An Intervention So Big You Can See it From Space

Over the last two decades there have been innumerable health service interventions around the world. But there has been nothing as large as the development of lay Community Health Workers (CHWs). By way of example, Africa is set to acquire around one million CHWs by the end of this year.[1] Moreover, the success of CHWs in low- and middle-income countries (LMICs) has inspired policy makers to increase CHW deployment in high-income countries (HICs), in places as far apart as New York [2] and Wales.[3]

In a previous blog we showed RCT and observational evidence that attests to the overall effectiveness of CHWs.[4] [5] They appear most effective when they are well supported, both in their communities and in the local health service. Much is made in sociological studies of the local roots of CHWs – they are ‘of the people, for the people’. Their motivation rests on their close link to the communities they serve and is strongly related to the esteem in which they are held.[6]

However, the fundamental nature of CHWs is changing. To an ever-greater extent, governments in LMICs are turning to CHWs to solve pressing problems. As they are doing the bidding of the government, they increasingly get paid for their work. Their emoluments might not be great, but all public expenditure must be accounted for. So CHWs no longer just ‘emerge’ – they must be appointed and trained, and they can be fired. India, for example, provides employment for no less than 600,000 CHWs on the basis of fee-for-service.[7] Their link to the health services is becoming more formal – they are a part of the family health teams in Brazil, for example. It would appear that the cadre of CHWs is being professionalised, albeit at different rates in different places.

It is appropriate to ask whether something may be lost in this process of professionalisation. For example, it has been shown that extrinsic motivation can ‘crowd out’ intrinsic motivation.[8] If the direction of travel is towards professionalisation, then this has implications for management of the service. It may be advisable to go with the grain and provide or facilitate privileges that other professions have, such as professional societies and well sign-posted opportunities for advancement and promotion. It will also be important to recognise that the market-clearing price for CHWs is likely to inflate, in part because of the putative crowding out of intrinsic motivations, but also because of generally improving salaries in emerging economies.

The CLAHRC WM Director hypothesises that many CHWs are going through an uncomfortable period, where they lose some of the satisfaction and kudos that comes with being a volunteer, but still lack the status, pay, and camaraderie of a fully-fledged profession. Different countries will deal with this phenomenon in different ways – in Ethiopia, for example, two cadres of CHWs have come into existence, one more formal than the other. CLAHRC Africa is actively studying education for CHWs and the ideal work configurations in two projects supported by the Medical Research Council, UK. This work complements CLAHRC WM studies on the use of unpaid lay health workers in improving outcomes for pregnant women with high social risk, e.g. single teenage parents (see previous blog).

— Richard Lilford, CLAHRC WM Director


  1. Singh P, Sachs JD. 1 million community health workers in sub-Saharan Africa by 2015. Lancet. 2013; 382: 363-5.
  2. Peretz PJ, Matiz LA, Findley S, et al. Community Health Workers as Drivers of a Successful Community-Based Disease Management Initiative. Am J Public Health. 2012; 102(8): 1443-6.
  3. Johnson CD, Noyes J, Haines A, et al. Learning from the Brazilian community health worker model in North Wales. Global Health. 2013; 9: 25.
  4. Lilford R. Lay Community Health Workers. CLAHRC WM News Blog. April 10 2015.
  5. Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev. 2010; 3: CD004015.
  6. Glenton C, Colvin CJ, Carlsen B, Swartz A, Lewin S, Noyes J, Rashidian A. Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis. Cochrane Database Syst Rev. 2013; 10: CD010414.REF
  7. Singh P, & Chokshi DA. Community Health Workers – A Local Solution to a Global Problem. N Engl J Med. 2013; 369(10): 894-6.
  8. Frey BS. How Intrinsic Motivation is Crowded Out and In. Rationality Society. 1994; 6(3): 334-52.

2 thoughts on “An Intervention So Big You Can See it From Space”

  1. That 1 million CHWs should be trained and deployed in sub-Saharan Africa by the end of 2015 is an important goal. But I fear the goal will not be achieved as you have suggested Richard. Of course, counting CHWs is a phenomenally difficult task; so much so that there is a defined operation that aims to do so (see The current total of CHWs reported by this operation is 141,987 – suggesting either that most cannot be seen from space or that they are yet to come into existence.

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