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Cited by 129Global Health Workforce IssuesHealthcare Systems and PracticesGlobal Maternal and Child Health

Community health workers at the dawn of a new era: 11. CHWs leading the way to “Health for All”

Open access
Perry, Henry B., Chowdhury, Mushtaque, Were, Miriam, LeBan, Karen, Crigler, Lauren, Lewin, Simon, Musoke, David, Kok, Maryse +3 more·2021·Health Research Policy and Systems
DOI 10.1186/s12961-021-00755-5PMC PMC8506098
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Abstract

Background: This is the concluding paper of our 11-paper supplement, “Community health workers at the dawn of a new era”. Methods: We relied on our collective experience, an extensive body of literature about community health workers (CHWs), and the other papers in this supplement to identify the most pressing challenges facing CHW programmes and approaches for strengthening CHW programmes. Results: CHWs are increasingly being recognized as a critical resource for achieving national and global health goals. These goals include achieving the health-related Sustainable Development Goals of Universal Health Coverage, ending preventable child and maternal deaths, and making a major contribution to the control of HIV, tuberculosis, malaria, and noncommunicable diseases. CHWs can also play a critical role in responding to current and future pandemics. For these reasons, we argue that CHWs are now at the dawn of a new era. While CHW programmes have long been an underfunded afterthought, they are now front and centre as the emerging foundation of health systems. Despite this increased attention, CHW programmes continue to face the same pressing challenges: inadequate financing, lack of supplies and commodities, low compensation of CHWs, and inadequate supervision. We outline approaches for strengthening CHW programmes, arguing that their enormous potential will only be realized when investment and health system support matches rhetoric. Rigorous monitoring, evaluation, and implementation research are also needed to enable CHW programmes to continuously improve their quality and effectiveness. Conclusion: A marked increase in sustainable funding for CHW programmes is needed, and this will require increased domestic political support for prioritizing CHW programmes as economies grow and additional health-related funding becomes available. The paradigm shift called for here will be an important step in accelerating progress in achieving current global health goals and in reaching the goal of Health for All.

AI snapshot

Written from the paper’s full text.

TL;DR

This concluding paper of an 11-paper supplement argues that CHWs are at the dawn of a new era as a foundation of health systems, but national CHW programmes remain constrained by inadequate financing, supplies, compensation, and supervision. It calls for sustainable domestic and donor investment, stronger political support, and rigorous monitoring, evaluation, and implementation research to achieve UHC and Health for All.

Key findings

  • In 29 national CHW programme case studies, the most frequently cited challenges were lack of supplies and commodities (20 programmes), inadequate/unstable/unsustainable financing (20), low compensation of CHWs (17), and inadequate supervision (15).
  • Only 2.5% of global public health donor assistance over the past decade was devoted specifically to CHW programmes, and two thirds of this was for vertical programmes related to HIV/AIDS, malaria, tuberculosis, reproductive health, or family planning.
  • Modelling cited in the paper estimates that raising population coverage of evidence-based maternal-child interventions deliverable by CHWs to 90% in the 74 countries with 97% of child and maternal mortality could avert an additional 2.6 million maternal and child deaths each year.
  • CHWs are increasingly recognized as critical for UHC, ending preventable child and maternal deaths, controlling HIV, tuberculosis, malaria, and noncommunicable diseases, and responding to pandemics; Brazil’s programme is cited as assigning 150–200 households per CHW for a comprehensive life-course approach.

Methods

  • This is the concluding paper of the 11-paper supplement “Community health workers at the dawn of a new era”; the authors relied on their collective experience, an extensive body of CHW literature, and the other papers in the supplement to identify pressing challenges and strengthening approaches.
  • The paper draws on the 2014 CHW Reference Guide, WHO guidelines on CHW programmes, and a compendium of 29 national CHW programme case studies; Table 2 summarizes challenges cited by the case study authors.
  • It is a narrative synthesis/commentary rather than a new empirical study; no primary data collection or systematic review methods are described.

Limitations

  • Stated: the suggestions are “not intended to be definitive,” and the authors welcome further ideas and discussion; Table 2 is not an all-encompassing list, only the most pressing challenges identified by the case study authors.
  • Stated: the evidence base lacks rigorous research on CHW programme effectiveness at scale under routine conditions; large-scale randomized controlled trials cannot provide the needed evidence, and more implementation research is required.
  • Evident: as a concluding commentary/synthesis, the paper presents no original empirical data or formal systematic search methods, so its conclusions rely on cited literature and expert judgment.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s12961-021-00755-5

Cites

93 of 93 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 77 cited sources checked · 0 supported · 0 flagged

  • Findingcitation

    Inadequate supervision was cited as a challenge for 15 of the 29 national CHW programmes in the case-study compendium.

    “Inadequate supervision | 15 | Brazil (ASC-agent); Ethiopia (HEW, WDA); India (ANM, AWW, SAHA, VHG); Mozambique (APE); Niger (ASC, RV); Rwanda (Binome; ASM); South Africa (WBPHCOT); Zambia (CH-assistant, CBV)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] Health for the People: National Community Health Programs from Afghanistan to Zimbabwe. [https://pdf.usaid.gov/pdf_docs/PA00WKKN.pdf. Accessed 11 Apr 2021

      Not checked in the free run.

    • Rests on an assumption: The 29 case studies in the compendium are representative enough of national CHW programmes generally that the challenges they report reflect the challenges facing national CHW programmes broadly.
  • Findingcitation

    Lack of supplies and commodities is among the most pressing challenges facing national CHW programmes.

    “Despite this increased attention, CHW programmes continue to face the same pressing challenges: inadequate financing, lack of supplies and commodities, low compensation of CHWs, and inadequate supervision.”
    • Also stated in: § Current challenges facing national CHW programmes · plain
      “the most commonly cited challenges were (1) inadequate programme financing, (2) interruptions in the supply chain for basic supplies, commodities, and medicines, (3) inadequate remuneration of CHWs, and (4) inadequate or poor-quality supervision.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] Health for the People: National Community Health Programs from Afghanistan to Zimbabwe. [https://pdf.usaid.gov/pdf_docs/PA00WKKN.pdf. Accessed 11 Apr 2021

      Not checked in the free run.

    • Rests on an assumption: The 29 case studies in the compendium are representative enough of national CHW programmes generally that the challenges they report reflect the challenges facing national CHW programmes broadly.
    • Rests on an assumption: The authors of the case studies correctly identified the most pressing challenges for their programmes.
  • Findingcitation

    Inadequate financing is among the most pressing challenges facing national CHW programmes.

    “Despite this increased attention, CHW programmes continue to face the same pressing challenges: inadequate financing, lack of supplies and commodities, low compensation of CHWs, and inadequate supervision.”
    • Also stated in: § Current challenges facing national CHW programmes · plain
      “the most commonly cited challenges were (1) inadequate programme financing, (2) interruptions in the supply chain for basic supplies, commodities, and medicines, (3) inadequate remuneration of CHWs, and (4) inadequate or poor-quality supervision.”
    • Also stated in: § Current challenges facing national CHW programmes · plain
      “The four most frequently seen challenges concern the supply chain for key programme commodities used by CHWs, programme financing, CHW compensation, and supervision.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] Health for the People: National Community Health Programs from Afghanistan to Zimbabwe. [https://pdf.usaid.gov/pdf_docs/PA00WKKN.pdf. Accessed 11 Apr 2021

      Not checked in the free run.

    • Rests on an assumption: The 29 case studies in the compendium are representative enough of national CHW programmes generally that the challenges they report reflect the challenges facing national CHW programmes broadly.
    • Rests on an assumption: The authors of the case studies correctly identified the most pressing challenges for their programmes.
  • Findingcitation

    Inadequate or poor-quality supervision is among the most pressing challenges facing national CHW programmes.

    “Despite this increased attention, CHW programmes continue to face the same pressing challenges: inadequate financing, lack of supplies and commodities, low compensation of CHWs, and inadequate supervision.”
    • Also stated in: § Current challenges facing national CHW programmes · plain
      “the most commonly cited challenges were (1) inadequate programme financing, (2) interruptions in the supply chain for basic supplies, commodities, and medicines, (3) inadequate remuneration of CHWs, and (4) inadequate or poor-quality supervision.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] Health for the People: National Community Health Programs from Afghanistan to Zimbabwe. [https://pdf.usaid.gov/pdf_docs/PA00WKKN.pdf. Accessed 11 Apr 2021

      Not checked in the free run.

    • Rests on an assumption: The 29 case studies in the compendium are representative enough of national CHW programmes generally that the challenges they report reflect the challenges facing national CHW programmes broadly.
    • Rests on an assumption: The authors of the case studies correctly identified the most pressing challenges for their programmes.
  • Findingcitation

    Lack of supplies and commodities was cited as a challenge for 20 of the 29 national CHW programmes in the case-study compendium.

    “Lack of supplies and commodities | 20 | Ethiopia (HEW, WDA); India (ANM, AWW, ASHA, VHG); Kenya (CHW); Liberia (CHA, CHSS); Malawi (CHW); Mozambique (APE); Niger (ASC, RV); Rwanda (Binome, ASM); Sierra Leone (CHW); South Africa (WBPHCOT); Zambia (CHA, CBV); Zimbabwe (VHW)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] Health for the People: National Community Health Programs from Afghanistan to Zimbabwe. [https://pdf.usaid.gov/pdf_docs/PA00WKKN.pdf. Accessed 11 Apr 2021

      Not checked in the free run.

    • Rests on an assumption: The 29 case studies in the compendium are representative enough of national CHW programmes generally that the challenges they report reflect the challenges facing national CHW programmes broadly.
  • May combine two claims. 21
  • Classified as probably not a substantial claim. 32

  • May combine two claims.

    Interpretationreasoning

    Developing, expanding, and strengthening national CHW programmes are promising approaches to accelerating progress toward Universal Health Coverage, ending preventable child and maternal deaths, and achieving Health for All.

    “Developing, expanding, and strengthening national CHW programmes represent promising approaches to accelerating progress in achieving the global health goals of Universal Health Coverage, ending preventable child and maternal deaths, and achieving “Health for All”.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Similar proposals for CHW cadres are emerging in the United States.

    “Similar proposals are emerging in the United States [29, 30].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [29] Waters R. Community Workers Lend Human Connection To COVID-19 Response. Health Aff (Millwood). 2020;39:1112–7. source

      Not checked in the free run.

    • cites [30] Goldfield NI, Crittenden R, Fox D, McDonough J, Nichols L, Lee Rosenthal E. COVID-19 crisis creates opportunities for community-centered population health: community health workers at the center. J Ambul Care Manage. 2020;43:184–90. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given

    There is growing recognition of the need for fair remuneration for full- and part-time CHWs.

    “There is growing recognition of the need for fair remuneration for full- and part-time CHWs.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    CHWs need to be understood as the foundation of primary healthcare and as an increasingly important component of health systems in settings where delivery or equity gaps are present.

    “CHWs need to be understood as the foundation of PHC as well as an increasingly important component of health systems in settings where delivery or equity gaps are present.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    Particularly in resource-constrained, high-mortality settings, there can be no primary healthcare without CHWs.

    “Similarly, it is fair to say, particularly in resource-constrained, high-mortality settings, there can be no PHC without CHWs.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationreasoning

    CHW programmes, long an underfunded afterthought, are now front and centre as the emerging foundation of health systems.

    “While CHW programmes have long been an underfunded afterthought, they are now front and centre as the emerging foundation of health systems.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The COVID-19 pandemic has led to a call for the creation of a CHW cadre in the United Kingdom that would continue, for the foreseeable future, to link all households with a CHW who can assist in addressing health needs in the household.

    “For example, the pandemic has led to a call for the creation of a CHW cadre in the United Kingdom that would continue, for the foreseeable future, to link all households with a CHW who can assist in addressing health needs in the household [28].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [28] Haines A, de Barros EF, Berlin A, Heymann DL, Harris MJ. National UK programme of community health workers for COVID-19 response. Lancet. 2020;395:1173–5. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Countries that have been making the strongest gains in population health outcomes have strong CHW programmes; Bangladesh, Brazil, Ethiopia, Nepal, and Rwanda are prominent examples.

    “Countries that have been making the strongest gains in population health outcomes have strong CHW programmes; Bangladesh, Brazil, Ethiopia, Nepal, and Rwanda are prominent examples [25].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [25] Community Health Workers. https://www.exemplars.health/topics/community-health-workers. Accessed 11 Apr 2021

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    CHWs can play a critical role in responding to current and future pandemics.

    “CHWs can also play a critical role in responding to current and future pandemics.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    As a result of Tedros Adhanom's transformation of Ethiopia's health system toward community-based primary healthcare, Ethiopia became a global leader in attaining the Millennium Development Goals for maternal and child health, HIV/AIDS, malaria, and tuberculosis, and in accelerating progress toward UHC.

    “As a result, Ethiopia became a global leader in attaining the Millennium Development Goals for maternal and child health, HIV/AIDS, malaria, and tuberculosis [16, 17] and in accelerating progress in achieving UHC [17].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [16] Assefa Y, Tesfaye D, Damme WV, Hill PS. Effectiveness and sustainability of a diagonal investment approach to strengthen the primary health-care system in Ethiopia. Lancet. 2018;392:1473–81. source

      Not checked in the free run.

    • cites [17] Assefa Y, Gelaw YA, Hill PS, Taye BW, Van Damme W. Community health extension program of Ethiopia, 2003–2018: successes and challenges toward universal coverage for primary healthcare services. Global Health. 2019;15:24. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The COVID-19 pandemic has led to calls throughout the world for CHWs to receive the proper respect and status they deserve, as well as the personal protective equipment they need to safely carry out their duties.

    “The result is that the pandemic has led to calls throughout the world for CHWs to receive the proper respect and status that they deserve, not to mention the personal protective equipment they need to safely carry out their duties [27].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] Community health workers are crucial to pandemic response. How to support them. https://theconversation.com/community-health-workers-are-crucial-to-pandemic-response-how-to-support-them-134908. Accessed 11 Apr 2021

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    There is a steady but persistently increasing professionalization of CHW roles.

    “There is a steady but persistently increasing professionalization of CHW roles.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    The lack of national political support and sustainable funding (from both domestic and donor sources) for national CHW programmes is perhaps the most critical challenge facing these programmes.

    “The lack of national political support and sustainable funding (from both domestic and donor sources) for national CHW programmes is perhaps the most critical challenge facing these programmes.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The 29 case studies in the compendium are representative enough of national CHW programmes generally that the challenges they report reflect the challenges facing national CHW programmes broadly.
    • Rests on an assumption: The authors of the case studies correctly identified the most pressing challenges for their programmes.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationnone given

    The effectiveness of the whole CHW programme depends on how well each component of the system is functioning, and addressing one component without consideration of the others is not likely to improve programme effectiveness.

    “A comprehensive approach is needed since the effectiveness of the whole programme is dependent on how well each component of the system is functioning; addressing one component without consideration of the other components is not likely to improve programme effectiveness.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    The enormous potential of CHW programmes will only be realized when investment and health system support matches rhetoric.

    “We outline approaches for strengthening CHW programmes, arguing that their enormous potential will only be realized when investment and health system support matches rhetoric.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    A role remains for voluntary CHWs, who can make important contributions as long as they are not expected to work more than a few hours per week or perform the role of regular full- or part-time workers.

    “A role also remains for voluntary CHWs, who can make important contributions as long as they are not be expected to work more than a few hours per week or perform the role of regular full- or part-time workers.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The world is in the midst of a process some call the third global health transition or a grand convergence, emerging from a demographic transition into an epidemiologic transition from a high burden of maternal and child conditions and communicable diseases to noncommunicable diseases.

    “On a broader scale, we are in the midst of a process some are calling “the third global health transition” [31] or “a grand convergence” [32]—emerging from a demographic transition (from higher to lower death and birth rates) into an epidemiologic transition (from a high burden of maternal and child conditions and communicable diseases to noncommunicable diseases [NCDs]).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [31] Rodin J, de Ferranti D. Universal health coverage: the third global health transition? Lancet. 2012;380:861–2. source

      Not checked in the free run.

    • cites [32] Jamison DT, Summers LH, Alleyne G, Arrow KJ, Berkley S, Binagwaho A, Bustreo F, Evans D, Feachem RG, Frenk J, et al. Global health 2035: a world converging within a generation. Lancet. 2013;382:1898–955. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    CHWs are now at the dawn of a new era.

    “For these reasons, we argue that CHWs are now at the dawn of a new era.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    An emerging dual cadre of CHWs exists in which professionalized CHWs supervise lower tiers of CHWs, who are often volunteers responsible for a small number of households.

    “There is also an emerging dual cadre of CHWs in which professionalized CHWs are supervising lower tiers of CHWs, who are often volunteers responsible for a small number of households.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    CHWs are increasingly being recognized as a critical resource for achieving national and global health goals, including the health-related SDGs of Universal Health Coverage, ending preventable child and maternal deaths, and control of HIV, tuberculosis, malaria, and noncommunicable diseases.

    “CHWs are increasingly being recognized as a critical resource for achieving national and global health goals.”
    • Also stated in: § Results · plain
      “These goals include achieving the health-related Sustainable Development Goals of Universal Health Coverage, ending preventable child and maternal deaths, and making a major contribution to the control of HIV, tuberculosis, malaria, and noncommunicable diseases.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    BRAC's CHW health programmes in Bangladesh reach over 100 million people and another 20 million people in other countries.

    “BRAC’s2 CHW health programmes in Bangladesh reach over 100 million people and another 20 million people in other countries [88].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [88] Chowdhury A, Perry H. NGO Contributions to Community Health and Primary Health Care: Case Studies on BRAC (Bangladesh) and the Comprehensive Rural Health Project, Jamkhed (India). In Oxford Research Encyclopedia, Global Public Health. New York: Oxford University Press USA; 2020.

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    An expansion of the six WHO building blocks has been proposed that highlights community-based service delivery as well as community mobilizing and organization, with attention to nontraditional health system components.

    “An expansion of the six WHO building blocks has been proposed that highlights community-based service delivery as well as community mobilizing and organization, with attention to nontraditional health system components such as social capital, inter-sectoral partnerships, local governance, equitable financing, community information and data systems, and household production of health [101].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [101] Sacks E, Morrow M, Story WT, Shelley KD, Shanklin D, Rahimtoola M, Rosales A, Ibe O, Sarriot E. Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all. BMJ Glob Health. 2018;3:e001384. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    NGOs sometimes operate their own CHW programmes separate from government CHW programmes, while others assist the government in strengthening government CHW programmes.

    “NGOs sometimes operate their own CHW programmes separate from government CHW programmes, while others are working hard to assist the government in strengthening government CHW programmes [89].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [89] Walker PR, Downey S, Crigler L, LeBan K. CHW “Principles of Practice”: Guiding principles for non-governmental organizations and their partners for coordinated national scale-up of community health worker programs. Washington: CORE Group/World Vision International; 2013. p. 21.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationcitation

    Evidence on CHW programmes needs to come from comprehensive, critical programme case studies and from investigations not only on what works but also on what conditions are required for such programmes to perform well, including health system requirements.

    “Evidence needs to come from comprehensive, critical programme case studies and from investigations not only on what works but also on what conditions are required for such programmes to perform well (including health system requirements) [13].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] Health for the People: National Community Health Programs from Afghanistan to Zimbabwe. [https://pdf.usaid.gov/pdf_docs/PA00WKKN.pdf. Accessed 11 Apr 2021

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    The 2018 WHO guidelines recommend focusing research on CHW selection, education, and certification; management and supervision; and integration into and support by health systems and communities.

    “Follow the recommendations of the 2018 WHO guidelines and focus research on (1) CHW selection, education, and certification, (2) management and supervision, and (3) integration into and support by health systems and communities [12].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] WHO guideline on health policy and system support to optimize community health worker programmes. https://apps.who.int/iris/bitstream/handle/10665/275474/9789241550369-eng.pdf?ua=1. Accessed 11 Apr 2021

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Although there is a rich body of literature on CHW programming, there is a striking lack of rigorous research on CHW programme effectiveness that can provide practical guidance on programme implementation.

    “In its guidelines for health policy and system support to optimize CHW programmes, WHO noted that although there is a rich body of literature on CHW programming, there is a striking lack of rigorous research on CHW programme effectiveness that can provide practical guidance on programme implementation [12].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] WHO guideline on health policy and system support to optimize community health worker programmes. https://apps.who.int/iris/bitstream/handle/10665/275474/9789241550369-eng.pdf?ua=1. Accessed 11 Apr 2021

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    Unprecedented new technologies, tools, and programmatic approaches offer the prospect of increasing the effectiveness of CHWs, provided they are given appropriate training and support.

    “There are unprecedented new technologies, tools, and programmatic approaches which offer the prospect of increasing the effectiveness of CHWs, provided they are giving appropriate training and support.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Proposals have been made to establish a permanent CHW cadre in the United Kingdom.

    “As noted above, proposals have also been made to establish a permanent CHW cadre in the United Kingdom [28].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [28] Haines A, de Barros EF, Berlin A, Heymann DL, Harris MJ. National UK programme of community health workers for COVID-19 response. Lancet. 2020;395:1173–5. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Evaluations of CHW programmes that employed integrated community case management (iCCM) for childhood illness in Burkina Faso, Ethiopia, and Malawi showed disappointing results regarding quality of care provided by CHWs, low utilization of their services, low population coverage of CHW services, and absence of demonstrated impact on mortality.

    “Hazel et al. [109] have documented the disappointing results of evaluations of CHW programmes that employed integrated community case management (iCCM) for childhood illness in Burkina Faso, Ethiopia, and Malawi regarding the quality of care provided by CHWs, the low utilization of their services, the low population coverage of CHW services, and the absence of a demonstrated impact on mortality.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [109] Hazel E, Bryce J. IIP-JHU ICCM Evaluation Working Group: On bathwater, babies, and designing programs for impact: evaluations of the integrated community case management strategy in Burkina Faso, Ethiopia, and Malawi. Am J Trop Med Hyg. 2016;94:568–70. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    The global experience and scientific evidence are unequivocal that CHWs are among the most cost-effective and most rapidly implementable approaches to improve the health of underserved populations.

    “The global experience and the scientific evidence are unequivocal: CHWs are among the most cost-effective and the most rapidly implementable approaches to improve the health of underserved populations.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Each case study in the compendium has at least one author with personal in-country experience with the programme described, and each follows a common format to facilitate comparisons across cases.

    “Each case study has at least one author who has personal in-country experience with the programme described, and each follows a common format to facilitate comparisons across cases.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Community case management of childhood illness, using proactive frequent home visitation, has shown promising results for reducing under-five mortality in Mali and improving access to care in Senegal, where CHWs are well supplied with needed medicines.

    “Community case management of childhood illness, using proactive frequent home visitation, has shown promising results as a strategy for reducing under-five mortality in Mali and for improving access to care in Senegal, in which CHWs are well supplied with the medicines they need [43, 44].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [43] Johnson AD, Thiero O, Whidden C, Poudiougou B, Diakite D, Traore F, Samake S, Kone D, Cisse I, Kayentao K. Proactive community case management and child survival in periurban Mali. BMJ Glob Health. 2018;3:e000634. source

      Not checked in the free run.

    • cites [44] Gaye S, Kibler J, Ndiaye JL, Diouf MB, Linn A, Gueye AB, Fall FB, Ndiop M, Diallo I, Cisse M, et al. Proactive community case management in Senegal 2014–2016: a case study in maximizing the impact of community case management of malaria. Malar J. 2020;19:166. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    NGOs have been global leaders in community health research and innovative program development.

    “NGOs have been global leaders in community health research and innovative program development [90].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [90] Ballard M, Schwarz R. Employing practitioner expertise in optimizing community healthcare systems. Healthcare (Amst). 2019;7:100334. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Study design and conductcitation

    The findings summarized in Table 2 provide a realistic, grounded view of the constraints under which national CHW programmes are currently functioning.

    “The findings, summarized in Table 2, provide a realistic, grounded view of the constraints under which such programmes are currently functioning.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] Health for the People: National Community Health Programs from Afghanistan to Zimbabwe. [https://pdf.usaid.gov/pdf_docs/PA00WKKN.pdf. Accessed 11 Apr 2021

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    CHW programmes rely on support from their nearest facilities, and without adequately functioning facilities, patients referred by CHWs will not receive proper care, undermining CHW programme functioning.

    “CHW programmes rely on support from their nearest facilities, and without adequately functioning facilities, patients referred by CHWs will not be able to receive proper care, thereby undermining CHW programme functioning.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    NGOs have been global leaders in pioneering the development and implementation of programmes, in community engagement, and in the research and development components of community-based PHC.

    “NGOs have been global leaders in pioneering the development and implementation of programmes, in community engagement, and in the research and development components of community-based PHC [87, 88].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [87] Perry HB, Rohde J. The Jamkhed comprehensive rural health project and the Alma-Ata vision of primary health care. Am J Public Health. 2019;22:e1–6.

      Not checked in the free run.

    • cites [88] Chowdhury A, Perry H. NGO Contributions to Community Health and Primary Health Care: Case Studies on BRAC (Bangladesh) and the Comprehensive Rural Health Project, Jamkhed (India). In Oxford Research Encyclopedia, Global Public Health. New York: Oxford University Press USA; 2020.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    The potential for CHWs and community engagement to serve as an integral component of PHC exceeds what can be achieved by facility-based care alone, for ending preventable child and maternal deaths and for controlling NCDs.

    “The potential for CHWs and for community engagement, more broadly, to serve as an integral component of PHC exceeds what can be achieved by facility-based care alone. This is true not only for ending preventable child and maternal deaths, but also for better controlling NCDs.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    There are now calls throughout the world for CHWs to be appropriately supported and protected to enable them to play a key frontline role against the pandemic and then, moving forward, a key part of the foundation of health systems.

    “Thus, there are now calls throughout the world for CHWs to be appropriately supported (and protected) to enable them to play a key frontline role against the pandemic and then, moving forward, a key part of the foundation of health systems.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: In many countries, CHWs are the frontline of defence against the COVID-19 pandemic.

  • May combine two claims.

    Premisecitation

    Calls are being made for the establishment of a national CHW cadre in the United Kingdom and for a community health corps in the United States to assist in controlling the COVID-19 pandemic and strengthen the health system.

    “Calls are being made for the establishment of a national CHW cadre in the United Kingdom [28] and for a community health corps in the United States [29, 30] to carry out similar functions—to assist in controlling the COVID-19 pandemic but also to strengthen the health system moving forward and to be able to be better prepared for future pandemics.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [28] Haines A, de Barros EF, Berlin A, Heymann DL, Harris MJ. National UK programme of community health workers for COVID-19 response. Lancet. 2020;395:1173–5. source

      Not checked in the free run.

    • cites [29] Waters R. Community Workers Lend Human Connection To COVID-19 Response. Health Aff (Millwood). 2020;39:1112–7. source

      Not checked in the free run.

    • cites [30] Goldfield NI, Crittenden R, Fox D, McDonough J, Nichols L, Lee Rosenthal E. COVID-19 crisis creates opportunities for community-centered population health: community health workers at the center. J Ambul Care Manage. 2020;43:184–90. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    By enabling national CHW programmes to reach their full potential, they in turn can lead the way toward accelerating progress in reducing inequities in health and achieving health for all.

    “By enabling national CHW programmes to reach their full potential, they in turn can lead the way toward accelerating progress in reducing inequities in health and achieving health for all.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: In many countries, CHWs are the frontline of defence against the COVID-19 pandemic.

  • Classified as probably not a substantial claim.

    Premisecitation

    With the availability of local data, local forums for sharing data, and local multi-sectoral stakeholder engagement, technical solutions will work better and deliver more.

    “With the availability of local data, local forums for sharing data, and local multi-sectoral stakeholder engagement, [such technical] solutions will work better and deliver more” [119].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [119] Sherry M, Ghaffar A, Bishai D. Community platforms for health inferventions. In: Jamison D, Gelband H, Horton S, Jha P, Laxminarayan R, Mock C, Nugent R, editors. Disease control priorities: improving health and reducing poverty. Washington: The World Bank; 2018. p. 267–83.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    A strong commitment by governments to community health initiatives, including CHW programming, will encourage donors and technical support organizations to follow suit.

    “A strong commitment by governments to community health initiatives, including CHW programming, will give a major boot at this critical moment will encourage donors and technical support organizations to follow suit.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    Without initiatives to help community health platforms flourish around the world, the health gains promised by evidence-based technical interventions will cost more and deliver less.

    “without initiatives to help community health platforms flourish around the world, the health gains promised by [specific evidence-based technical] interventions will cost more and deliver less….”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [119] Sherry M, Ghaffar A, Bishai D. Community platforms for health inferventions. In: Jamison D, Gelband H, Horton S, Jha P, Laxminarayan R, Mock C, Nugent R, editors. Disease control priorities: improving health and reducing poverty. Washington: The World Bank; 2018. p. 267–83.

      Not checked in the free run.

43 of 43

  • The paper relies on this without support.

    The 29 case studies in the compendium are representative enough of national CHW programmes generally that the challenges they report reflect the challenges facing national CHW programmes broadly.

    “The studies look at a mix of CHW types, from the more professionalized end of the spectrum to less formalized volunteer CHW programmes. The programmes described are drawn from diverse regions and from both low-income and middle-income countries.”

  • The paper relies on this without support.

    The authors of the case studies correctly identified the most pressing challenges for their programmes.

    “What Table 2 provides is a listing of those that were considered by the authors of the case studies to be the most pressing challenges for that programme.”

  • The paper relies on this without support.

    With adequate support, CHW programming is possible even when health facility functioning is compromised.

    “We know that fragile states and areas with armed conflict have higher levels of collateral mortality (especially for mothers and children) [74, 75] and that with adequate support, CHW programming is possible even when health facility functioning is compromised.”

  • The paper relies on this without support.

    NGOs and their donors have sometimes undercut government leadership, pressured governments to pursue fragmented, disease-specific projects, and instituted approaches damaging to national health systems in the longer term.

    “However, NGOs and their donors have sometimes undercut government leadership, pressured governments to pursue fragmented, disease-specific projects, and have instituted approaches that have been damaging to national health systems in the longer term.”

  • The paper relies on this without support.

    In Afghanistan and South Sudan, among other countries, the government contracts with NGOs to run its national CHW programme.

    “In Afghanistan and South Sudan, among other countries, the government contracts with NGOs to run its national CHW programme.”

  • The paper relies on this without support.

    Ethiopia and Brazil are struggling with task overload, burnout, and career (de)motivation for CHWs.

    “Ethiopia and Brazil are struggling with these issues and provide a good example of how these issues might be addressed.”

  • The paper relies on this without support.

    Research on CHWs in urban settings is quite limited at present.

    “Build the evidence base on the role of CHWs in urban settings. Research in the area is quite limited at present.”

  • The paper relies on this without support.

    Lack of mutual support among health workers has hindered effectiveness of CHW programmes.

    “We need to build mutual support and collaboration among health workers, the lack of which has hindered effectiveness of CHW programmes.”

  • The paper relies on this without support.

    In many countries, professional associations of nurses and physicians have opposed the introduction of CHW programmes as well as efforts to delegate authority to CHWs to manage dispensing medication.

    “In many countries, professional associations of nurses and physicians have opposed the introduction of CHW programmes as well as efforts to delegate authority to CHWs to manage dispensing medication (e.g., childhood pneumonia and malaria).”

  • The paper relies on this without support.

    CHW programmes and community health initiatives more broadly remain relatively underdeveloped areas of endeavour in global public health in terms of the number of professionals working to advance the field, investments in expanding the evidence base, and investigations into factors affecting implementation effectiveness at scale.

    “At the same time, it is necessary to recognize that CHW programmes and community health initiatives more broadly remain relatively underdeveloped areas of endeavour in global public health in terms of (1) the number of professionals working to advance the field, (2) investments in expanding the evidence base, and (3) investigations into the factors affecting implementation effectiveness at scale.”

  • The paper relies on this without support.

    There is a lack of evidence to guide implementation, and there is a lack of implementation because of a lack of evidence; there is also plenty of evidence that is not being acted upon.

    “Too often we find ourselves faced with a dilemma—there is a lack of evidence to guide implementation, and there is a lack of implementation because of a lack of evidence. But there is also plenty of evidence that is not being acted upon.”

  • The paper relies on this without support.

    UHC will be required to achieve the SDGs.

    “UHC will be required to achieve the SDGs.”

  • The paper relies on this without support.

    In many countries, CHWs are the frontline of defence against the COVID-19 pandemic.

    “Furthermore, in many countries, CHWs are the frontline of defence against the COVID-19 pandemic.”
13 of 13

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Claim that community-based services save more lives reverses the stated figures

    Minor

    The sentence says expanding interventions provided by CHWs could save more lives than expanding facility-based services, but gives the figures as 1.7 million versus 2.3 million, respectively. The CHW figure is smaller.

1 of 1

Cites

Flagged first, then by citations

2 of the 95 references couldn’t be matched to a known paper.

Research works printed but not linked: 7

  1. Perry HB, editor. Engaging communities for improving mothers’ and children’s health: reviewing the evidence of effectiveness in resource-constrained settings. Edinburgh: Edinburgh University Global Health Society; 2017.
  2. Perry H, Morrow M, Davis T, Borger S, Weiss J, DeCoster M, Ricca J, Ernst P. Care Groups II: a summary of the child survival outcomes achieved using volunteer community health workers in resource-constrained settings. Glob Health Sci Pract. 2015;3:370–81. · DOI
  3. Damtew Z, Lemma S, Zulliger R, Moges A, Teklu A, Perry H. Ethiopia’s Health Extension Program. In: Perry H, editor. Health for the People: National Community Health Programs from Afghanistan to Zimbabwe. Washingon: USAID/Maternal and Child Survival Program; 2020. p. 75–86.
  4. Joardar T, Javadi D, Gergen J, Perry H. The BRAC Shasthya Shebika and Shasthya Kormi Community Health Workers in Bangladesh. In: Perry H, editor. Health for the People: National Community Health Programs from Afghanistan to Zimbabwe. Washington: USAID/Jhpiego/Maternal and Child Survival Program; 2020.
  5. Walker PR, Downey S, Crigler L, LeBan K. CHW “Principles of Practice”: Guiding principles for non-governmental organizations and their partners for coordinated national scale-up of community health worker programs. Washington: CORE Group/World Vision International; 2013. p. 21.
  6. Odendaal W, Anstey Watkins J, Leon N, Daniels K. Health workers’ perceptions and experiences of using mHealth technologies to deliver primary health care services. Cochrane Database Syst Rev. 2020;4:987.
  7. Sherry M, Ghaffar A, Bishai D. Community platforms for health inferventions. In: Jamison D, Gelband H, Horton S, Jha P, Laxminarayan R, Mock C, Nugent R, editors. Disease control priorities: improving health and reducing poverty. Washington: The World Bank; 2018. p. 267–83.

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Authors
Perry, H. B., Chowdhury, M., Were, M., LeBan, K., Crigler, L., Lewin, S., Musoke, D., Kok, M., Scott, K., Ballard, M., & Hodgins, S.
Affiliations
  • Johns Hopkins University (US)
  • BRAC University (BD)
  • Hillsborough Community College (US)
  • South African Medical Research Council (ZA)
  • Makerere University (UG)
  • Royal Tropical Institute (NL)
  • Icahn School of Medicine at Mount Sinai (US)
Corresponding author
Perry, Henry B.
ORCID
Venue
Health Research Policy and Systems
Publisher
Springer Science and Business Media LLC
Published
2021-10
Volume
19
Issue
S3
Pages
111-111
ISSN
1478-4505 (ISSN-L)
DOI
10.1186/s12961-021-00755-5
PMC
PMC8506098
OpenAlex
W3206264955
Semantic Scholar
de9aa5b44cdad5b043194169404c6d0e21af5e19
Cited by
129
References
95
Citations by year
2026: 27 · 2025: 28 · 2024: 25 · 2023: 29 · 2022: 10 · 2021: 10
FWCI
4.55
Type
journal article
Language
en
Open access
Licence
Locations
  • Health Research Policy and Systems (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • NORA - Norwegian Open Research Archives (submittedVersion, other-oa)
  • Greater South Information System
Funders
Bill and Melinda Gates Foundation (ID OPP 1197181)
Topics
  • Health Sciences › Health Professions › Emergency Medical Services › Global Health Workforce Issues
  • Health Sciences › Health Professions › General Health Professions › Healthcare Systems and Practices
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
Keywords
community health workers, health care financing, universal health coverage, Sustainable Development Goals, health for all, pandemic preparedness, monitoring and evaluation, implementation research, global health goals
MeSH terms
Child, Community Health Workers, Humans, Motivation, Global Health

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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