By: Dr. Lennie Bazira, Director of Policy, Community Health Impact Coalition and Sheringham Elisha Odhiambo, community health worker and Secretary General of the Community Health Worker Champions Network, Kenya.
Undeniable evidence proves that community health workers (CHWs) are essential to realizing health for all. However, too many CHW programs are held back by poor service design that embeds ineffectiveness and injustice by not recognizing CHWs are professionals.
Linked Causes of Misery
Half of all CHWs in low- and middle-income countries (LMICs), including 86% in Africa, still aren’t paid at all. A third globally face stockouts of essential medicines. This status quo is exploitative and immoral, depending upon the unpaid labor of millions of people, predominantly women of color. But that’s not all, when set up in this way, as a quick, stop-gap source of cheap labor, CHWs are rarely able to match the outcomes of their adequately resourced counterparts. So it’s a dual-sided human rights issue: CHWs are exploited and less effective.
Rigorous research shows that investing in professional CHW (proCHW) programs — where workers are salaried, skilled, supervised, and supplied — could save as many as 6.9 million lives annually, and could reduce child mortality by almost half. That’s why over half a decade ago, WHO Guidelines cemented the principles of the proCHW model as a globally recognised best practice standard. But these Guidelines will only deliver on their potential if they are put into practice — that means winning and delivering national proCHW policies.
What Does it Take to Change National Policy?
Today 43 out of 92 low- and middle-income countries have a policy in place where the role of CHWs is supported with training, accreditation and minimum wages. This is huge progress, with 10 countries creating and implementing policy in just the last year alone. But it isn’t good enough. At Community Health Impact Coalition our goal is to reach 95! So how do we get there?
We know there is no one-size-fits-all solution. Different national contexts, government structures, economic situations, budgetary mechanisms, and histories with CHW programs demand tailored strategies and tactics. There may not be a single formula, but we do know that a strong evidence base, networked collaboration, public awareness, government engagement, and organised CHW Advocates are all crucial ingredients. And major wins in countries like Kenya, Togo, Malawi, Sierra Leone, and Mongolia have all provided valuable insights for those of us on a mission to make such policies the norm, everywhere.
Learning from Progress
In Kenya, the COVID-19 pandemic put the vital work of CHWs in the spotlight and prompted legislation in 2023. Now proCHW best practices are embedded into state policy meaning that over 100,000 CHWs are paid monthly wages, receive health insurance, and are supplied with comprehensive resources and smartphones for digital data collection. But, these radical changes would not have happened without the longstanding advocacy of CHWs, supported by political, implementing, and funding partners.
Since 2017, CHWs in Kenya have been pushing for proCHW policies; lobbying and engaging key politicians; speaking out in the local media; and mobilizing communities to engage in public debate. The bill presented to parliament had been shaped and amended by the ‘Advocates for Community Health Volunteers in Kenya (ACHVO-K)’ group, formed and led by CHWs. So the proposed legislation reflected not just the best practice enshrined in WHO Guidelines, but the lived experience and practical knowledge of CHWs and the communities they serve.
ACHVO-K’s success in securing justice-based healthcare practices was also dependent on the solidarity of a global movement for change. As members of the Coalition, CHW Advocates were able to draw on global resources and evidence (such as the CHW Assessment and Improvement Matrix) for their investment case.
A similar analysis conducted in Sierra Leone in 2018 contributed to the momentum for policy change addressing CHW pay, training, workloads, and the scaling of CHW programs across the country. A network of partners participated in shaping the revised policy, adopted in 2023, which has increased wages for proCHWs, especially for those workers serving communities at the last mile. This has helped with the retention of workers and the consistency and quality of care provided.
Change Happens When Workers Organize
While the Sierra Leone policy still does not wholly embrace WHO’s guidelines – as programs are still reliant on external donors to finance payments – its worker organisation looks set to secure a fully proCHW model. CHWs (equipped and trained through CHW Adovcates training) have established a forum to convene, compare experiences, and work together to address challenges. This organizing has directly led to a new draft government bill assuming responsibility for paying CHWs from the national budget.
In Malawi, progress is also being pushed forward by a CHW Association. Unlike most countries in Africa, Malawi has had proCHWs on the official government payroll for nearly 30 years. The country now has approximately 14,000 salaried CHWs providing diverse services from immunizations to water and sanitation inspections. CHWs have leveraged this recognition to drive deeper government engagement and further improvements to the policy, such as the National Community Health Framework (2023-2030). The strength of this organizing means that CHW Advocates are now able to work with the government to extend payment practices to their Village Health Committee Volunteers (VHC) colleagues — who currently remain unsalaried.
Put simply, organizing allows CHWs to address power asymmetries by pooling resources, sharing skills, cultivating collaboration, and acting together.
Building Momentum
Because healthcare is both technical and political, changing the status quo will take whole systems change, and work from us all. Together we must equip international norm-setters with the evidence they need to create guidelines and influence global financing institutions to increase funding. This creates the enabling environment needed for CHWs, allied organizations and their governments to create and implement proCHW policy.
By working in this way – led by CHWs – we win change and build momentum at the same time. We guarantee that each victory strengthens our global network, deepens our evidence base, and strengthens relationships with changemakers. Combined, this expands our tactics and strategies for next time. This is how we create a rising tide and guarantee quality care for all, including those who provide it.
Always nothing for a CHW in the community without them, there had work pays alot