pegurri, Fox-Rushby & Damian, 2005). The employment of CHWs in outreach programmes was
evaluated in relatively small but diverse communities, vis--vis vaccination campaigns offered
periodically. In one case, it was the urban areas of Mexico (Caldern-Ortiz & Meja-Meja, 1996) and in
the other it was communities dispersed along a river in the Amazon, Ecuador (San Sebastian et al., 2001).
The involvement of communities improved services, as it meant that houses were located with precision,
they were registered and the days of vaccination were chosen in accordance with parents. The paper by
San Sebastian et al. was one of only two papers for which cost-effectiveness was also evaluated. The use
of CHWs was reported to be a successful strategy, i.e. it cost less and was more effective than outreach
teams by health staff in the Amazon areas of Ecuador. Such comparisons can help to distinguish whether
differences in cost-effectiveness are due to the nature of the interventions or to the circumstances of the
countries. For example, in this paper, the characteristics of the Amazon area in Ecuador substantially
influenced the effectiveness (due to the extraordinary potential of CHWs in such an isolated community)
and cost results (given the peculiarity of transportation by canoe and the possibility of employing
volunteers).
Managing CHW programmes

Management is one of the most crucial, yet often sorely neglected, factors of CHW programmes. Their
geographical and organizational location on the periphery, often with ill-defined ownership and
accountability, means that while they need particularly careful and attentive management, in practice they
are often forgotten and dropped off the list of priorities. In this section we will discuss key elements of
CHW programme management: i.e. recruitment and selection, training, support and supervision. The
related topic of governance who owns and takes responsibility for programmes and also their
management will be discussed in the following section.
It must be stressed that, while the different aspects of management will be discussed separately, as a rule
the success or failure of programme management is made up of a combination of these factors, as is
illustrated by the short case summary below:
In Zambia, a large CHW programme in Kalabo District almost completely collapsed. Key reasons identified were a
shortage of drugs and poor selection criteria (Stekelenburg, Kyanamina & Wolffers, 2003). Erratic drug supply is an
indication of a programmes low priority and also has a very negative effect on CHWs standing in community.
Furthermore, authors found that the community members in charge of CHW selection knew little about selection
criteria. Further, quality of supervision was poor and in 50% of cases nonexistent. Both community members and
CHWs felt that the latter were not well supported by communities.
Recruitment and selection

Virtually every document discussing community health workers emphasizes: (1) that CHWs should be
chosen from the communities they will serve and (2) that communities should have a say in the selection
of their CHWs. As far as the selection of the CHW is concerned, the consensus today is that nonnegotiably, she should be directly chosen by the households that she will work with. Neither health or
other officials, nor even Panchayat members should make this choice. She should be accountable to the
local neighborhood community that she volunteers to serve, for which she will be trained and supported by
the health bureaucracy and Panchayats (Mander, not dated).
But while the practice of selecting CHWs from local communities is widely accepted and implemented,
direct and meaningful participation of communities in the selection process is not. In the evaluation of the
Indian mitanin programme, for example, it was found that as a rule local bureaucrats, village chiefs or
other dignitaries held sway over who was selected (SOCHARA, 2005). This is a common experience, as
selection is often considered a form of patronage.
Gilson et al. found in a study of three countries programmes that CHWs are mostly selected by health
personnel rather than the community even where, as in Botswana, the local institutions through which
selection could occur are well known (Gilson et al., 1989).
Whether and how communities are in practice involved in selection processes will largely depend on
issues of governance, the role of formal health services and particularly forms and structure of broader
community participation, which will be discussed below. The most common approach employed by
organizations to initiate CHW selection has been the setting up of village health committees (VHCs),
which then are responsible for selecting VHW/CHW candidates (Knowles, 1995; Kaseje, 1987b; Daniel &
Mora, 1985; Diallo, Ly & Sakho, 1995; Ghebreyesus et al., 1996; Kaseje, 1987a and b; Bamisaiye et al.,
1989; Kaseje, 1986; Mitchell, 1995; Opoku, 1997; Sepehri & Pettigrew, 1996; Tumwine, 1993). Little
detail is available on the finer details of selection processes and how the VHCs were constituted
although issues of domination through village elders and issues of gender inequities are raised repeatedly.
In some cases, as in Somalia, existing village committees were used to play the role of VHC (Bentley,
1989). However, most studies report only that CHWs were chosen or selected by the communities
themselves.
Ofosu-Amaah argues that a balance is needed between the views of the community, the health system
and also the training institutions, since the pattern of allegiance is said to be influenced by who does the
selection. She also noted that where the community is actively involved in the selection process, those
selected for training may turn out, in many cases, to be acknowledged opinion leaders in the community,
e.g. a member of the village panchayat (village council), the vice-president of the school society, ()
(Ofosu-Amaah, 1983).
In summary, while the selection of CHWs from local communities is common practice, participatory
selection processes remain an ideal that is relatively rarely practised, particularly in large-scale
programmes. Questions of whether and how selection processes could and should be structured differently
relate directly to broader issues of community participation, as discussed below.
Initial and continuing training

While a large number of articles discuss or at least mention the training of CHWs, not surprisingly length,
depth, organization of, responsibility for and approaches to training vary dramatically across programmes.
At Maradi in Niger, for example, courses of seven to ten days (seven days medical training, three days
literacy) were provided at the rural dispensary base to which the project was attached. The courses were
simple and offered in the local vernacular. They covered: general health concepts, emergencies and
referrals, epidemic diseases, health education (including nutrition), elementary health care, environmental
sanitation and some record keeping (Sanders, 1985). Each year the VHWs were sent to a 10-day refresher
course, where they would be introduced to new items such as the treatment of malnutrition and the
preparation of weaning foods.
In Tanzania, VHWs would undergo three to six months training (Chagula & Tarimo, 1975), while in
Nigeria, VHWs were trained for three months in groups of 20, and sent for refresher courses twice a year
subsequently (Hilton, 1983).
Training is in many cases conducted by members of the formal health services, either doctors or nurses, as
in Brazil, or, in the case of NGO-driven programmes, by the NGOs themselves.
Approaches to training have changed over the years. While in the past complaints about inappropriate
training which was too theoretical, too classroom-based or too complicated were quite common
(Gilson et al., 1989), today competence-based approaches are usually used, as Gilroy & Winch report in
the case of CHW training in the management of sick children (Gilroy & Winch, 2006):
In this approach, the skills and competencies required of the CHW are defined and usually
expanded into steps and standardized procedures required for a specific skill. The training
materials and activities all focus on the learners mastery of the specifically chosen competencies.
The competencies that are achieved during training are also those that should be assessed during
supervisory visits or follow-up, frequently with the checklists used during training.
They further comment:
The ideal location of training, where CHWs will have sufficient opportunity to practise, varies by
CHW programme. Some programmes recommend that the training take place in the community
rather than in health facilities to provide hands-on experience in the work environment of the
CHW. In other contexts, training may take place in the facilities because there are more cases of
sick children presenting within the training period, thus providing more opportunities for the
trainer to demonstrate skills in a real-life situation and for CHWs to practise newly learned skills.
Because CHWs work within the constraints of the community and usually have limited formal
education, programmes often develop or adapt training materials and activities specifically for
CHWs rather than using training packages developed for facility-based workers. For example,
CARE India, in collaboration with the Government of India and WHO, has developed an IMCI
training package for basic health workers, or CHWs, based on the facility-based IMCI course but
with simpler language, more illustrations and more interactive components for the less-educated
basic health workers.
But while the literature reflects a great diversity of approaches, location, organization and length of
training, there is agreement on one matter: that continuing or refresher training is as important as initial
training. A number of studies have found that if regular refresher training is not available, acquired skills
and knowledge are quickly lost (Ashwell & Freeman, 1995) and that, on the other hand, good continuing
training may be more important than who is selected (Ande, Oladepo & Brieger, 2004).
Community-based distributors (CBDs) have been trained ad utilized to promote a variety of health
commodities. In addition, a variety of different types of community residents have been trained
ranging from traditional birth attendants (TBAs) to patent medicine vendors. A training
programme for CBD agents in the Akinyele Local Government Area of Oyo State, Nigeria,
provided the opportunity to compare the knowledge of two different types of CBD agents, TBAs
and volunteer village health workers (VHWs). Although VHWs were younger and better educated
than the TBAs, the two groups had similar levels of knowledge about diarrhea recognition, cause
and prevention. ()Overall knowledge results showed some gaps that may likely be a natural
result of knowledge decay. The major lesson learned is that the type of CBD agent may not be as
important as the fact that they receive follow-up after they have been trained (Ande, Oladepo &
Brieger, 2004).
Curtale et al. suggest that three additional training days provided regularly to the CHV every year, will
result in improved quality of service with consequent increased utilization (Curtale et al., 1995).
Supervision and support

It is widely acknowledged and emphasized in the literature that the success of CHW programmes hinges
on regular and reliable support and supervision (Ofosu-Amaah, 1983; Bhattacharyya et al., 2001). It is
equally acknowledged, however, that supervision is often among the weakest links in CHW programmes.
Small-scale projects are often successful because they manage to establish effective support and
supervisory mechanisms for CHWs, often including a significant amount of supervision and oversight by
the community itself. National programmes are rarely able to achieve this consistently, as has been shown
in the Zimbabwe experience, for example (Sanders, 1992).
Many evaluations have documented the weakness of supervision and support in national programmes,
which are often irregular or nonexistent (WHO 1990) Gray & Ciroma, 1988). In the worst cases, CHWs
do not even know who their supervisors are or what they can expect from them.
There are a number of reasons for the lack or poor quality of supervision. Gilson et al. (1989) point out
that the cost of supervision has, in particular, been overlooked, although the frequent contact required to
support CHWs effectively can generate supervision costs that represent 40% of the cost of one CHW. But
not only has the cost been overlooked: often the need for supervision has been either overlooked or
underestimated, or not adequately planned for. Also, who supervisors should be and what their tasks are is
often ill-defined. Ofosu-Amaah (1983) mentions cases in which community participation in supervision
was successfully implemented, but this remains the exception; supervision is left mostly to staff (mainly
nurses) in the health services. They, however, may not understand the CHWs or their own role properly
and furthermore may resent the additional task (Gilson et al., 1989).
Most importantly, however, the greatest need for supervision exists in the most remote areas, where health
services are most overstretched and ill-equipped.
Although supervision is often identified as the vehicle through which the quality of health care
services can be assured, it typically receives neither the human nor financial support needed to
fully conduct and sustain the necessary supervisory activities. In the current decentralization of
health services management occurring in many countries, full responsibility for the supervision of
facility and community health workers has been shifted to area and district levels, often without
providing the training and resources needed to undertake supervisory functions. Furthermore, the
activities with which supervisors are charged are often poorly defined. Health care systems have a
wide range of options in developing a locally appropriate and sustainable supervision strategy at
the primary level. Key issues are who supervises and how often, and the use of supervisory job
aids in measuring the quality of care (Stinson et al., 1998).
What difference supervision can make is described by Curtale et al. (1995) in their study of the impact of a
nutrition intervention on a CHW programme. They found that continuous supervision diminishes the
sense of isolation that CHVs usually experience in the field and helps to sustain their interest and
motivation to do their assigned tasks. These findings are echoed by experiences in a Bolivian CHW
programme (Charleston, Johnson & Tam, 1994).
Hand in hand with supportive supervision go other forms of support, in particular logistics and
infrastructure support. Issues such as the reliable provision of transport, drug supplies and equipment have
been identified as another weak link in CHW effectiveness. Reasons can again be found in the fact that
CHWs as a rule operate on the periphery, both organizationally and geographically. They are the first to
lose training opportunities and supervisory visits, but also transport and drug supplies (Gilson et al., 1989).
The result is not only that they cannot do their job properly, but also that their standing in communities is
undermined. Failure to meet the expectations of these populations [with regard to supplies] , will destroy
the image or the credibility of the CHW (Ofosu-Amaah, 1983). If CHWs are used in programmes that
have drug treatment at their core, such as TB DOTS or HAART, the situation becomes more critical
(Farmer et al., 2001), but most programmes include the need for supply of drugs and/or equipment,
including transport (SOCHARA, 2005).
While not abundant, the literature does report success stories in organizing drug and equipment supplies.
In Somalia and Burkina Faso, for example, supplies were organized through district or regional
dispensaries, and collected and delivered by CHWs (Bentley, 1989; Sauerborn, Nougtara & Diesfeld,
1989).
In some parts of Senegal, village dispensaries have been established to cater for the drug needs of
the populations of very remote villages. The dispensaries are given a 20% rebate on drug
purchases and villagers are required to pay for the drugs dispensed to them. () In China, the
cooperative medical service organization to which community members contribute, entitles them
to free drugs (Ofosu-Amaah, 1983).
As a rule, however, forms of infrastructure support remain a weak and unresolved area even in wellthought-through and -supported programmes such as the Indian mitanin programme (SOCHARA, 2005).
But Gilson et al. (1989) make the important point that problems of support and supervision are not
peculiar to CHW programmes but affect all peripheral health services. They are as true for nurses and
other health workers at the primary care level as they are for CHWs. This again raises the need of
discussing the logistics of CHW programmes as part of a broader need for strengthening primary level
services, particularly in remote areas.
Governance, ownership and accountability

At the heart of debates around CHW programmes lie questions about who owns and governs these
programmes and to whom CHWs are accountable. The literature is unanimous in its assertion that CHW
programmes should be owned and driven by communities and that CHWs should be accountable to their
communities. Yet most articles also acknowledge that the reality of programmes often strays quite far
from this ideal. In this section we will discuss three elements central to these debates: the role of
communities and community participation, the relationship between CHW programmes and formal health
services, and the question of whether CHWs should be paid or should render services on a voluntary basis.
Community participation
One would be hard-pressed to find an article that does not emphasize the importance of community
participation for the success of CHW programmes. However, there is much less clarity about the exact
meaning and purpose of community participation. It carries with it a number of different underlying
philosophies and political agendas. Muller, in the early 1980s, distinguished between community
participation as the mobilization of community resources (people, money, materials) to carry out health
programmes versus community participation as increasing peoples control over the social, political,
economic and environmental factors determining their health (Muller, 1983), a distinction reflecting the
Alma Ata discourse. Todays debates are unlikely to make use of this discourse, although the tension it
reflects undoubtedly still exists.
And while todays discourse tends to be much more pragmatic and technical, it is nevertheless widely
acknowledged that a considerable gulf exists between the ideal of programmes driven and owned by
communities and programme realities. It is further agreed that while there are few success stories of
lasting community participation, the sustainability and impact of programmes require the ownership and
active participation of communities as a non-negotiable pre-condition (Mathews, van der Walt & Barron,
1994; Quillian, 1993; Bhattacharyya et al., 2001; Gilson et al., 1989).
This appears to be easier to achieve in small-scale programmes initiated within and by communities, often
with assistance from an NGO or a church group. Examples of these can be found right through the history
of CHW programmes, such as in the Philippines in the 1970s (Barcelon & Hardon, 1990), in India in the
1970s and 1980s (Kaithathara, 1990), in Kenya in the 1980s and 1990s (AKHS, not dated) or in Belize
since the mid-1990s (Council, 2004). There is also experience that active participation of communities in
health and social action, including CHW programmes, is more likely to occur and be sustained in
conditions of popular mobilization, such as in the aftermath of a liberation struggle or after the
replacement of military or repressive regimes by popular governments (Cufino Svitone, 2000; Sanders,
1992; Garfield, 1993).
In most of these, cases substantial and time-consuming investments were made in: (1) securing
participation of communities and (2) involving them in all aspects of the programme, including the
identification of priorities and project planning. In other words, community mobilization precedes and
accompanies the establishment of CHW programmes. An AKHS policy brief summarizes the experiences
with a project in Western Kenya (AKHS, not dated):
One of the most important conditions for sustainability is the capacity of the community members
for organizing themselves. And it is perhaps one of the most important achievements of KPHC
[Kisumu PHC project] that the local people had been mobilized in such a way that they were able
to carry on solving their own problems and securing the health services that they wanted. Right
from the beginning, the project staff encouraged representative groups to identify and prioritize
their needs, to contribute money for the construction and maintenance of water points and other
facilities, and to select their own health workers. It is crucial for the continuation of the projects
work that, in both Kajulu and Nyakach, committees have been formed to coordinate the efforts of
the volunteers, to secure support of the Ministry of Health, donors and NGOs engaged in health
care and health education, to promote the training of CHWs.
National or state-wide programmes are usually initiated from the centre (Brazil, China, Ghana, India,
Indonesia, to name but a few). While in these cases, too, community participation is explicitly part of the
agenda, for a number of reasons it is much more difficult to achieve. Rifkin argues that a key reason is that
community participation has been conceived in a paradigm which views community participation as a
magic bullet to solve problems rooted both in health and political power. For this reason, it is necessary to
use a different paradigm which views community participation as an iterative learning process allowing
for a more eclectic approach to be taken. Viewing community participation in this way will enable more
realistic expectations to be made (Rifkin, 1996). This iterative process is described by AKHS above and
also by Ahluwalia et al., who suggest that community capacity building increases community
participation, which in turn leads to increased support for VHWs (Ahluwalia, 2003).
Evidence also seems to suggest that problems arise when CHWs are expected to take responsibility for
mobilizing communities, rather than working with the support of already active communities.
Mangelsdorf, for example, conducted a quantitative analysis to evaluate the effectiveness of the health
care worker (CHW) training programme used by the Ministry of Public Health in Ecuador (Mangelsdorf,
1988). He found that higher levels of community organization were associated with improved CHW
knowledge. He also assessed the community impact of the programme:
Surprisingly, neither the demographic characteristics of the health worker nor his or her level of
competence affected the impact of the programme on the community, as measured by patient
satisfaction, utilization indices, and adoption of preventive health behaviors. It was the
characteristics of the beneficiaries themselves that accounted for the variance in community
impact.
Similar findings were reported in Nicaragua, where brigadistas were trained as CHWs with the intention
of encouraging local community involvement in health. However, in field research at two sites, these
primary health care brigadistas were found to have rather limited roles and were dependent upon the nurse
auxiliary for direction (Scholl, 1985).
Where community participation is institutionalized, it is usually through village health committees
(VHCs), known often by different names, which are charged with managing and guiding the work of
community health workers. But VHCs also play an ambiguous role within CHW initiatives. The position
of VHCs within village hierarchies is not always clear and is often contested, leading to tensions between
VHC members and other community leaders or becoming the site of political contestation (Sanders, 1992;
Sauerborn, Nougtara & Diesfeld, 1989; Twumasi & Freund, 1985; Streefland, 1990; Ebrahim, 1988).
The character, role and organization of community participation in health care in general and in the
running of CHW programmes in particular form an immensely complex and contested area with a vast
literature of its own. This section barely scratches the surface of this rich debate.
Relationships with the formal health services

The attitudes and interactions of health personnel in the formal health services with CHWs have an
immediate impact on critical aspects of CHW programme management, such as selection, continuing
training and supervision. In many cases these interactions have been affected by how programmes have
been introduced. CHW programmes have commonly been advocated by enthusiasts with local experience,
who persuade policy-makers to scale up initiatives and implement programmes on a large scale (Gilson et
al., 1989). This has frequently resulted in the implementation of inadequately-thought-through schemes
without the full participation of health personnel at the local level. In many programmes, even those
personnel who come into most contact with CHWs, usually nurses, are not involved in the planning,
implementation, monitoring and evaluation of such programmes. It is hardly surprising, therefore, that
they lend little support to these initiatives.
Furthermore, many health personnel lack the background and orientation to provide a supportive
environment for CHW programmes. They are socialized into the hierarchical framework of diseaseoriented medical care systems and have a poorly developed concept of primary health care. Such
paradigms are ill-suited to providing an environment supportive of partnerships and teamwork between
different health workers, particularly if some categories are thought of as less important.
Health professionals often perceive CHWs as lowly aides (WHO, 1989; WHO, 1990; Walt, 1992) who
should be deployed as assistants within health facilities, often completely misunderstanding their health
promoting and enabling role within communities. A sense of superiority of health personnel has been
observed as a problem (Sanders, 1992), together with some suggestions as to how this was addressed in
the training of medical students (Waterston & Sanders, 1987).
The curricula of the medical and other health science teaching institutions often do not equip health
professionals to undertake priority tasks that must be performed to deal with the health problems of
communities (WHO, 1985). A study of Nigerian medical students found that community health was one of
the subjects that students disliked most. Some expressed doubts as to its relevance in their training to
become physicians (Otti, 1989). Attitudes to CHWs inevitably suffer as a result.
Although improving attitudes involves a complex process of educational and institutional reform, giving
medical and health science students specific experience of working collaboratively can assist in
developing positive attitudes towards CHWs. At the Jimma School of Health Sciences, in Ethiopia, for
example, doctors, nurses and other health workers were trained as teams in a community-oriented training
programme. During the training period, teams lived in villages where they assessed various health and
social problems through action-oriented research. Ultimately staff trained in this way developed a new
culture of working. As a bonus, even while they were learning, their assistance was supportive to the
CHW programme (WHO, 1990). Similar experiences have been reported from Zimbabwe (Waterston &
Sanders, 1987). Unfortunately we were not able to find longitudinal impact studies of these initiatives.
Incentives
A range of questions falls under the topic of incentives:
Should CHWs be paid or should they be volunteers?
If they are not paid, what other forms of incentives should or could be employed?
If they are paid, should payment be in cash or in kind?
Should payment come from individual users, communities, NGOs or the state?
Many of these link directly to broader governance issues and have been discussed above. Here we will
briefly discuss the question of whether CHWs should be paid or not, but then focus on the question of
what incentives are known in the literature to work or not work. We will draw primarily on the review
conducted by Bhattacharyya et al. (2001) on this topic.
Volunteers versus paid workers

Whether CHWs ought to be volunteers supported in kind by the community, or paid through community
or government funds, has been much debated. Much of the literature tends to imply that volunteers are the
ideal to which most CHW schemes aspire, and assumes that there is a sufficient pool of willingness to
conduct voluntary social service in rural areas and informal settlements (Mander, not dated; Walt, 1988).
However, the reality is different, probably in acknowledgement of the fact that as a rule CHWs are poor
people, living in poor communities, who require income.
Evidence shows that most programmes pay their CHWs either a salary or an honorarium and almost no
examples exist of sustained community financing of CHWs. Even NGOs tend to find ways of financially
rewarding their CHWs. Moreover, while there are programmes in Zambia in which CHWs work on a
completely voluntary basis, attrition rates are high and the few enthusiastic and reliable volunteers become
overloaded with tasks from other agencies and sectors. A WHO draft document concludes that there is
little evidence that the mobilization of volunteers in CHW programmes is an effective policy (WHO,
1987).
Incentives and disincentives

Bhattacharyya et al. ask in their 2001 study how and which incentives and disincentives affect CHW
motivation, retention and programme sustainability. They conclude that:
there is no tidy package of three incentives that will ensure motivated CHWs who will continue to
work for years. Rather, a complex set of factors affects CHW motivation and attrition, and how
these factors play out varies considerably from place to place. However, programme planners can
draw on the extensive experience of the public health community with CHW programmes.
A tabular listing of what they found to work and not work provides a useful overview:
CHW Incentives and disincentives organized by a systems approach

Incentives
Disincentives
Monetary factors that motivate

individual CHWs
Satisfactory remuneration/ Material

Incentives/financial incentives
Inconsistent remuneration
CHW Incentives and Disincentives

Organized by a Systems Approach
Possibility of future paid

employment
Inequitable distribution of incentives

among different types of community
workers
Nonmonetary factors that motivate

individual CHWs
Community recognition and respect

of CHW work
Person not from community
Acquisition of valued skills
Inadequate supervision
Personal growth and development
Excessive demands/time
Change in tangible incentives
Inadequate refresher training
CHW Incentives and disincentives organized by a systems approach

Incentives
Accomplishment
Peer support
CHW association
Disincentives
constraints
Lack of respect from health facility
staff
Identification (badge, shirt) and job

aids
Status within community
Preferential treatment
Flexible and minimal hours
Clear role
Community-level factors that
motivate individual CHWs
Community involvement in CHW

selection
Community organizations that
support CHW work
Inappropriate selection of CHWs

Lack of community involvement in
CHW selection, training and
support
Community involvement in CHW

training
Community information systems
Factors that motivate communities
to support and sustain CHWs
Witnessing visible changes

Contribution to community
empowerment
CHW associations
Successful referrals to health
facilities
Factors that motivate MoH staff to

support and sustain CHWs
Policies/legislation that support

CHWs
Unclear role and expectations

(preventive versus curative care)
Inappropriate CHW behaviour
Needs of the community not taken
into account
Inadequate staff and supplies
Witnessing visible changes

Funding for supervisory activities
from government and/or community
Source: Bhattacharyya et al. (2001).
They further conclude:

Monetary incentives can increase retention. CHWs are poor people trying to support their families.
But monetary incentives often bring a host of problems because the money may not be enough,
may not be paid regularly, or may stop altogether. Monetary incentives may also cause problems
among different cadres of development workers who are paid and not paid. However, there are
some success stories of programmes paying CHWs. Many programmes have used in-kind
incentives effectively.
Non-monetary incentives are critical to the success of any CHW programme. CHWs need to feel
that they are a part of the health system through supportive supervision and appropriate training.
Relatively small things, such as an identification badge, can provide a sense of pride in their work
and increased status in their communities. Appropriate job aides such as counseling cards and
regular replenishment of supplies can help ensure that CHWs feel competent to do their jobs.
Peer support can come in many forms, such as working regularly with one or two other CHWs,
frequent refresher training, or even CHW associations.
In the end, the effectiveness of a CHW comes down to his or her relationship with the
community. Programmes must do everything they can to strengthen and support this relationship.
First, programme planners must recognize the social complexity of communities and that
communities are not all alike. Different communities will need different types of incentives,
depending on the other job opportunities available, prior experience with CHWs, the economic
situation of the community, and other factors.
Unfortunately, very little experience or guidance is available on how best to differentiate
communities. It is important to involve communities in all aspects of the CHW programme but
especially in establishing criteria for CHWs and making the final selection. Programmes can
provide opportunities for quick visible results that will promote community recognition of CHWs
work. CHWs must be trained in appropriate and respectful interactions with all community
members and in how to respond to difficult people or situations. Community-based organizations,
such as religious groups or youth clubs, can provide support to CHWs and significantly lessen
their load by taking on health education activities.
Many successful programmes use multiple incentives over time to keep CHWs motivated. A
systematic effort that plans for multiple incentives over time can build up a CHWs continuing
sense of satisfaction and fulfillment.
Summary of lessons learnt

The question this review aims to answer is: CHWs what do we know about them? Given the
extensiveness of the topic and the diversity of the literature informing the review, there are few neat and
easy answers. Nevertheless, there is consensus in the literature on a number of issues.
First, CHWs can make a valuable contribution to community development and, more specifically, can
improve access to and coverage of communities with basic health services. There is robust evidence that
CHWs can undertake actions that lead to improved health outcomes, especially, but not exclusively, in the
field of child health. However, although they can implement effective interventions, they do not
consistently provide services likely to have substantial health impact and the quality of services they
provide is sometimes poor.
Second, for CHWs to be able to make an effective contribution, they need to be carefully selected,
appropriately trained and very important adequately and continuously supported. Large-scale CHW
systems require substantial increases in support for training, management, supervision and logistics.
Third, CHW programmes are therefore neither the panacea for weak health systems nor a cheap option to
provide access to health care for underserved populations. Numerous programmes have failed in the past
because of unrealistic expectations, poor planning and an underestimation of the effort and input required
to make them work. This has unnecessarily undermined and damaged the credibility of the CHW concept.
Fourth, by their very nature, CHW programmes are vulnerable, unless they are driven, owned by and
firmly embedded in communities themselves. Where this is not the case, they exist on the geographical
and organizational periphery of the formal health system, exposed to the vagaries of policy swings without
the wherewithal to lobby for and advocate their cause, and thus are often fragile and unsustainable.
However, the concept of community ownership and participation is often ill-conceived and poorly
understood as a by-product of programmes initiated from the centre. Evidence suggests that CHW
programmes thrive in mobilized communities but struggle where they are given the responsibility of
galvanizing and mobilizing communities. Examples of successful programmes can thus be found in the
wake of community mobilization efforts, either as part of large-scale political transformation, such as in
Brazil or China; or through local mobilization, often facilitated by nongovernmental, community-based or
faith-based organizations. In many cases programmes last through the lifespan of the mobilization effort
and wither or collapse entirely as the momentum of mobilization is lost.
The rhythms and dynamics of community participation lie outside the scope of this review, yet are crucial
to better understanding and discussing the future of CHW programmes. A key challenge lies in
institutionalizing and mainstreaming community participation. To date, the largest and most successful
programme in this regard is the Brazilian Family Health Programme, which has integrated CHWs into its
health services and institutionalized community health committees as part of municipal health services to
sustain social participation. This means that community participation does not become an alternative but
an integral part of the states responsibility for health care delivery.
Fifth, the question of whether CHWs should be volunteers or paid in some form remains controversial.
There exists virtually no evidence that volunteerism can be sustained for long periods: as a rule
community health workers are poor; they expect and require an income. Although in many programmes
they are expected to spend only a small amount of time on their health-related duties, leaving time for
other breadwinning activities, community demand often requires full-time performance. The reality is that
CHWs as a rule and by their very nature provide services in environments where formal health services
are inaccessible and people are poor. This also complicates the issue of community financing, which is
rarely successful unless institutionalized, as in China. Most of the evidence reflects failures of community
financing schemes, leading to high drop-out rates and the ultimate collapse of programmes.
Given present pressures on health systems and their proven inability to respond adequately, the existing
evidence overwhelmingly suggests that particularly in poor countries CHW programmes are not cheap or
easy but are nonetheless a good investment, since the alternative in reality is no care for the poor living in
geographically peripheral areas. While there is a lot to learn, there is a lot we do know about making
programmes work better: appropriate selection, continuing education, involvement and reorientation of
health service staff and curricula and improvement in supervision and support are non-negotiable
requirements. These need political leadership and substantial and consistent financial, technical and
material support. We need to learn from examples of large-scale successful programmes in this regard,
particularly providing longitudinal evidence of what works and what does not work. This presently
constitutes the biggest knowledge gap.
CHW programmes have been revered as a panacea and decried as a delusion in the past. A sober view
reveals today, as it did in the late 1980s, that with political will, however, governments can adopt more
flexible approaches by planning CHW programmes within the context of overall health sector activities,
rather than as a separate activity. Weaknesses in training, task allocation and supervision need to
addressed immediately. CHWs represent an important health resource whose potential in providing and
extending a reasonable level of health care to underserved populations must be fully tapped (Gilson et al.,
1989).
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Community health workers:

What do we know about them?

Community health workers: what do we know about them? Page iii

Community health workers: what do we know about them? Page iv

Community health workers: what do we know about them? Page v

Community health workers: what do we know about them? Page vi

acute respiratory infection

community health worker

directly observed treatment support

highly active antiretroviral treatment

integrated management of childhood illnesses

local government area

lay health worker

oral rehydration solution

people living with HIV/AIDS

randomized controlled trial

traditional birth attendant

village health committee

village health worker

World Health Organization

Community health workers: what do we know about them? Page vii

lay health workers

lady health workers

volunteer health workers

voluntary health workers

community health workers

community health distributors

community health surveyors

community health assistants

community health promoters

These were later supplemented with the following:

community health agents (agentes de sade)

rural health auxiliaries (used primarily in the 1970s)

traditional birth attendants

The state of the evidence

Community health workers: what do we know about them? Page 2

Defining community health workers

Agente comunitario de salud

Agente comunitrio de sade

Community health workers: what do we know about them? Page 3

Barangay health worker

Basic health worker

Community drug distributor

Community health agent

Community health promoter

Community health representative

Community health volunteer

Community health worker

Community nutrition worker

Community resource person

Female community health volunteer

Female multipurpose health worker

Lady health worker

Maternal and child health worker

Rural health motivator

Shastho karmis (leaders of shastho shebika)

Traditional birth attendant

Village drug-kit manager

Village health helper