CHWs: are national programmes in crisis?

Community health workers (CHWs) have become the distinguishing feature of many primary health care schemes. CHW programmes expanded during the 1970s and early 1980s as long-term evidence for the effectiveness of small-scale programmes grew. However, there is a growing suggestion of a decline in support for CHWs. Criticisms have grown, evaluations of existing programmes have pointed to difficulties in implementation and a number of reviews have highlighted weaknesses in key areas. Training of CHWs has been suspended in some countries, and fewer than originally planned are being trained in others. In this paper it is argued that although the financial recession has affected support for CHW programmes, there are other reasons why they are now under pressure. On the whole they have been implemented as ‘vertical’ programmes, against a background of unrealistic expectations and minimal professional interest. Structural political and economic factors have been neglected. Lessons have not been drawn from the experience of community workers in other sectors such as agriculture and community development. The paper analyses all these issues within a health policy perspective concluding that, unless adjustments are made, CHW programmes will drift towards demise, not because CHWs themselves cannot deliver, but because the support that makes them effective is, in general, absent.