POWERFUL AND PROVEN:
How Community Health Workers Build Health and Equity Worldwide

Community Health Workers: Trusted Intermediaries

CHWs vary widely in age and education level. Although they generally enter the workforce without the formal education that most healthcare workers have, they possess a strong understanding of, and a connection to, the community they serve. 

All CHWs undergo training specific to their roles, and are often required to pass an exam or obtain a certification before working and liaising with the existing health system. The exact training CHWs receive and the role they will serve, however, can vary widely -- both in terms of their personal level of effectiveness in communities and effectiveness as health workers.

We spoke with Dr. Madeleine Ballard, Executive Director of the Community Health Impact Coalition, an organization that seeks to make professional CHWs a norm worldwide. Ballard tells us, “really rigorous research demonstrates that community health workers can provide a range of preventive, curative and promotive services that ultimately reduce morbidity and mortality,”. In addition CHWs “can actually provide a return on investment of up to 10 to one when you take into account effects on employment and health.”

CHWs can help tackle a large-scale problem, like reducing the mortality of children under five throughout Ethiopia, or neonatal and infant mortality in India. CHW programs tend to be most successful when they are used to increase access to existing healthcare services or to address needs that go unmet by those services, such as reducing postpartum depression in Southeastern Louisiana and supporting stroke rehabilitation in Chiang Mai, Thailand.  

Less obvious but just as important, says Esther Goh, an Early Childhood Development Specialist who works with the Bernard Van Leer Foundation, is that “community health workers play a huge role in combating misinformation.” Goh works at BVLF to support the health of caregivers and children, in part through the deployment of CHWs across Asia, Africa, Europe, and South America.

CHWs Provide Unique & Crucial Support to Address Community Needs

The most effective community health worker programs can address systemic needs within a community. Orb Media’s interviews and analysis of studies reveal that CHWs can provide the following:

• Basic physical and mental healthcare support. This includes diagnosing health issues, providing preventive care, and providing treatments or referrals for urgent problems.

  Support for strained healthcare systems. The community’s access to healthcare increases, but at relatively lower costs to the country or region since CHWs require less education and training than nurses and doctors.

• Gateway to healthcare in places with limited access to clinics, hospitals, and other medical facilities. CHWs can provide healthcare to remote or rural communities. In urban areas, they can offer free or cost-effective services to families in need. In both cases, CHWs that are integrated with the formal healthcare system can also help arrange timely treatments and make specialist referrals when needed.

• Improvement of health through education. CHWs can educate those in their community about healthful lifestyle changes or the availability of certain healthcare services. This can lead to behavioral changes by promoting healthcare-seeking behaviors.

• More specific roles in developed countries. CHWs can be trained to carry out tasks that are usually assigned to healthcare workers. For example, they may help provide follow-up care or mental health support through telehealth services or may give on-the-ground support by performing key tasks such as cancer screenings.

• Mental health support. At present, not all CHWs receive mental health training. As cases in South Africa or South Asia demonstrate however, CHWs with even limited training on these issues can generate positive influences on mental health in their communities.

• Building networks of trust. CHWs often act as translators, cultural mediators, and healthcare facilitators. These roles are crucial in shaping positive health outcomes in the communities they are deployed in.

Successful CHW programs need to be fundamentally community-driven -- the local community or government must have some stake in its implementation to ensure long-term success. Once the specificity and scale of the problems are identified, an appropriate training program is set up to educate CHWs about their role (systems for reporting and providing support are also established).

Successful CHWs take anywhere from a few days to a year or two to be trained, depending on their responsibilities. They also require ongoing refresher courses. A functional referral service is vital for CHWs to do their job properly. This means that nurses, doctors, midwives, and other healthcare professionals should be prepared to engage with CHWs and provide support in urgent care scenarios.

CHWs Are Trained to Serve The Communities They Live In

‘They accept me completely because they know me,” says a 47-year-old male CHW in a qualitative study of CHW motivations in Morogoro Region, Tanzania. 

Virtually all CHW programs recruit CHWs based on their presence and personal history within a community, as well as their commitment to living and working in that region. This is a practice that every CHW program will emphasize from the beginnings, and one that the World Health Organization also recommends.

Almost anyone can be a community health worker, from grandmothers to high school dropouts. That being said, specific community needs as well as local conditions will determine the profile of an ideal CHW.

By way of example, Goh explains how “Kraamverzorgsters”, postnatal maternity care workers in the Netherlands, are trained. They must complete “high school, and they have to go through the ... training program; and they do get regular professional development updates.” In contrast, CHWs in Brazil must also complete secondary school, but “they go through a 10-week program, and then they start working,” with heavy oversight from a supervisor. Meanwhile, some areas like remote regions of Africa are home to very few people with a primary school education, which means basic training (as well as the supervisory and support structures) for CHWs have to be more robust.

Dr. Wendy Leonard is the Founder and Executive Director of TIP Global Health (formerly known as The Ihangane Project), based in Rwanda. In yet another iteration of community health work, she explains that CHWs in her organization are elected. “There are four [CHWs] in each village, primarily focusing on child health, maternal health, and infectious diseases.” These four CHWs receive ongoing training once a month as part of a continuous quality improvement initiative.

In some countries, the CHW role is gender-specific. In Pakistan for example, communities also elect CHWs, known as Lady Health Workers, who in addition to being female, must have at least eight years of schooling and undergo 15 months of training in the prevention and treatment of common illnesses. This initiative has proven to be exceptionally successful, not least because the male-dominated traditional healthcare system in Pakistan remains inadequate in providing reproductive health services for women. Ethiopia enjoyed similar success with its Health Extension Program, which trained 34,000 female CHWs and contributed to a remarkable decrease in child mortality.

A Worker’s ‘Community’ Can Mean A Lot of Different Things

Compensating CHWs is Crucial to Successful Programs

All types of CHWs can be beneficial for communities, but the compensation, format, supervision, and training structures for CHWs all appear to significantly impact their effectiveness. The issue of CHW compensation has attracted considerable attention recently, as it seems to be closely related with a program’s success and sustainability.

“What we've seen again and again is that people get excited about this idea of the community health worker. But then they kind of want to do it on the cheap.” Says Dr. Ballard, whose work advocates for recognition and fair compensation for CHWs.

There are many ways to compensate these workers – some may be categorized as government employees who receive a monthly salary, while others receive compensation through pay for performance methods. Other CHWs are considered volunteers – some of whom receive a nominal tax-free stipend. These payment structures are also related to differences in training, roles, access to resources, and in some cases, outcomes.

“We see so many community health worker programs where the health workers are not really supervised. They're not remunerated or not remunerated with a living wage. They never get any feedback on their performance. They're out of stock of essential supplies,” Dr. Ballard says.

“It's kind of like if you ran a factory like that everyone would know and would have an idea what the product might look like. And yet, we're constantly surprised that when we don't support CHWs we don't get the economic and health outcomes that we had hoped for.”

Retention rates can also be a serious issue among volunteer programs. In one study of CHW programs in Bangladesh, researchers found that programs that gave volunteers more responsibility without a simultaneous raise in compensation resulted in worker resentment. 

In a study on Tanzania, CHWs cited that the provision of stipend to attend training eased the burden of volunteer work. “At first my family was saying, ‘You are not going to the farm. The corn will spoil. Instead you are going to the bush for this volunteer work.’” A male 51-year-old CHW was also quoted as saying, “They encouraged me to go on and work hard because I was making some money from seminars but not from the village side … If these seminars were more frequent, it would be better.” This CHW used his stipends from seminars to hire extra farm labor. 

“[CHWs] need to be valued and appreciated within the system,” says Dr. Leonard. “They need to have a certain level of accountability to skill sets. And all of that, I think, comes with really fair and equitable pay.” 

In short, volunteer CHWs can be used as part of a healthcare support system, but they cannot build a sustainable system for long-term returns. 

Long-term Paid Programs Lack Support

Inadequate pay is a problem that many CHW programs acknowledge. Unfortunately, this remains a complex issue that is caused, in part, by continuous changes in funding. In many parts of the world, healthcare systems are built through public, private, and nonprofit partnerships. This makes it difficult to ensure long-term funding priorities like fair compensation for CHWs.

Adoyo, who has been a CHW in Kenya since 2011, works within this model. Adoyo says her work can range between part-time and full-time work, but she is essentially on call 24 hours a day. Yet, she says that her government pay is “2,000 [Kenyan shillings per month], but it’s not even consistent … it may take even three to four months when you are being paid.” Her only regular financial support comes from Lwala Community Alliance, which supplements this salary with a small stipend. Lwala has also been supporting the CHWs affiliated with them by providing PPE, which is crucial for pandemic response. 

As of June 2020, the average full-time worker salary is XYZ. When asked, Adoyo said she would like to be paid “20,000 [Kenyan] shillings” for her work. And she believes her supervisors deserve double that. In Adoyo’s program, if you’re a CHW supervisor, “you have to supervise [the CHWs], you have to do the purchase, you have to do the follow up, you have to do the accompaniment.” 

For some CHWs, the issue of fair pay is complicated by other reasons. In Uganda, for instance, a CHW program that used a pay per performance strategy was initially very well received. This program, which provided CHWs with both health education and entrepreneurial training, had CHWs traveling door-to-door to distribute essential medical supplies and dispense healthcare services.

Researchers wanted to see if CHWs would be increasingly motivated to distribute their goods if they were doing so at a profit. Yet, a recent study of these Ugandan CHWs reported that  financial incentives can backfire on the healthcare system. In this case, the act of selling medical products resulted in social stigma, making CHWs less likely to visit homes compared to their peers who were asked to distribute the same products for free.

Community Health Work Can Be a Career Pipeline 

There are many ways that CHWs are making communities healthier around the world. This map highlights a range of unique and impactful ways that CHWs have supported and improved the health of their communities. This small sampling of programs focuses on either large-scale programs, substantial community benefit, or programs that have the potential to have large-scale impact. 

An important note: CHW programs are often funded by multiple institutions. Here, Orb Media has highlighted work funded by a diverse range of funding bodies. While many of the programs highlighted may have received later-stage funding from an international or non-community source, used to research or scale-up existing models elsewhere, we have made our best effort to highlight programs that are driven by the community, for the community.

Why haven’t we featured more CHW programs in Europe and North America, Australia and New Zealand? 

Community health workers have been around since the 1970s, yet studies that demonstrate their benefits and implementation in countries like the USA, Canada, New Zealand, and Australia have not been widely documented as compared with the rest of the world. CHW-related studies that are published in relation to the Global North generally focus on healthcare for minority populations or minority, low-income populations, or an even smaller subgroup, like pregnant women within these populations.

While CHWs in these countries are doing meaningful work, there is concern that health systems will not formally recognize them or the value of their roles. This issue is exacerbated as CHWs are rarely integrated into the greater healthcare system, limiting their effectiveness.

Experimental models indicate that CHW training can provide long-term career opportunities -- and motivation. 

Adoyo, who has been a CHW since 2011, is hoping to move into a supervisory role in the near future. “I know how to engage other community health workers,” she says. “So many people have developed trust in me. I am very proud to say that one can come from a different village to come to me to inquire about something or to confide in me, telling me something very confidential that he or she is not able to tell [the CHW] working in her or his village.”

Other CHW programs, like the Government of Zambia’s, offer CHWs the potential to eventually take on other roles within the formal health system by moving into nursing or another healthcare specialty. However, as of the moment, Orb Media identified only one program, in Ethiopia, that actively allows CHWs to move into nursing roles through non-traditional means. This career trajectory is competitive and requires CHWs to gain experience and obtain additional education, but is a valuable and novel way to incorporate CHWs into the healthcare worker pipeline.

One reason for this, Goh says, is that most CHW supervisory programs require applicants to have completed high school (grade 12). But most CHWs haven’t obtained this level of education, and aren’t able to later on unless their program provides them with this support. This ultimately means that these CHWs are blocked from advancing in these careers. “Not that many actually go through the pathway. This is actually one of the issues across most of the countries we work in.” 

While thousands of people of all manner of backgrounds around the world have become CHWs, few programs facilitate a leap to more advanced career options. Orb Media has identified this lack of available data or global discussion as an opportunity for future journalistic investigation and research by partner organizations in their own communities.

Future Frontiers for CHWs

According to Goh and Dr. Ballard, the 2020 pandemic may make CHWs more important than ever. “In a lot of [prior] pandemics, more people died because of the decline of essential health services than the pandemic itself,” said Dr. Ballard. 

“Hospitals are overburdened in a lot of places ... and the guidance has been [to implement] strategies to keep people from going to the health service ... both to try to not overburden the health system, but also to try to reduce transmission. And so, they're trying to push services out to the community.”

Many parts of the world do not have adequate infrastructure to support such strategies. Even in places where hospitals, clinics, and other healthcare services are still accessible, people tend to wait longer to use these services, regardless of how minor or urgent their needs are. 

But as hospitals become overwhelmed, Goh says, “there is even more of a role for the healthcare worker to say: ‘Here's what you can do. This is a place that you can go that is safe. And here's how you can get there without further endangering yourself or your child or your family.’ ”

In the long run, CHWs remain an undervalued and easily deployable community-driven intervention.

Even in countries with robust healthcare systems, they can help widen reach and coverage so that access to healthcare extends to a wider range of people in society, regardless of variations in cultural, religious, racial, or economic demographic.