By: Stephen Hodgins
Community-based primary healthcare (CB-PHC) can mean different things. It can refer to the government’s “last-mile” PHC services, for example vaccinators providing services at an outreach site. It can also refer to what members of a community are doing collectively to improve their lives. Associated with these various types of activity there are various workers, volunteers and other community “actors,” with a wide range of different roles, many of whom can be referred to as “community health workers” (CHWs). Yet, even the term “community health worker” refers to a broad and highly diverse group of community health actors.
Interest, on the part of global agencies and international NGOs, in CHWs has waxed and waned over the decades. But in recent years there has been renewed interest and we have, in important ways, made meaningful progress. One important contributor to progress is learning from the experience of others, so we’re not always re-inventing the wheel. Innovative approaches used in other countries may have relevance for work in our own country. But in trying to draw lessons from elsewhere for application in our own contexts, we can be tripped up by important differences that may not be evident because of ambiguities of the terms we use. The label “community health worker” is used for professionalized, full-time government workers acting as PHC extension service providers; but the term is often also used for community members serving on local health or development committees but only infrequently involved in a service delivery role, on behalf of government PHC.
It is important that we recognize the diversity of roles falling under the broad umbrella term “community health worker.” Colleagues and I recently published an article in PLoS Global Public Health, “Comparing apples with apples: A proposed taxonomy for “Community Health Workers” (Hodgins 2025), which discussed the complexity of these issues and proposed a “taxonomy” to help us think more clearly about the range of roles CHWs play. This scheme builds on the classification system used by the International Labor Organization (ILO 2012).
In this figure, on the far left we have what ILO recognizes as health professionals, engaged in CB-PHC service provision; public health nurses are a good example. They are not normally thought of as CHWs. Next, to the right, we have salaried, formally employed workers who would be categorized by ILO as “associate professionals.” There are many examples of health workers in this category who are considered CHWs, e.g., health extension workers in Ethiopia, health assistants and family welfare assistants in Bangladesh, and health surveillance assistants in Malawi. But there are other workers with similar training, and in similar roles, who are commonly not thought of as CHWs, e.g., enrolled or assistant nurses or midwives engaged in CB-PHC.
The middle category illustrated in the figure includes CHWs who are not formally employed but who are regularly engaged in CB-PHC service delivery, typically 10 hours or more per week. We categorize these CHWs as “regular.” Examples include India’s Accredited Social Health Activists (ASHA) workers and CHWs in South Africa and Sierra Leone. They normally receive some form of remuneration but are not salaried. What’s labeled “intermediate-level” CHWs in the figure above have a similar status to the “regular” CHWs but commonly put in less time in this role; examples include polyvalent CHWs in Rwanda, female community health volunteers (FCHVs) in Nepal, and kaders in Indonesia.
Those involved “occasionally or intermittently,” as this title suggests, may play a service delivery role but not on a regular basis. This category includes many cadres designated as “volunteers” or in francophone countries, “relais.” The column on the far right includes community members not having a significant role in delivery of government PHC services but who do play an important role in community action or governance (e.g., as members of local health or development committees).
The PLoS article ends with a call: “To build on many decades of accumulated program learning, extending back to Alma-Ata in 1978 and earlier, and to draw on and apply lessons from current programs, we encourage the use of a standardized terminology, allowing us to compare apples with apples, and oranges with oranges.” As countries are further expanding their CHW programs, increasing investment and developing new strategies, they look to examples from around the world. Having a clear taxonomy will help governments draw from the right examples and set clear goals about where they want to take their CHW programs along the spectrum of institutionalization, training and support and how these new CHWs will fit into and relate to the health workforce overall.
Stephen Hodgins is a Canadian public health physician whose work has focused on community health systems and maternal-newborn & child health. Most of his career, he has been engaged in program work in South Asia and Sub-Saharan Africa (he has lived in Nepal and Zambia). He has been associated with the journal Global Health: Science and Practice since its inception over 10 years ago, most recently as editor-in-chief. He is based at the School of Public Health at the University of Alberta, where he jointly leads a teaching and research program on global health.
References
– Hodgins S, Lehmann U, Perry H, Leydon N, Scott K, Agarwal S, et al. (2025) Comparing apples with apples: A proposed taxonomy for “Community Health Workers” and other front-line health workers for international comparisons. PLOS Glob Public Health 5(2): e0004156. https://doi.org/10.1371/journal.pgph.0004156
– ILO. International Standard Classification of Occupations: ISCO-08 / International Labour Office. Geneva; 2012.
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