In discussing possible solutions to health problems in CLAHRC Africa, the role of Lay Community Health Workers (LCHWs) often comes up. In fact, there is seldom a large-scale health problem that someone does not suggest can be laid at the door of LCHWs.
What are LCHWs?
- LCHWs (sometimes referred to as Lay Health Workers or Community Health Workers) cover a range of functions. However, LCHWs tend to have the following features:
- They are of the community in the sense that they live among the people they serve. They tend to be nominated/selected by their local community.
- They have a connection to the health service – for example, they have established lines of communication and can refer.
- They are not full-time and generally have other roles/jobs in the community.
- They may receive some monetary payment from health services, but this is small in amount relative to substantive health care workers.
What is the history of LCHWs?
The CLAHRC WM Director finds it difficult to follow the evolution of present day LCHWs, but he fancies that some people have differentiated themselves to provide services to their community from the beginning of time, for example, providing birth assistance. The present day CHW:
- is differentiated from traditional healers and hews, to some extent at least, to an Enlightenment-based scientific model;
- performs a role that forms part of, or complements, the local health service.
Recent examples of initiatives that relied on LCHWs include:
- The “barefoot doctor” programme in China.
- An extensive reproductive health programme in Iran associated with a steep drop in fertility.
- An extensive child health programme in Brazil that was associated with a large (over 50%) and precipitate drop in childhood mortality.
- The anti-retroviral programme in Africa where LCHWs played a part in identifying cases and helping clients adhere to exacting treatment regimes. 
Lay workers are also found in high-income countries and may even be making something of a come-back. Our CLAHRC, for instance, has evaluated the role of such volunteer support workers in the case of vulnerable women over the perinatal period.
Are LCHWs effective?
This question invites the response “compared to what?” They played a large (arguably essential) part in the above programmes and the programmes were themselves successful. LCHWs make a small call on the public purse and so there are good reasons to think they are cost-effective compared to health service personnel who might be deployed to perform the same function. There is empirical support for the theoretical idea that being part and parcel of the local community and being selected by local people provides credibility and enhances the effectiveness of LCHWs. A collaborator of the CLAHRC WM Director, Dr Alex Plowright, argues that the empathy they display is especially important where health systems are weak and staff are often disaffected. Summative evaluations (82 RCTs) show that LCHWs are effective on average, but the results, as with many service interventions, are heterogeneous. This reflects, at least in part, the fact that LCHWs are deployed in very different social and political environments that might be neutral, supportive, or antipathetic to their efforts.  Salient questions include the education of LCHWs (how much, in what form, over what time periods), whether LCHWs should specialise, and what functions they should perform.
Towards a theory of LCHWs deployment
The argument proposed here has two premises:
- LCHWs do not tend to have detailed theoretical knowledge, nor a deep understanding of patho-physiological pathways. If they did, they would not be LCHWs.
- Most health gains in deprived communities in low- and middle-income countries turn not on intensive medical practice, but on a small number of conceptually straightforward processes – basic nutrition, bed nets, oral rehydration, vaccination, access to contraception, and so on.
Putting these two ideas together can help shape an answer to the above question relating to role definitions. First, it would suggest that LCHWs should not become a type of “dumping ground” for all ills – mental health, untreated ear disease, skin infections, etc. Rather, they should learn what the red flags are and have a generally low threshold of referral to a health facility. A corollary of this idea is that LCHWs should not be required to specialise, though this is not to say that they should not develop a special interest. Childbearing might be an exception, since a type of CHW called a traditional birth attendant can improve outcomes of labour, at least where trained midwives are not available. Once the above fundamentals are covered, then one can imagine a role in health promotion – for example, discouraging salt and sugar and perhaps checking for the silent killer that is hypertension, as recommended by Margaret Thorogood.
— Richard Lilford, CLAHRC WM Director
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