A comparative study of community health worker programs in Sierra Leone and India: Lessons for strengthening primary healthcare systems

Introduction: Community health workers (CHWs) are a key component of primary health care (PHC), particularly in low-income and other marginalized areas. In Sierra Leone and India, both countries have formalized their CHW programs to bridge access, equity, and delivery of services at the community level. Two such large-scale programs that emphasize health interventions at the community level are the CHW Program in Sierra Leone and the Accredited Social Health Activist scheme in India. However, while they have a similar goal, the way these programs look and work can differ dramatically in terms of how training is presented and opportunities provided, and how well technology is supported at the system level. We sought to compare the two programs, to identify areas of strength but also operational constraints, as well as lessons of policy relevance for replicability of the Brazilian experience in strengthening PHC systems in the global south. Methodology: A cross-sectional descriptive study was conducted from January 2025 to April 2025 on mixed-method type. A purposive sample of 236 (118 from Sierra Leone and 118 from India) that included CHWs, PHC supervisors, and community beneficiaries was drawn to be part of a structured interview. The quantitative data were analyzed by SPSS version 25 to compute descriptive and inferential statistics Chi-square test. Qualitative free-text comments (47) were also thematically analyzed to further support the interpretation of the overall quantitative data. Results: The evaluation findings indicate that CHW programs in both Sierra Leone and India are highly trusted by local populations and are perceived as vital conduits to healthcare access in rural areas. Notably, several differences emerged between the two country contexts in key operational parameters. CHWs in India more frequently reported consistent access to regular supervision, standardized reporting tools, and ongoing training support. In contrast, CHWs in Sierra Leone more commonly cited systemic constraints such as irregular remuneration, inadequate supervisory support, and logistical challenges. A statistically significant association was found between the frequency of supervision and self-reported CHW performance (χ² = 9.45, P < 0.01), underscoring the critical role of sustained programmatic support in enhancing CHW effectiveness. Conclusions: CHW programs in Sierra Leone and India are essential to health equity and well-being, yet dependent on systemic facilitating factors for effectiveness. To enhance the quality of MHCP, the Government of Ghana and the Nigerian Government will have to strengthen the system of supervision, integrate mHealth tools, ensuring timely and enough payment as well as routine training. Cross-learning and policy dialog between nations can also help to enhance the adaptability, effectiveness, and sustainability of CHW models in diverse health system contexts.