National community health worker programs: how can they be strengthened?

This article is based on a collaborative research study of policy and practice in national community health worker (CHW) programs in developing countries. The study involved a review of the relevant literature, case studies in Botswana, Colombia and Sri Lanka, and an international workshop where the future of such programs was discussed. The findings of this research are discussed under four headings: unrealistic expectations, poor initial planning, problems of sustainability, and the difficulties of maintaining quality. It is clear that existing national community health worker programs have suffered from conceptual and implementation problems. However, given the interest and political will, governments can address these problems by adopting more flexible approaches within their CHW programs, by planning for them within the context of all health sector activities rather than as a separate activity, and by immediately addressing weaknesses in task allocation, training and supervision. CHWs represent an important health resource, whose potential in extending coverage and providing a reasonable level of care to otherwise underserved populations must be fully tapped.