On Health Policy and System Support To Optimize Community Health Worker Programmes

WHO guideline
on health policy and

system support to
optimize community
health worker
programmes
WHO guideline
on health policy and
system support to
optimize community
health worker
programmes
WHO guideline on health policy and system support to optimize community health worker programmes
ISBN 978-92-4-155036-9
© World Health Organization 2018

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WHO guideline on health policy and system support to optimize community health worker programmes
Contents
Foreword 8
Contributors and acknowledgements 9
Abbreviations 11
Key messages 12
Executive summary 13
++ 1. Introduction 18
++ 2. Rationale 19
++ 3. Target audience 20
3.1 End-users of the guideline 20
3.2 Persons affected by the recommendations 20
++ 4. Objectives and scope of the guideline 21

4.1 Goal and objectives 21
4.2 Types of health workers covered by this guideline 21
4.3 Geographical areas covered 23
4.4 Categories of interventions covered 24
++ 5. How this guideline was developed 26

5.1 Steering Group, Guideline Development Group and External Review Group 26
5.2 Sources of evidence for guideline 27
++ 6. Results 29
6.1 Systematic review of reviews 29
6.2 Systematic reviews on the 15 PICO questions 29
6.3 Stakeholder perception survey 31
3
7. Recommendations 32
Recommendation 1: Selection for pre-service training 32
7.1.1 Background to the recommendation 32
7.1.2 Rationale for recommendation 32
7.1.3 Summary of evidence 33
7.1.4 Interpretation of the evidence and other considerations by the GDG 34
7.1.5 Implementation considerations 34
Recommendation 2: Duration of pre-service training 35
Recommendation 3: Competencies in curriculum for pre-service training 37
Recommendation 4: Modalities of pre-service training 41
Recommendation 5: Competency-based certification 43
Recommendation 6: Supportive supervision 45
Recommendation 7: Remuneration 47
4 WHO guideline on health policy and system support to optimize community health worker programmes
Recommendation 8: Contracting agreements 49
Recommendation 9: Career ladder 51
Recommendation 10: Target population size 52
Recommendation 11: Data collection and use 54
Recommendation 12: Types of CHWs 56
Recommendation 13: Community engagement 57
Recommendation 14: Mobilization of community resources 60
5
Recommendation 15: Availability of supplies 62
++ 8. Research priorities and guideline update 64

8.1 Selection, education and certification 64
8.2 Management and supervision 65
8.3 Integration into and support by health systems and communities 65
8.4 Implications for non-health development outcomes 66
8.5 Future research and guideline update 66
++ 9. Guideline use 67
9.1 Plans for guideline dissemination 67
9.2 Plans for guideline adaptation, implementation and evaluation 68
++ 10. General implementation considerations 70

10.1 Key principles 70
10.2 Operational aspects of CHW programme design and implementation 71
10.2.1 Programme design 71
10.2.2 Policy coherence 71
10.2.3 Health system support 71
10.2.4 Financing implications 72
++ References 73
++ Annex 1. S
earch terms to identify CHWs and other relevant
community-based health workers 90
++ Annex 2. S
ervice delivery areas on which there is published
evidence of CHW effectiveness 92
++ Annex 3. E
xisting WHO guidelines that identify specific roles
and services rendered by CHWs 100
++ Annex 4. L
ist of members of Steering Group, Guideline
Development Group and External Review Group 103
++ Annex 5. Selected findings of stakeholder perception survey 109
++ Annex 6. E
vidence profiles and evidence-to-decision tables
(WHO/HIS/HWF/CHW web annex/18.1)
Figures and tables
Figure 1: Geographical distribution of included studies across the 15 systematic reviews on the
PICO questions 23
Figure 2: Primary health care services for which there is some evidence of CHW effectiveness 25
Figure 3: PRISMA diagram of studies assessed by the systematic reviews 30
Figure A5.1: Acceptability and feasibility of social media use in redistribution of commodities
and supplies 111
Figure A5.2: Acceptability and feasibility of selecting older candidates 112
Table 1: Overarching search strategy for the 15 PICO questions 28
Table 2: Inclusion and exclusion criteria 28
Table 3: Duration of training for CHWs with a polyvalent role 37
Table 4: Variations in contents of pre-service training curriculum for CHWs 39
Table 5: Categories of community engagement strategies 58
Table A4.1: Steering Group members 103
Table A4.2: Guideline Development Group members 104
Table A4.3: External Review Group members 105
Table A4.4: GDG conflict of interest management 106
Table A4.5: ERG conflict of interest management 108
Table A5.1: Acceptability and feasibility of CHW interventions 110
7
Foreword
The World Health Organization was founded on the principle that all people have the right to the highest attainable standard of
health. You could say that “Health for all” is in our DNA.
While every country’s journey towards universal health coverage is unique, we know that having a competent, motivated and
supported health workforce is the backbone of every health system. There is simply no health without health workers.
Community health workers have been acknowledged as a vital component of primary care since the Alma Ata Declaration
in 1978. Forty years later, we now have compelling evidence demonstrating the valuable contribution of community health
workers in delivering basic and essential life-saving health services.
Investing in community health workers represents good value for money. And yet, they are often operating at the margins of
health systems, without being duly recognized, integrated, supported and rewarded for the crucial role they play.
This new WHO guideline has identified state-of-the-art evidence on what is required to facilitate the proper integration
of community health workers in health systems and communities. It contains pragmatic recommendations on how to
improve and strengthen their selection, education, deployment, management, supervision, career advancement, community
embeddedness and system support.
I urge all policy-makers and managers in countries, as well as our international partners, to consider these recommendations
and to put them into practice. By fully harnessing the potential of community health workers, including by dramatically
improving their working and living conditions, we can make progress together towards universal health coverage and
achieving the health targets of the Sustainable Development Goals.
Dr Tedros Adhanom Ghebreyesus
Contributors and acknowledgements
This guideline is part of the World Health Organization (WHO) Africa; Olufemi Taiwo Oladapo, Reproductive health research;
programme of work on human resources for health. It Kunhee Park and Indrajit Hazarika, Regional Office for the
represents a technical tool to facilitate the implementation Western Pacific; Galina Perfilieva, Regional Office for Europe;
of the WHO Global Strategy on Human Resources for Health: Denis Georges Porignon, Health governance and financing;
Workforce 2030, the recommendations of the United Nations Gunasena Sunil Senanayake, Regional Office for South-
High-Level Commission on Health Employment and Economic East Asia; Lana Syed, Global TB Programme; and Jerome
Growth and WHO’s Thirteenth general programme of work Pfaffmann, Health Unit, Child Health, UNICEF.
2019−2023.
The Guideline Development Group refined the scope of the
The concept for the guideline was initiated by Giorgio Cometto, guideline, reviewed the evidence summaries, and developed
James Campbell and Marie-Paule Kieny of WHO. Further the recommendations. Its members included Elie Akl,
conceptual refinement of the guideline, its coordination and American University of Beirut, Lebanon (methodologist and
content was led by Giorgio Cometto (coordinator, human co-chair); Barbara McPake, University of Melbourne, Australia
resources for health policies, norms and standards, Health (co-chair); Uta Lehmann, University of Western Cape, South
Workforce Department, WHO) under the oversight of James Africa (co-chair); Amel Abdalla, Ministry of Health, Sudan;
Campbell (Director, Health Workforce Department, WHO). The Zulfiqar Bhutta, Aga Khan University, Pakistan; Howard Catton,
WHO Health Workforce Department is part of the Universal International Council of Nurses, United Kingdom; Tesfaye
Health Coverage and Health System Cluster led by the Chala, Deputy Director PHC, Ministry of Health, Ethiopia; Yoswa
Assistant Director-General, Naoko Yamamoto. Dambisya, Limpopo University, South Africa; Gilles Dussault,
Instituto Hygiene e Medicina Tropical, Lisbon, Portugal; Miatta
The Steering Group led the development of the planning Gbanya, Ministry of Health, Liberia; Zhang Guangpeng, National
proposal of the guideline, identified members of the Health Development Research Centre, China; Luis Huicho,
Guideline Development Group and External Review Group, Universidade Peruana, Peru; Nicolae Jelamschi, Ministry of
facilitated the Guideline Development Group meetings, Health, Moldova; Arthur Kauffman, University of New Mexico,
and contributed to the development of the first draft of the United States of America; Arieta Latianara, Ministry of Health,
guideline document and to subsequent rounds of revisions. Fiji; Leonard Mbiu, Ministry of Health, Kenya; Guadalupe
Its members included the following WHO staff members: Medina, Universidade Federal de Bahia, Brazil; Catherine
Samira Aboubaker, Maternal, newborn, child and adolescent Mugeni, Ministry of Health, Rwanda; Margaret Mungherera,
health; Islene Araujo De Carvalho, Ageing and life course; World Medical Association, Uganda; Maxensia Nakibuuka,
Mohammad Assai Ardakani, Regional Office for the Eastern CHW, Uganda; Makhduma Nargis, Ministry of Health,
Mediterranean; Shannon Barkley, Service delivery and Bangladesh; Shirley Ngwenya, University of the Witwatersrand,
safety; Giorgio Cometto (responsible technical officer), South Africa; Ram Shresta, Tufts, Nepal; Sandra Vermuyten and
Health Workforce; Tarun Dua, Mental health and substance Aye Babatunde, Public Services International, Belgium; Polly
abuse; Jose Francisco Garcia Gutierrez, Regional Office for Walker, World Vision, United Kingdom; and Jean White, Welsh
the Americas; Fethiye Gulin Gedik, Regional Office for the Government – Health and Social Services Group Wales, United
Eastern Mediterranean; Thomas Moran, Polio, emergencies Kingdom. Nazo Qureshi, United States Agency for International
and country collaboration; Eyerusalem Kebede Negussie Development, United States, participated in the Guideline
and Nathan Ford, HIV; Jennifer Nyoni, Regional Office for Development Group meetings as observer.
9
The External Review Group provided a peer review of The systematic review team coordinated by Bianca Albers,
a draft of the guideline document and of the systematic David Taylor (Centre for Evidence and Implementation) and
reviews of the literature. Its members included Madeleine Aron Shlonsky (University of Melbourne) led the development of
Ballard, Community Health Impact Coalition, Germany; the 15 systematic reviews assessing the evidence on the policy
Jennifer Breads, Jhpiego, United States; Camila Giugliani, questions specifically examined in the guideline. The authors
Federal University of Rio Grande do Sul, Porto Alegre, Brazil; of each systematic review are also gratefully acknowledged,
Stephen Hodgins, University of Alberta, Canada; Ochiawunma and their names are listed in the references of the reviews.
Ibe, ICF/Maternal and Child Survival Program, Nigeria; Sara
Javanparast, Flinders University, Australia; Ari Johnson, A group of researchers from Johns Hopkins University,
University of California, San Francisco, Global Health Sciences comprising Kerry Scott, Sam Beckham, Margaret Gross,
Muso, United States; Karin Källander, Malaria Consortium, George Pariyo, Krishna Rao and Henry Perry, prepared the
United Kingdom; Samson Kironde, University Research systematic review of literature reviews exploring the broader
Co., LLC, Uganda; Maryse Kok, Royal Tropical Institute, the evidence base on community health workers.
Netherlands; Maisam Najafizada, Memorial University of
Newfoundland Health Sciences Centre, Newfoundland and A large number of individuals from a variety of institutions
Labrador, Canada; Peter Ngatia, Amref Health Africa, Kenya; and constituencies provided anonymous inputs in the
Ruth Ngechu, Living Goods, Kenya; Abimbola Olaniran, public hearing contributing to the scope of the guideline
Liverpool School of Tropical Medicine, United Kingdom; document, and in a stakeholder perception survey assessing
Rajesh Panjabi, Last Mile Health, United States; Bhanu Pratap, the relative importance of outcomes and the feasibility and
International Federation of Red Cross and Red Crescent acceptability of the policy options under consideration in
Societies, Switzerland; Magali Romedenne, UNICEF, Senegal; the guideline development.
Eric Sarriot, Save the Children, United States; and Sunita
Singh, London School of Hygiene and Tropical Medicine, India. Onyema Ajuebor (Health Workforce Department, WHO)
coordinated the initial public hearing on the scope of
Declarations of interest were collated from members of the guideline and led the development and analysis
the Guideline Development Group and the External Review of the stakeholder perception survey. Zahra Zeinali
Group and assessed by the WHO Secretariat. The interests (intern, Health Workforce Department, WHO) collated and
declared were not considered to hinder participation in summarized existing WHO guidelines that refer to the role of
the process to develop or review recommendations. community health workers in the delivery of specific health
interventions. John Dawson copy-edited the document.
Other individuals provided selective inputs on
Funding
methodological aspects of the literature reviews or peer
WHO’s core resources supported the majority of the funding
review and inputs on specific sections of the guideline
for the development of this guideline. In addition, financial
document: Susan Norris (Guideline Review Committee
support for development, dissemination and uptake of
Secretariat, WHO); Dena Javadi (Alliance for Health Policy
this guideline was received from the Global Fund to Fight
and Systems Research, WHO); Dermot Maher (Tropical
AIDS, Tuberculosis and Malaria, the Federal Ministry of
Diseases Research, WHO); Tomas Allen (Library and
Health of Germany – BMG, the United States Agency for
Information Networks for Knowledge, WHO); Tomas Zapata
International Development, the Norwegian Agency for
(WHO Regional Office for South-East Asia); Elongo Lokombe
Development Cooperation, the Alliance for Health Policy
(WHO Regional Office for Africa); and Christiane Wiskow
and Systems Research and UNICEF. The financial support
(International Labour Organization).
from these partners is gratefully acknowledged.
Abbreviations
AMSTAR Assessment of Multiple Systematic Reviews
CHW community health worker
ERG External Review Group
GDG Guideline Development Group
HIFA Healthcare Information For All
ILO International Labour Organization
ISCO International Standard Classification of Occupations
PICO population, intervention, control, outcome
PRISMA Preferred Reporting Items of Systematic reviews and Meta-Analyses
RCT randomized controlled trial
SDG Sustainable Development Goal
SG Steering Group
TB tuberculosis
TT tetanus toxoid
UNICEF United Nations Children’s Fund
WHO World Health Organization
11
Key messages
Addressing health workforce shortage, maldistribution and • including, in the contents of pre-service training,
performance challenges is essential for progress towards promotive and preventive services, diagnostic and
all health-related goals, including universal health coverage. curative services where relevant, and interpersonal
Further, the health sector has the potential to be a driver of and community mobilization skills;
economic growth through the creation of qualified employment • balancing theoretical and practical pre-service training,
opportunities, in particular for women. and blending face-to-face and e-learning where feasible,
Effective health workforce strategies include the education with adequate attention to a positive training environment
and deployment of a diverse and sustainable skills mix, and faculty;
harnessing in some contexts the potential of community health • using competency-based formal certification for CHWs
workers (CHWs) operating in interprofessional primary care who have successfully completed pre-service training
teams. However, the support for CHWs and their integration to improve CHW quality of care, motivation and
into health systems and communities are uneven across employment prospects;
and within countries; good-practice examples are not • adopting supportive supervision strategies;
necessarily replicated and policy options for which there is • providing practising CHWs with a financial package
greater evidence of effectiveness are not uniformly adopted. commensurate with the job demands, complexity, number
Conversely, successful delivery of services through CHWs of hours worked, training and roles that they undertake;
requires evidence-based models for education, deployment • providing paid CHWs with a written agreement specifying
and management of these health workers. role and responsibilities, working conditions, remuneration
and workers’ rights;
The starting point for an effective design of CHW programmes
• offering a career ladder to well performing CHWs;
is a sound situation analysis of population needs, health
• determining an appropriate target population size in
system requirements and resource implications. The role of
relation to expected workloads, frequency, nature and time
CHWs should be considered in relation to other health workers,
requirements of contacts required;
in order to integrate CHW programmes into the general
• collecting, collating and using health data by CHWs on
health system and into existing community structures in an
routine activities, including through relevant mobile
appropriate manner.
health solutions, while respecting data confidentiality
This guideline was developed through a critical analysis of and security;
the available evidence and provides policy recommendations • adopting service delivery models comprising CHWs with
to optimize the design and performance of CHW programmes, general tasks as part of integrated primary health care
including: teams, in which CHWs with selective tasks can play a
• selecting CHWs for pre-service education, considering complementary role;
minimum education levels appropriate to the tasks to be • adopting strategies for CHWs to engage communities and
performed, membership of and acceptance by the local to harness community resources; and
community, promotion of gender equity, and personal • ensuring adequate availability of commodities and
attributes and capacity of the candidates; consumable supplies to CHWs.
• determining duration of pre-service training in the local
context based on competencies required according to
role, pre-existing knowledge and skills, and expected
conditions of practice;
Executive summary
Introduction Objectives and scope
Addressing health workforce shortage, maldistribution and The overall goal of this guideline is to assist national
performance challenges is essential for progress towards governments and national and international partners
all health-related goals, including universal health coverage. to improve the design, implementation, performance
Further, as evidenced by the recommendations of the United and evaluation of CHW programmes, contributing to the
Nations High-Level Commission on Health Employment and progressive realization of universal health coverage.
Economic Growth, there is increasing recognition of the
potential of the health sector to create qualified employment This guideline is primarily focused on CHWs (as defined by
opportunities, in particular for women, contributing to the International Labour Organization through its International
the job creation and economic development agenda. The Standard Classification of Occupations), but its relevance and
education and deployment of interprofessional primary applicability include also other types of community-based
care teams of health workers should reflect a diverse and health workers. The recommendations of this guideline are
sustainable skills mix; in some contexts this may entail of relevance to health systems of countries at all levels of
harnessing the potential of community health workers socioeconomic development.
(CHWs) as part of broader efforts to strengthen primary
health care and the health workforce more generally. The guideline follows a health system approach and
specifically it identifies the policy and system enablers required
There is growing recognition that CHWs and other types of to optimize design and performance of CHW initiatives. It does
community-based health workers are effective in the delivery not appraise the body of evidence on which health services or
of a range of preventive, promotive and curative health interventions CHWs can deliver to quality standards, which are
services, and that they can contribute to reducing inequities covered by other World Health Organization (WHO) guidelines.
in access to care.
Methodology
Rationale The development of this guideline followed the standard WHO
The support for CHWs and their integration into health approach: a critical appraisal of the evidence through the
systems and communities are uneven across and within development of systematic reviews of the relevant literature
countries; good-practice examples are not necessarily and the assessment of the quality of the evidence through
replicated and policy options for which there is greater standardized methodologies, including the assessment
evidence of effectiveness are not uniformly adopted. There of the certainty of the evidence. A Guideline Development
is a need for evidence-based guidance on optimal health Group, comprising a geographically and gender-balanced
policy and system support to optimize the performance representation across different constituencies (including
and impact of these health workers. policy-makers, end-users of guidelines, experts, health
professional associations, CHWs and labour union
Target audience representatives) led the formulation of recommendations,
The primary target audience for this guideline is with the support of a Steering Group, and benefiting from
policy-makers, planners and managers responsible for health peer review by a competitively-selected External Review
workforce policy and planning at national and local levels. Group. One systematic review of published literature reviews,
Secondary target audiences include development partners, 15 systematic reviews (one for each policy question) of
funding agencies, global health initiatives, donor contractors, relevant primary studies, and a stakeholder perception
researchers, CHW organizations, CHWs themselves, civil survey were conducted for the specific purpose of identifying
society organizations and community stakeholders. relevant evidence contributing to this guideline.
13
Results Recommendation 1C
The systematic review of published literature reviews WHO recommends not using the following criterion for
identified 122 eligible reviews (75 systematic reviews, selecting CHWs for pre-service training:
of which 34 were meta-analyses, and 47 non-systematic • marital status.
reviews). The systematic reviews for the studies for the Certainty of the evidence – very low. Strength of the
15 questions considered by the guideline screened almost recommendation – strong.
88 000 records, resulting eventually in the identification of
2. Duration of pre-service training
137 studies eligible for inclusion and analysis in the reviews.
Recommendation 2
The stakeholder perception survey obtained inputs from
WHO suggests using the following criteria for determining
96 respondents (largely policy-makers, planners, managers
the length of pre-service training for CHWs:
and researchers involved in the design, implementation,
• scope of work, and anticipated responsibilities and role;
monitoring and evaluation of CHW programmes) on the
• competencies required to ensure high-quality
acceptability and feasibility of the interventions under
service delivery;
consideration in the guideline.
• re-existing knowledge and skills (whether acquired
p
Recommendations through prior training or relevant experience);
1. Selection • social, economic and geographical circumstances
Recommendation 1A of trainees;
WHO suggests using the following criteria for selecting • institutional capacity to provide the training;
CHWs for pre-service training: • expected conditions of practice.
• minimum educational level that is appropriate Certainty of the evidence – low. Strength of the
to the task(s) under consideration; recommendation – conditional.
• membership of and acceptance by the target community; 3. C
ompetencies in curriculum for pre-service training
• gender equity appropriate to the context (considering Recommendation 3
affirmative action to preferentially select women to WHO suggests including the following competency
empower them and, where culturally relevant, to domains for the curriculum for pre-service training of
ensure acceptability of services by the population CHWs, if their expected role includes such functions.
or target group);
Core:
• ersonal attributes, capacities, values, and life and
p
• promotive and preventive services, identification of
professional experiences of the candidates (e.g.
family health and social needs and risk;
cognitive abilities, integrity, motivation, interpersonal
• integration within the wider health care system in relation
skills, demonstrated commitment to community service,
to the range of tasks to be performed in accordance
and a public service ethos).
with CHW role, including referral, collaborative relation
Certainty of the evidence – very low. Strength of the
with other health workers in primary care teams, patient
recommendation – conditional.
tracing, community disease surveillance, monitoring, and
Recommendation 1B data collection, analysis and use;
WHO suggests not using the following criterion for • social and environmental determinants of health;
selecting CHWs for pre-service training: • providing psychosocial support;
• age (except in relation to requirements of national • interpersonal skills related to confidentiality,
education and labour policies). communication, community engagement and
Certainty of the evidence – very low. Strength of the mobilization;
recommendation – conditional. • personal safety.
Additional: • ensuring supervisors receive adequate training;
• diagnostic, treatment and care in alignment with • coaching and mentoring of CHWs;
expected role(s) and applicable regulations on scope • use of observation of service delivery, performance data
of practice. and community feedback;
Certainty of the evidence – moderate. Strength of the • prioritization of improving the quality of supervision.
recommendation – conditional. Certainty of the evidence – very low. Strength of the
4. Modalities of pre-service training recommendation – conditional.
Recommendation 4 7. Remuneration
WHO suggests using the following modalities for Recommendation 7A
delivering pre-service training to CHWs: WHO recommends remunerating practising CHWs for
• balance of theory-focused knowledge and practice- their work with a financial package commensurate with
focused skills, with priority emphasis on supervised the job demands, complexity, number of hours, training
practical experience; and roles that they undertake.
• balance of face-to-face and e-learning, with priority Certainty of the evidence – very low. Strength of the
emphasis on face-to-face learning, supplemented by recommendation – strong.
e-learning on aspects on which it is relevant; Recommendation 7B
• prioritization of training in or near the community WHO suggests not paying CHWs exclusively or
wherever possible; predominantly according to performance-based incentives.
• delivery of training and provision of learning materials Certainty of the evidence – very low. Strength of the
in language that can optimize the trainees’ acquisition recommendation – conditional.
of expertise and skills;
8. Contracting agreements
• ensuring a positive training environment;
Recommendation 8
• consideration of interprofessional training approaches
WHO recommends providing paid CHWs with a written
where relevant and feasible.
agreement specifying role and responsibilities, working
conditions, remuneration and workers’ rights.
5. Competency-based certification recommendation – strong.
Recommendation 5
9. Career ladder
WHO suggests using competency-based formal
Recommendation 9
certification for CHWs who have successfully completed
WHO suggests that a career ladder should be offered
pre-service training.1
to practising CHWs, recognizing that further education
and career development are linked to selection criteria,
duration and contents of pre-service education,
6. Supportive supervision competency-based certification, duration of service
Recommendation 6 and performance review.
WHO suggests using the following supportive supervision Certainty of the evidence – low. Strength of the
strategies in the context of CHW programmes: recommendation – conditional.
• appropriate supervisor–supervisee ratio allowing
meaningful and regular support;
1
Certification is defined in this context as a formal recognition awarded by relevant authorities to health workers who have successfully completed
pre-service education and who have demonstrated meeting predetermined competency standards.
15
10. Target population size 12. Types of CHWs
Recommendation 10 Recommendation 12
WHO suggests using the following criteria in determining a WHO suggests adopting service delivery models
target population size in the context of CHW programmes. comprising CHWs with general tasks as part of integrated
Criteria to be adopted in most settings: primary health care teams. CHWs with more selective
• expected workload based on epidemiology and and specific tasks can play a complementary role when
anticipated demand for services; required on the basis of population health needs, cultural
• frequency of contact required; context and workforce configuration.
• nature and time requirements of the services provided; Certainty of the evidence – very low. Strength of the
• expected weekly time commitment of CHWs (factoring recommendation – conditional.
in time away from service provision for training, 13. Community engagement
administrative duties, and other requirements); Recommendation 13
• local geography (including proximity of households, WHO recommends the adoption of the following
distance to clinic and population density). community engagement strategies in the context of
Criteria that might be of relevance in some settings: practising CHW programmes:
• weather and climate; • pre-programme consultation with community leaders;
• transport availability and cost; • community participation in CHW selection;
• health worker safety; • monitoring of CHWs;
• mobility of population; • selection and priority setting of CHW activities;
• available human and financial resources. • support to community-based structures;
Certainty of the evidence – very low. Strength of the • involvement of community representatives in
recommendation – conditional. decision-making, problem solving, planning and
budgeting processes.
11. Data collection and use
Certainty of the evidence – moderate. Strength of the
Recommendation 11
recommendation – strong.
WHO suggests that practising CHWs document the
services they are providing and that they collect, 14. Mobilization of community resources
collate and use health data on routine activities, Recommendation 14
including through relevant mobile health solutions. WHO suggests that CHWs contribute to mobilizing wider
Enablers for success include minimizing the reporting community resources for health by:
burden and harmonizing data requirements; ensuring • identifying priority health and social problems and
data confidentiality and security; equipping CHWs developing and implementing corresponding action
with the required competencies through training; and plans with the communities;
providing them with feedback on performance based • mobilizing and helping coordinate relevant local
on data collected. resources representing different stakeholders, sectors
Certainty of the evidence – very low. Strength of the and civil society organizations to address priority
recommendation – conditional. health problems;
• facilitating community participation in transparent
evaluation and dissemination of routine community data
and outcomes of interventions;
• strengthening linkages between the community and
health facilities.
15. Availability of supplies and effectiveness of approaches that would impact the
Recommendation 15 applicability and generalizability of policy options and
WHO suggests using the following strategies for recommendations in this guideline.
ensuring adequate availability of commodities
Implementation considerations
and consumable supplies, quality assurance, and
The starting point for an effective design of CHW initiatives
appropriate storage, stocking and waste management
and programmes is a sound situation analysis of population
in the context of CHW programmes:
needs and health system requirements. Planners should
• integration in the overall health supply chain;
adopt a whole-of-system approach, taking into consideration
• adequate reporting, supervision, compensation, work
health system capacities and population needs, and framing
environment management, appropriate training and
the role of CHWs vis-à-vis other health workers, in order
feedback, and team quality improvement meetings;
to integrate CHW programmes into the health system in an
• availability of mHealth to support different supply
appropriate manner.
chain functions.
Certainty of the evidence – low. Strength of the
CHW initiatives and programmes should therefore be
aligned to and be part of broader national health and health
Research priorities workforce policies. As relevant, they should also be linked
Evidence was identified to provide policy recommendations with national education, labour and community development
for most areas under consideration in the guideline. However, sectoral or subsectoral policies and frameworks.
in several instances important gaps in both scope and
certainty of evidence emerged from the systematic reviews, Countries should use a combination of CHW policies selected
providing an opportunity to outline priorities for a future based on the objectives, context and architecture of each
research agenda on CHWs. health system. This guideline is not a blueprint that can
be immediately adopted. It should be read as an analytical
The research activities undertaken in support of this guideline overview of available evidence that informs a menu of
found a near-absolute absence of evidence in some areas (for interrelated policy options and recommendations. The options
example, on certification or contracting and career ladders and recommendations subsequently need to be adapted
for CHWs, appropriate typology, and population target size). and contextualized to the reality of a specific health system.
Across most policy areas considered there is some evidence Further, the recommendations should not be considered
– often substantial – that broad strategies (for example, in isolation from one another. There is a need for internal
competency-based education, supportive supervision, and coherence and consistency among different policies, as they
payment) are effective. However, this evidence may not be represent related and interlocking elements that complement
sufficiently granular to recommend specific interventions, such and can reinforce one another.
as which education approaches, which supervision strategies,
or which bundles of financial and non-financial incentives The deployment of CHWs has been identified as a
are most effective or more effective than others. Other cost-effective approach. The policy options recommended
cross-cutting considerations include the absence of economic in this guideline have, in the aggregate, considerable
evaluations of the various interventions under consideration, cost implications, and these require long-term dedicated
and the importance of tracking policy effectiveness over time financing. Countries at all levels of socioeconomic
through longer-term longitudinal studies. development, including low-income ones, have demonstrated
that it is possible to prioritize investments in large-scale CHW
As most of the evidence retrieved for this guideline initiatives. In contexts where this is relevant, development
originated in low- and middle-income countries, additional partners and external funders should strive to harmonize their
research should be considered in advanced economies to support to CHW programmes, and align it with public policy
better identify any differences in contextual factors and national health systems.
17
1
Introduction
Health workforce shortages, maldistribution, imbalances World Health Assembly in 2016, encourages countries to
and quality and performance challenges represent some adopt a diverse, sustainable skills mix, harnessing the
of the main obstacles to the scale-up of essential health potential of community-based and mid-level health workers
interventions and services (1). Addressing these bottlenecks in interprofessional primary care teams.
is essential for progress towards all health-related goals,
including universal health coverage and Sustainable Several systematic reviews and other studies demonstrate
Development Goal 3 to “Ensure healthy lives and promote the effectiveness of various types of CHWs in delivering a
well-being for all at all ages”. range of preventive, promotive and curative services related
to reproductive, maternal, newborn and child health (4–8),
The health workforce underpins the health goal, with a target infectious diseases (9), noncommunicable diseases (10, 11),
(3c) to “substantially increase health financing, and the and neglected tropical diseases (12). However, successful
recruitment, development and training and retention of the delivery of services requires evidence-based models for
health workforce in developing countries, especially in least educating, deploying, remunerating and managing CHWs to
developed countries and small island developing States” (2). optimize their performance and contribution to the health
Further, as evidenced by the recommendations of the United system across various health service areas. Other systematic
Nations High-Level Commission on Health Employment and reviews have identified the most effective policy approaches
Economic Growth, there is increasing recognition of the for successful integration of health workers into health
potential of the health sector to create qualified employment systems and the communities they serve. These include
opportunities, in particular for women, contributing to the job providing CHWs with predictable financial and non-financial
creation and economic development agenda (3). incentives, frequent supportive supervision, continuous
training, and embedding CHWs in health systems and in
Following decades of ebbing and flowing interest, in the the communities where they work, with clear roles and
last few years there has been growing attention to the communication channels for CHWs (13–17). There is also
potential of community health workers (CHWs) and other substantial evidence that delivering essential health services
types of community-based health workers in reducing through CHWs may represent a cost-effective approach in a
inequities in access to essential health services. The World diversity of contexts (18–20). Empowering CHWs also offers a
Health Organization (WHO) Global Strategy on Human critical opening for change towards achieving greater gender
Resources for Health: Workforce 2030, adopted by the equity within communities.
2
Rationale
The support for CHWs and their integration into the health doctors, midwives and nurses), policies and practices vary
system and in the communities they serve are uneven enormously across countries in relation to the application
across and within countries; good-practice examples are not of these same functions to CHWs. As CHWs typically
necessarily replicated and policy options for which there is undergo shorter training than health professionals, have a
greater evidence of effectiveness are not uniformly adopted. more restricted scope of practice, and in many cases are
not paid, they often exist and operate at the margins of
Although they should be considered as an integral part of or outside public policy, with varying (and often informal)
primary health care strategies and of the health system, CHW policy arrangements around their inclusion in and support
programmes are often fraught with challenges, including poor by the health systems. The added value of this guideline,
planning; unclear roles, education and career pathways; lack therefore, rests in identifying whether management support
of certification hindering credibility and transferability; multiple systems and strategies similar to those offered to other
competing actors with little coordination; fragmented, disease- occupational groups should also be applied to CHWs and
specific training; donor-driven management and funding; other community-based health workers, and if so how and
tenuous linkage with the health system; poor coordination, under what circumstances.
supervision, quality control and support; and lack of recognition
of the contribution of CHWs (21). These challenges can Governments, development partners, civil society
contribute to wastage of both human capital and financial organizations, and research and academic institutions
resources: many well intentioned and performing CHW have expressed a clear demand for scaling up CHW
initiatives fail to be properly integrated into health systems, programmes (22), and are committed to integrating
and remain pilot projects or small-scale initiatives that are CHW programmes into health systems and harmonizing
excessively reliant on donor funding; or, conversely, uneven their actions accordingly (23). Optimizing the design and
management and support for these health workers in many performance of CHW programmes requires clarity on the
contexts can result in substandard capacities and performance competencies and roles of CHWs, and agreed criteria for
of CHWs. Accordingly, the performance of community-based sustainable support by and integration into local and
health worker programmes is highly variable, hindering the full national health systems and plans (20). The guidance should
realization of their potential contribution to the implementation be based on evidence to better define factors such as the
of primary health care policies. education, regulation, remuneration, performance, quality
and career advancement prospects of these cadres. The
Whereas standard human resource management functions development of this new guideline on health policy and
such as formalized training, certification, and payment are system support to optimize CHW programmes addresses
taken as a given for professional health workers (such as this normative gap.
19
3
Target audience
3.1 End-users of the guideline
The primary target audience for this guideline is policy-makers, Secondary target audiences include development partners,
planners and managers responsible for health workforce policy funding agencies, global health initiatives, donor contractors,
and planning at national and local levels. Throughout this researchers, CHW organizations, CHWs themselves, civil
document, policy and actions at “country” or “national” level society organizations, community stakeholders and activists
should be understood as relevant in each country in accordance who fund, support, implement, conduct research into, and
with subnational and national responsibilities. advocate greater and more efficient involvement of CHWs
in the delivery of health services.
3.2 P
ersons affected by the recommendations
The most direct beneficiaries of this guideline are the CHWs The largest beneficiary group of this guideline, beyond
themselves. It is hoped and envisioned that the guideline CHWs themselves, are the individuals and communities
will contribute to increased recognition, adequate and living in these contexts, who often lack equitable access
harmonized training, better integration into the health to primary health care and other services and consequently
system and community, and improved employment and lag behind in terms of health service coverage and health
working conditions for these occupational groups. outcomes, as well as development outcomes more broadly.
The guideline, therefore, has a potential to contribute to
The scope and penetration of CHW programmes is extremely the reduction of inequities among these populations by
variable across and within countries. While reliable and strengthening the competencies, motivation, performance
comprehensive data for these health workers do not exist and management of CHWs and enhancing programme
for the majority of WHO Member States, these occupational sustainability, which in turn can improve effective
groups are most commonly employed in the context of coverage of essential health interventions.
primary health care services, particularly in expanding access
to essential health services in underserved areas, including
rural and remote areas, marginalized populations, pastoral
and nomadic communities, and urban slums.
4
Objectives and scope
of the guideline
4.1 Goal and objectives
The overall goal of this guideline is to assist national management, supervision, performance enhancement,
governments and national and international partners incentives, remuneration, governance, health system
to improve the design, implementation, performance integration and community embeddedness;
and evaluation of CHW programmes, contributing • identify relevant contextual elements and
to the progressive realization of universal health implementation and evaluation considerations at
coverage. the policy and system levels;
• suggest tools to support the uptake of the
The specific objectives of this guideline are to: recommendations at the country level in the context of
• provide gender-sensitive recommendations in the the planning and implementation of CHW programmes;
areas of CHW selection, education, continuing • identify priority evidence gaps to be addressed
training, linkage with other health workers, through further research.
4.2 Types of health workers covered by this guideline

Unclear nomenclature and classification complicate the policy The official definition of community health workers in the
discourse on CHWs: the term “community health workers” International Labour Organization (ILO) International Standard
is often used in a non-specific way, referring to a diverse Classification of Occupations (ISCO) refers to community health
typology of lay and educated, formal and informal, paid and workers as a distinct occupational group (ISCO 3253) within
unpaid health workers. the associate health professionals category (Box 1).
21
Box 1. ILO definition of community health workers (ISCO 3253)
Lead statement
Community health workers provide health education and referrals for a wide range of services, and provide support and
assistance to communities, families and individuals with preventive health measures and gaining access to appropriate
curative health and social services. They create a bridge between providers of health, social and community services
and communities that may have difficulty in accessing these services.
Task statement
Tasks include: (a) providing education to communities and families on a range of health issues including family planning,
control and treatment of infectious diseases, poisoning prevention, HIV risk factors and measures to prevent transmission,
risk factors associated with substance abuse, domestic violence, breastfeeding and other topics; (b) assisting families
to develop the necessary skills and resources to improve their health status, family functioning and self-sufficiency;
(c) conducting outreach efforts to pregnant women, including those who are not involved in prenatal, health or other
community services, and other high risk populations living to help them with access to prenatal and other health care
services; (d) ensuring parents understand the need for children to receive immunizations and regular health care;
(e) working with parents in their homes to improve parent-child interaction and to promote their understanding of normal
child development; (f) providing advice and education on sanitation and hygiene to limit the spread of infectious diseases;
(g) storing and distributing medical supplies for the prevention and cure of endemic diseases such as malaria and
tuberculosis and instructing members of the community in the use of these products; (h) assisting families in
gaining access to medical and other health services (24).
The generic definition and the blurred boundaries among Recognizing the ambiguity surrounding the use of the term
these health workers, the existence of overlapping terminology “community health worker”, and the blurred boundaries
in the literature (such as “lay health workers”, “front-line with other types of community-based health workers, this
health workers”, “close-to-community providers”), as well guideline and the corresponding methodology for the search
as widely differing policies relating to their scope of practice, strategies informing the literature reviews were developed
education, and relation with health systems, have contributed adopting a broad search strategy that, in addition to the
to undermining efforts to strengthen service delivery systems term “community health worker”, included a wide range of
at community level (13). search terms capturing both CHWs (according to the ILO
ISCO definition) and other types of community-based health
Classification according to the ISCO occupational groups and workers. This guideline therefore is primarily focused on
official job titles in a jurisdiction do not always cohere: in some CHWs but its relevance and applicability include other types
contexts, the term “community health worker” or a similar term of community-based health workers, defined in the context
is used to refer to health workers that, according to the ILO of this document as “health workers based in communities
ISCO classification, might more appropriately be referred to as (i.e. conducting outreach beyond primary health care facilities
nursing and midwifery associate professionals (ISCO 3221 and or based at peripheral health posts that are not staffed by
3222), paramedical practitioners (ISCO 2240), traditional and doctors or nurses), who are either paid or volunteer, who are
complementary medicine associate professionals (ISCO 3230), not professionals, and who have fewer than two years training
and others. Conversely, health workers who have a role and but at least some training, if only for a few hours” (25). The
profile consistent with ILO ISCO category 3253 for community full search strategy for the scoping review of the literature
health workers may be classified and termed differently in a (Chapter 5 and Annex 1), and the detailed methodology,
country or jurisdiction (for example, community health officer, including inclusion and exclusion criteria, provide additional
promoter, aide, educator or volunteer). details on the evidence base that was considered in the devel-
opment of this guideline. Additional methodological detail is
provided in the methods section of the accompanying system-
atic reviews.
4.3 Geographical areas covered
This is a global WHO guideline, and as such no restrictions from those to which the primary evidence refers. These
were posed in terms of geographical focus of the aspects are discussed in more detail under the interpretation
recommendations, nor in the search strategies of the and implementation considerations of each recommendation.
literature reviews that were commissioned.
Each review was structured according to the standard
It should be noted, however, that the majority of studies population, intervention, control, outcome (PICO) approach.
included in the 15 systematic reviews for the policy questions The setting for the questions was identified as underserved
referred to CHW experiences in sub-Saharan Africa and South communities, noting the particularly important role that CHWs
Asia, with evidence from other regions less well represented, can play in these contexts – while recognizing also that
and a more limited availability of studies from high-income underserved communities may exist in countries at all levels
countries (with the notable exception of the United States of of socioeconomic development. Many recommendations
America, where several included studies were conducted) however refer to actions and policies at the health system
(Figure 1). This has ramifications for the generalizability of level, making them of broader relevance and applicable
the evidence found and its applicability to contexts different to an entire country or jurisdiction.
Figure 1: G
eographical distribution of included studies across the 15 systematic reviews on the
PICO questions
23
4.4 Categories of interventions covered
The guideline follows a health system approach. Specifically, 13. In the context of CHW programmes, are community
it identifies the policy and system enablers required to optimize engagement strategies effective in improving
design and performance of CHW initiatives; within this overall CHW programme performance and utilization?
structure, a gender and decent work lens was adopted, in 14. In the context of CHW programmes, should practising
particular in relation to recommendations where those aspects CHWs mobilize wider community resources for health
were most relevant. The 15 policy questions that guided the versus not?
research and informed the recommendations can be structured 15. In the context of practising CHW programmes, what
into three broad categories: strategies should be used for ensuring adequate
1. Selection, education and certification availability of commodities and consumable supplies
1. For CHWs being selected for pre-service training, over what other strategies?
what strategies for selection of applications for
CHWs should be adopted over what other strategies? These questions have not been addressed through previous
2. For CHWs receiving pre-service training, should WHO guidelines and represent the core focus of this guideline.
the duration of training be shorter versus longer?
3. F or CHWs receiving pre-service training, should This guideline did not appraise critically the body of evidence
the curriculum address specific versus non- on which specific health services CHWs can deliver to
specific competencies? quality standards, and thus it contains no recommendations
4. For CHWs receiving pre-service training, should the regarding these aspects. Published evidence and existing WHO
curriculum use specific delivery modalities versus not? guidelines encourage the delegation of certain tasks relating
5. For CHWs who have received pre-service training, to prevention, diagnosis, treatment and care, for example
should competency-based formal certification be used for HIV, tuberculosis (TB), malaria, other communicable and
versus not used? noncommunicable diseases, a range of reproductive, maternal,
2. Management and supervision newborn and child health services, hygiene and sanitation,
6. In the context of CHW programmes, what strategies ensuring clients’ adherence to treatment, rehabilitation and
of supportive supervision should be adopted over services for people affected by disabilities, and advocating and
what other strategies? facilitating underserved groups’ access to services (Figure 2
7. In the context of CHW programmes, should and Annex 2). Current (and future) disease-specific WHO
practising CHWs be paid for their work versus not? guidelines remain the primary source of normative guidance on
8. In the context of CHW programmes, should which specific preventive, promotive, diagnostic, curative and
practising CHWs have a formal contract versus not? care services CHWs are effective in providing (Annex 3).
9. In the context of CHW programmes, should practising
CHWs have a career ladder opportunity or framework In addition to the delivery of interventions at the individual
versus not? and family levels, there is long-standing recognition of the
3. Integration into and support by health system potential for CHWs to play a social and political role at the
and communities community level, related to the action on social determinants
10. In the context of CHW programmes, should there of health for the transformation of living conditions and
be a target population size versus not? community organization. This dimension includes
11. In the context of CHW programmes, should participatory identification with the community of health
practising CHWs collect, collate, and use health problems and a reorientation of the concept and the model
data versus not? of health care (26, 27).
12. In the context of CHW programmes, should practising
CHWs work in a multi-cadre team versus in a single-
cadre CHW system?
Figure 2: Primary health care services for which there is some evidence of CHW effectiveness
Maternal & newborn health

Reducing neonatal mortality and morbidlity
through home-based preventive Maternal
and &
newborn health
curative care
Promoting the uptake of reproductive,
maternal, newborn and child health
behaviours and services, including Child health
antenatal care and promotion
Sexual & reproductive of breastfeeding
Immunization uptake, integrated
health management of newborn and
childhood illnesses (e.g. for malaria,
Providing contraception, increasing pneumonia and diarrhoea)
uptake of family planning
Health education
Communicable diseases
Mental health Prevention, diagnosis, treatment
Providing psychosocial, and/or and care of malaria and tuberculosis
psychological interventions to treat Counselling, treatment and care
or prevent mental, neurological for HIV/AIDS
or substance abuse disorders
Control of neglected tropical diseases
(Buruli ulcer), influenza prevention
Public health & Noncommunicable

Global Health Security diseases
Working as cultural brokers and Behaviour change (diet change,
facilitating patient access to care physical activity)
for underserved groups Increased care utilization (cancer screening,
Trauma & making and keeping appointments)
surgical care Diabetes, hypertension and
asthma management
and care
25
5
How this guideline was
developed
The Health Workforce Department at WHO headquarters led the development of this guideline in conformity with the process
and requirements outlined in the WHO handbook for guideline development (28).
5.1 Steering Group, Guideline Development Group and

External Review Group
A WHO Steering Group (SG) was established to oversee review (Annex 4, Table A4.3). The role of the ERG was to
and manage the guideline development process, with provide a peer review of a draft of the guideline document
representation from all six regions of WHO and several developed by the SG and the GDG.
departments; the United Nations Children’s Fund (UNICEF) was
also directly represented in the SG (Annex 4, Table A4.1). The Declarations of interest were collected from GDG and ERG
SG led the initial conceptualization and developed the planning members and managed according to WHO requirements. The
proposal of the guideline, identified members of the Guideline interests declared were not considered to hinder participation
Development Group (GDG) and External Review Group (ERG), in the process to develop or review recommendations (more
facilitated the GDG meetings, developed the first draft of the details are provided in Annex 4, Table A4.4). All three bodies
guideline document and made subsequent rounds of revisions (SG, GDG, ERG) had a balanced geographical, constituency and
following the inputs and comments from the GDG and ERG. gender representation.
The GDG, whose members were directly identified by the SG The GDG held a two-day meeting in October 2016 in Geneva,
on the basis of the selection criteria of the WHO handbook for Switzerland, to define the scope of the guideline through the
guideline development, was convened to refine the scope of identification of the population, intervention, control, outcome
the guideline, review the evidence summaries, and develop the (PICO) questions that would guide the retrieval of evidence, and
recommendations. Panel members included content experts, provide guidance to inform the methodology of the systematic
academic researchers, potential end-users such as planners reviews of the literature.
and policy-makers from governments, CHWs, health sector trade
unions and professional association representatives, and experts A public hearing was held in advance of the first GDG
skilled in guideline development (Annex 4, Table A4.2). meeting on the scope of the guideline, as a result of which
over 60 contributions were made. The GDG considered
The ERG was formed through an open call for expressions of the inputs from the public hearing in its deliberations, and
interest and a competitive selection process, which assessed broadened the scope of the guideline from the initial list of
the technical capacity to contribute to the guideline peer 10 PICO questions to a final total of 15. The second meeting
of the GDG took place over three days in December 2017 in recommendations, the GDG made a strong recommendation
Addis Ababa, Ethiopia, to review the evidence summaries despite the low or very low certainty of the evidence, taking
and formulate the guideline recommendations. into account other factors, including health workers’ rights
and equity and gender considerations. In the cases where
In developing the evidence to decision tables, the GDG strong recommendations were proposed despite a low or
considered the evidence and other elements under very low certainty of the evidence, the GDG took an explicit
consideration, including the magnitude of effects, balance of vote, the outcome of which is reported in the sections
benefits and harms, costs and cost-effectiveness, implications referring to the specific recommendations. In the cases
for health equity, acceptability and feasibility. when voting took place, a majority was defined as 80%
or above of the voting members in attendance at the
In relation to the direction and strength of recommendations, GDG meeting.
the GDG always attempted to make decisions through
discussion leading to a consensus. In most cases it Following the second meeting of the GDG, the SG prepared
was possible to achieve a unanimous decision through a draft of the guideline document, which was reviewed
discussion, and no explicit voting was required for the subsequently by the GDG and ERG, revising and improving the
majority of recommendations under consideration. For most draft through an iterative process, before formal submission
recommendations a low or very low certainty of the evidence to the WHO Guidelines Review Committee, which approved
translated into conditional recommendations. For a few the guideline document on 20 June 2018.
5.2 Sources of evidence for guideline

Three main sources of evidence were specifically commissioned in support of the development of this guideline and were
considered as the main information basis:
• An overview of the relevant literature was developed involving CHWs across all countries (Table 1); the
through a systematic review of published literature results were then further searched for studies of
reviews (29); 11 databases were searched for review specific relevance to the 15 PICO questions. In
articles published between 1 January 2005 and 15 addition, a 16th review was conducted consolidating
June 2017. Review articles on CHWs with no more common factors relating to feasibility, acceptability
than two years of training were included. The review and implementation considerations. Specific
team assessed the methodological quality of the inclusion and exclusion criteria were developed
reviews according to AMSTAR criteria and reported antd applied consistently throughout the reviews
findings based on PRISMA standards.2 (Table 2). The methodology of the reviews included
• Dedicated systematic literature reviews were an attempt to stratify evidence according to a set
conducted for each of the 15 PICO questions. Eight of criteria differentiating CHWs according to such
electronic databases were searched for relevant characteristics as their role, level of training, status
studies: Medline, Embase, the Cochrane library, and remuneration. The reviews adopted a common
CINAHL, PsycINFO, LILACS, Global Index Medicus and methodology, including reviewing the certainty
POPLINE. In addition, three databases (OpenGrey, of the evidence through GRADE evidence profiles,
TROVE, and Google Scholar) were searched for the Cochrane Risk of Bias tool, the Newcastle-
grey literature. All 15 systematic reviews referring Ottawa Scale and the GRADE Confidence in the
to the 15 PICO questions were underpinned by an Evidence from Reviews of Qualitative research
initial search to broadly identify all possible studies (CERQual).
2
AMSTAR = Assessment of Multiple Systematic Reviews; PRISMA = Preferred Reporting Items of Systematic reviews and Meta-Analyses.
27
A stakeholder perception survey was carried out to assess the the Healthcare Information For All (HIFA) online platform; and
relative importance of different outcomes, and the feasibility participants at the 2017 Institutionalizing Community Health
and acceptability of the interventions under consideration in Conference held in South Africa in 2017. Eligible participants
the emerging guideline (30). included stakeholders who were involved directly or indirectly
in the implementation of CHW programmes in countries.
A self-administered online survey was disseminated in English Responses were graded using a 9-point Likert scale (with
and French languages to stakeholders through three major 9 being the highest level of importance, acceptability or
channels: the WHO human resources for health contact list; feasibility, and 1 the lowest).
Table 1: Overarching search strategy for the 15 PICO questions

PICO category Approach
Population Studies that focus on CHWs as defined through specific inclusion criteria were included in the project. This overarching search
was applied to all PICOs that were part of this project.
Intervention PICO-specific search strings were developed to capture the different interventions included in each of the 15 systematic
reviews. Each of these specific search strategies was combined with the overarching search to form the final search strategy
for each systematic review topic.
Control No further search terms were utilized to limit the output to specific comparison conditions. All studies were included
irrespective of the comparisons reported.
Outcome(s) No further search terms were utilized to limit the output to specific outcomes. Instead, all publications were retrieved
irrespective of the outcomes reported.
Study design Any study design was included in the 15 systematic reviews.
Table 2: Inclusion and exclusion criteria

Included Excluded
Publications that report a study Publications that do not report a study, e.g. opinion pieces, editorials,
conference abstracts; single case studies; letters; advocacy materials
Studies focused on practising community health workers: Studies focused on non-CHWs such as nurses, doctors, formally trained
• CHWs who carry out population-based, health-related activities nurse aids; medical assistants, physician assistants; paramedical workers
in their community in emergency and fire services; others who are auxiliaries, e.g. mid-level
• these activities take place in a community they are directly workers and self-defined health professionals or health paraprofessionals;
connected to (they live in the community; are accountable to traditional, faith and complementary healers and traditional birth attendants
the community)
Studies focused on non-practising (i.e. retired or unemployed) CHWs
• CHWs who have received no or only basic formal training;
this training may be recognized by health services or a
certification authority, but it is not a part of a formal tertiary
education programme or qualification (e.g. degree, diploma,
title, certificate course)
Studies conducted in high-income countries, and in low- and
middle-income countries
Studies conducted in underserved community settings (as identified Studies conducted in well-served community settings
by the authors of the primary studies)
Studies conducted in general population settings Studies conducted in specific population settings (e.g. refugee camps,
nomadic populations)
Studies published in English Non-English studies
Studies published in 1990 or later Studies published before 1990
6
Results
6.1 Systematic review of reviews
An international team based in Johns Hopkins University (whereby community members have a sense of ownership
was selected through a competitive procurement process of the programme and positive relationships with the CHWs),
to conduct the systematic review of reviews. supportive supervision, continuous education, adequate
logistical support and supplies, and integration with the health
The objective of this analysis was to synthesize current system. The review team found gaps in the evidence, including
understanding of how CHW programmes can best be on the rights and needs of CHWs, on effective approaches
designed and operated in health systems. The review team to training and supervision, on CHWs as community change
identified 122 reviews (75 systematic reviews, of which agents, and on the influence of health system decentralization,
34 were meta-analyses, and 47 non-systematic reviews). social accountability, and governance. While the findings of the
CHW programmes included in these reviews were diverse in systematic review of reviews, having captured evidence from
the interventions provided, selection and training of CHWs, independently commissioned reviews, were typically not specific
supervision, remuneration and integration into the health to the focus of the PICO questions, in several cases they provided
system. Features that appeared to enable positive CHW useful complementary evidence and contextual information on
programme outcomes included community embeddedness some of the PICO questions.
6.2 Systematic reviews on the 15 PICO questions

The Centre for Evidence and Implementation, in consortium In the aggregate, a total of 137 studies were included in the
with the University of Melbourne, Campbell Collaboration, 15 PICO reviews, out of a total of 87 933 abstracts meeting
International Initiative for Impact Evaluation (3ie), University the initial screening criteria (Figure 3). Some reviews found
of Toronto, University of Newcastle, University of Sydney, several dozen articles to be eligible for inclusion, while others
University of Adelaide, University of Iowa, American Institutes did not result in the inclusion of any study. Despite a deliberate
for Research and Aga Khan University, was selected through a attempt to do so, most of the identified studies did not provide
competitive bidding process to develop the systematic reviews sufficient information on the characteristics of CHWs to allow a
for each of the 15 PICO questions selected by the GDG. stratification of the findings and the resulting recommendations
29
according to the characteristics of CHWs, such as their role, level Detailed findings on evidence and policy implications are
of training and payment status. An important limitation of the categorized based on the PICO questions and discussed in more
PICO-specific systematic reviews was that only English language depth in the next section on the guideline recommendations. The
studies were included. The broader evidence on CHWs published full text of the draft literature reviews is available on the WHO
in languages other than English was however captured by the website.3 In addition, the evidence gaps identified through the
review of reviews, whose search strategy had no language systematic reviews have been consolidated in the section on
restrictions, and which included also four reviews published in research gaps.
Portuguese. The review of reviews also captured – indirectly
through the reviews identified – the evidence from primary Validation and quality assurance of the systematic reviews was
studies published in multiple languages. provided through peer review by the commissioning department
(WHO Health Workforce Department), other members of the SG,
and selected members of the GDG and ERG.
Figure 3: PRISMA diagram of studies assessed by the systematic reviews

Identification
Citations from Citations from

Citations from
database Grey literature
expert(s)
searches searches
n = 15,554
n = 67,129 n = 5250
Duplicates removed
Met abstract
Screening
Abstract
n = 26,343
screening
criteria
Ineligible records
n = 87,933
n = 55,984
Not eligible n=5373

Full-text screening
Published pre-1990 : n = 532

Studies Not in English: n = 84
selected for Not a study: n = 774
full text Not focused on CHW: n = 701
screening Could not be Outcomes not relevant to PICO: n = 1469
n = 5606 located Intervention not relevant to PICO: n = 1789
n = 106 Duplicate reference: n = 24
Studies included: n=137

Studies
Included
Eligible Eligible Eligible included from

quantitative qualitative methods reference
studies studies studies review
n = 55 n = 63 n = 19 n=4
3
T he drafts of the literature reviews are available for consultation and reference to contextualize the contents of this guideline. The systematic reviews
will also be submitted for consideration by peer-reviewed journals, and might undergo some additional modifications as a result of the peer review and
editorial process.
6.3 Stakeholder perception survey
A survey was conducted to assess the acceptability and critical. The most critical outcomes were increased health
feasibility of the policy options under consideration in the service coverage and improved quality of health services
guideline by stakeholders, with a view to increasing uptake provided by CHWs. Most of the health policy and system
and use of the emerging recommendations. interventions under consideration in the guideline were also
deemed to be acceptable and feasible for implementation.
A total of 96 submissions were obtained, with representation Acceptability and feasibility were uncertain for a few
largely from policy-makers, planners, managers and interventions considered, such as the use of essential and
researchers involved in the design, implementation, desirable attributes to select CHWs for pre-service training;
monitoring and evaluation of CHW programmes. The majority these included, for example, selecting CHWs on the basis
of the respondents were from the African Region; a limitation of age and completion of a minimum secondary level of
was that CHWs themselves were not adequately represented education. The findings of the survey – presented in Annex 5
in this group. All outcomes of the CHW interventions were – informed the development of evidence to decision tables
deemed to be at least important and several were rated as and ultimately the recommendations by the GDG.
31
7
Recommendations
Recommendation 1: Selection for pre-service training
Recommendation 1A
WHO suggests using the following criteria for selecting CHWs for pre-service training:
• minimum educational level that is appropriate to the task(s) under consideration;
• membership of and acceptance by the target community;
• gender equity appropriate to the context (considering affirmative action to preferentially select women to empower them and, where culturally
relevant, to ensure acceptability of services by the population or target group);
• personal attributes, capacities, values, and life and professional experiences of the candidates (e.g. cognitive abilities, integrity, motivation,
interpersonal skills, demonstrated commitment to community service, and a public service ethos).
Certainty of the evidence – very low. Strength of the recommendation – conditional.
Recommendation 1B
WHO suggests not using the following criterion for selecting CHWs for pre-service training:
• age (except in relation to requirements of national education and labour policies).
Recommendation 1C
WHO recommends not using the following criterion for selecting CHWs for pre-service training:
• marital status.
Certainty of the evidence – very low. Strength of the recommendation – strong.
7.1.1 Background to the recommendation 7.1.2 Rationale for recommendation

Effective CHW recruitment and selection for pre-service The GDG considered the benefits and harms of having
training may improve CHW performance and the quality of selection criteria for enrolment of candidates in pre-service
services delivered. Selection criteria may vary depending on education to become CHWs. The GDG consensus view was
which sociodemographic characteristics are most relevant that selection of the most appropriate people as CHWs is
to the community or to the intervention being delivered. crucial to the success of a community health intervention.
For large-scale CHW programmes, criteria considered The choice of criteria to be adopted, however, depends on
typically include age, gender, literacy level, educational the evidence of effectiveness, as well as broader policy
attainment, marital status and geographical location (31). considerations related to values and preferences, which
The active involvement of the community being served in the may vary considerably across different contexts.
recruitment of CHWs is typically assumed to ensure that the
CHW is trusted and accepted into the community. Furthermore, the GDG noted that this recommendation touches
on a human rights dimension, the fundamental right of equality
of opportunity and treatment in employment or occupation (32).
On balance, based on an assessment of the available evidence, 7.1.3 Summary of evidence
the GDG experience, and a rights-based perspective, the GDG The systematic review (Annex 6.1)4 addressing the following
concluded that the potential benefits outweigh the harms question – “In community health workers being selected
when CHWs are selected for pre-service training based for pre-service training, what strategies for selection of
on personal attributes and capacities, such as motivation, applications for CHWs should be adopted over what other
integrity, interpersonal skills, memberships of and acceptability strategies?” (34) – identified 16 eligible studies, of which
by the community, through community engagement in the three were quantitative (35–37) and 13 were qualitative
selection process, and appropriate minimum education level. (38–50). Ten of them referred to CHW programmes in
Conversely, the potential risks, particularly in relation to unfair sub-Saharan Africa, with three studies from South-East
discrimination, probably outweigh the potential advantages Asia and two from the Region of the Americas. All studies
with regard to criteria such as age and, in particular, referred to experience from low- and lower middle-income
marital status. Given multiple barriers that women face to countries, except one from the United States of America.
workforce participation and the resultant gender stratification The review identified some evidence that higher levels of
inequities in the global health workforce, proactive policies education may improve productivity and health knowledge,
are encouraged to promote gender equity (33) and maximize two essential elements for the provision of efficient and
women’s participation in selection and recruitment. And in effective services. This may be related to higher levels of
some circumstances – where the role and cultural norms of literacy enabling quicker and more accurate completion of
CHWs dictate – it may be appropriate to restrict selection to certain tasks. The findings from quantitative studies were
women, for instance where the delivery of reproductive and supported by additional insights from qualitative studies
maternal health services is accepted by the communities only that highlighted that more highly educated CHWs were
if the providers are female. viewed more positively than less educated CHWs when
performing potentially difficult tasks. One practice that has
The certainty of the evidence was found to be very low been perceived in qualitative studies as probably leading to
(see below). Because of this, the GDG made a conditional more positive results is involvement of community members
recommendation in favour of adopting as selection criteria in the CHW selection process. Results seem to indicate that
personal attributes, membership of and acceptance by the communities may play an important role in determining the
community, and appropriate minimum education levels, success of CHWs. Overall, the certainty of the evidence was
while recognizing that good practices outside the minimum rated as very low.
education levels recommended in this document exist.
The systematic review of reviews found that CHWs are
No evidence was found on the adoption of age as a selection accepted by communities when community members trust
criterion. Recognizing the risk for misuse resulting in and respect them and feel a sense of ownership over the
potentially discriminatory policies, the GDG decided on a programme, which can be achieved by giving communities
conditional recommendation against this criterion. As no a role in CHW selection and definition of CHW activities (51).
evidence was found supporting the use of marital status The community’s acceptance of CHWs and their sense that
as a selection criterion, but recognizing that it is applied the CHW programme is locally appropriate and “owned”
in some settings, the GDG made unanimously a strong is probably associated with increased CHW retention,
recommendation not to use marital status as a selection motivation, performance, accountability and support.
criterion in order to avoid the risk of discriminatory practices.
Using marital status as a criterion would encroach on human The stakeholder perception survey identified a high
rights relating to access to education and employment acceptability and feasibility of selecting CHWs on the basis
opportunities, with the risk of unfair and unnecessary of their personal attributes (for example, cognitive abilities
discrimination. The GDG was also concerned that selection and prior relevant experience) and membership of the target
based on marital status might perpetuate and exacerbate communities, but variable and uncertain feasibility and
existing gender disempowerment dynamics. acceptability of selection based on level of education and,
especially, age.
4
A nnex 6 summarizes the main evidence elements emerging from each of the 15 reviews which were considered in the formulation of the guideline
recommendations. Due to size it is available only as a web annex.
33
7.1.4
Interpretation of the evidence and other Gender. No evidence was found supporting gender as a
considerations by the GDG selection criterion. The GDG considered that from an equity
Level of education. The most appropriate level of primary and rights perspective, it is necessary to avoid unfair
or secondary education prior to CHW training may depend discrimination based on gender. Considering the existing
on the complexity of the tasks undertaken by CHWs. While gender inequities, particularly in low-resource settings,
a higher level of prior education may be associated with the GDG noted the importance of adopting in the selection
improved knowledge and performance, attrition (due to process criteria that would be instrumental in improving
better and more diverse work opportunities) might be higher gender equity. Recruitment and selection procedures that
among more educated CHWs. A requirement for relatively maximize women’s participation and promote women’s
higher levels of education may restrict excessively the pool empowerment should be encouraged. The GDG also
of potential candidates, risks excluding women in particular recognized that in certain cultural contexts it is necessary
in many contexts, and would be difficult to implement in for certain services – particularly reproductive, maternal,
contexts with low levels of educational attainment. The newborn and child health – to be rendered by female
minimum level of education considered to be appropriate providers. The choice on the use of gender as a selection
will depend on the tasks to be delivered, the context of the criterion under certain circumstances and for certain services
services and the training support available. Testing for certain should be made on the basis of the local sociocultural context
competencies during selection (for example, literacy and and the specific role expected of the CHWs.
numeracy) may be considered as an alternative approach
in contexts where employing strict education attainment Marital status. Marital status is used as a selection criterion
requirements would imply restricting excessively the in some contexts. However, no evidence was found to support
applicant pool, for women in particular. the use of marital status as a selection criterion. In contrast
to other selection criteria, the GDG considered that there are
Membership of target community. The GDG considered no circumstances under which any theoretical (and unproven)
that membership of and acceptance by the target community benefits of the use of marital status can plausibly outweigh
(whether defined in geographical terms or in relation to its negative implications. The use of this criterion therefore
population group, such as nomadic communities, people can limit the potential for recruitment of effective CHWs and
living with HIV, caste, religion or cultural beliefs) may could represent an unjustifiable discrimination and violate
represent an important criterion in the selection process. human and labour rights. With the aims to improve equity
and the potential pool of effective CHWs, the GDG therefore
Age. No evidence was found to justify age as a selection adopted a strong recommendation against the use of marital
criterion (beyond adherence to the minimum legal working status as a selection criterion.
age). Age can be an important factor in some contexts, but
it is not necessarily clear in which way it can or should be 7.1.5 Implementation considerations
used: educating younger CHWs may theoretically contribute Successful pre-service selection is likely to involve more than
to a longer working lifespan, but at the same time there are screening formal qualifications of candidates, such as their
reports of higher turnover among younger CHWs. Individual level of education. Individual attributes and values to consider
values and capacities gained through previous life experience in the selection process may include relevant cognitive
may be more important than age. The GDG considered that skills, prior relevant work experience, a demonstrated
from an equity and rights-based perspective, the potential commitment and attitude to community service, leadership
harms of discriminating based on age would probably skills, being proactive, cooperative and adaptable, and
outweigh potential benefits under most circumstances. the capacity and willingness to progressively develop an
Age should therefore not be a restricting factor; personnel understanding of the local context and community. It may
responsible for selection should prioritize other criteria, such be important to complement screening and selection with
as relevant life experience, acceptability, caring attitude, community involvement; the selection of an eligible CHW
commitment and other relevant individual attributes. from within the community may also facilitate the delivery
of more linguistically and culturally appropriate services. bias and discrimination should be avoided. In some contexts,
Where a CHW from outside the community must be selected preferential selection of female CHWs for the delivery of
(for example, because no one from the community wants reproductive, maternal, newborn and child health services
to perform the task or meets the minimum requirements to may be necessary to ensure acceptability by communities.
serve in that role), ensuring that the community members Community and end-users may need to take into
still have a voice may improve the chances that the CHW consideration as selection criteria core values and
will be integrated and that they can more meaningfully help attributes of the candidates.
the health organization tailor services to local needs. In
addition, community participation in CHW recruitment and The selection criteria should take into consideration
selection enables a dialogue between community members acceptability and feasibility, as well as suitability in the
and health organizations, helping them understand local local context and in relation to the needs of the end-users
issues. The selection process should take into account the of services.
values of the inherent community structures. Potential for
Recommendation 2: Duration of pre-service training

Recommendation 2
WHO suggests using the following criteria for determining the length of pre-service training for CHWs:
• scope of work, and anticipated responsibilities and role;
• competencies required to ensure high-quality service delivery;
• pre-existing knowledge and skills (whether acquired through prior training or relevant experience);
• social, economic and geographical circumstances of trainees;
• institutional capacity to provide the training;
• expected conditions of practice.
Certainty of the evidence – low. Strength of the recommendation – conditional.
7.2.1 Background to the recommendation days), whereas programmes where CHWs play a polyvalent
The effectiveness of CHWs may be affected by the role across different areas of primary health care typically
pre-service training they receive (52). Inadequate training have a pre-service duration of several months. The GDG also
may leave CHWs ill equipped to manage health issues and noted the heterogeneity of CHW roles and responsibilities,
can adversely affect their motivation and commitment (53). and in the baseline capacity and conditions, as well as the
Currently the length of CHW training is not standardized, with wide variability of duration of training across countries. In
its duration ranging from a few hours to several years (54, light of these factors, the prevailing view of the GDG was
55). Longer training periods are typically assumed to allow that, while duration of training is an important determinant
greater exposure to training content designed to enhance of the expertise and capacity of CHWs to provide services,
knowledge, skills and competence; more comprehensive the appropriate duration of training should be determined
training, however, may be cost prohibitive, impractical and in at the national level or in a specific jurisdiction according
some cases unnecessary (56). to the local context and requirements. Therefore, the GDG
focused on the identification of the criteria that should inform
7.2.2 Rationale for recommendation the domestic policy dialogue on the determination of an
The GDG approached this question from the perspective appropriate duration of pre-service training.
of exploring whether an ideal or desirable duration for
pre-service training of CHWs could be identified. Evidence 7.2.3 Summary of evidence
gathered through the systematic review process was limited, The systematic review (Annex 6.2) conducted for this
and was largely concerned with comparing models with question – “For community health workers (CHWs) receiving
relatively short training durations (a few hours versus a few pre-service training, should the duration of training be shorter
35
versus longer?” (57) – identified eight eligible studies (six may be related to required competencies, which may be
quantitative, two qualitative). Four of the included studies basic or advanced depending on expected roles (promotive
were conducted in three countries in Africa (Uganda, United and preventive versus also curative), as well as pre-existing
Republic of Tanzania, Zambia), two in the United States, and literacy and numeracy. Factors such as scope of work,
one each in Haiti and Lao People’s Democratic Republic. All anticipated role, overall workforce composition and service
the studies comparing different training durations referred delivery model may determine the content of training and as
to intervention and control groups of very short duration a reflection also the length of the training.
(days or hours of training). Two trials comparing training
duration suggested that training of greater duration or Factors influencing the most appropriate length of the
frequency (for example, half a day versus half an hour, or training can include status after training (for example,
three hours versus no training) may be positively correlated contracted or paid full-time employee versus part-time
with improved measures of CHW competency in screening volunteer); scope, responsibilities and roles; baseline
and diagnostic test performance (58, 59). Findings from knowledge and skills (for example, in some contexts it may
three cross-sectional studies regarding associations between be necessary to provide some initial bridging basic literacy
measures of CHW competency and pre-service training and numeracy training to compensate for a limited level of
duration were however equivocal, with one study showing an prior educational attainment); prior relevant professional
association of greater competency with longer initial training and life experience (for instance, some trainees may have
duration (60), one study showing mixed effects for extended meaningful pre-existing capacity through membership of
training (61), and another showing an inverse relationship patient support groups or similar); institutional capacity
between training duration and competency (62). One cluster to provide the trainings (including availability of training
randomized controlled trial (RCT) did not find a difference infrastructure, faculty and workplace supervisors); social
in CHW skill advancement with regard to the number of and geographical circumstances of trainees (for instance,
attempts required to pass the course examination between for CHWs coming from or operating in isolated geographical
groups of CHWs undergoing pre-service education of different locations, a limited access to supportive supervision may
duration (63). Two qualitative studies reported a preference require a longer initial duration of training).
by CHWs for longer training (64, 65). The systematic review
team rated the overall certainty of the evidence as low. 7.2.5 Implementation considerations
The most appropriate duration of training should be
The systematic review of reviews found that CHW training established in a national or subnational context on the basis
resulted in improvements in CHW knowledge or skills, of local needs and circumstances, including the need to
but that training duration had no consistent effect on the maintain a clear delineation of roles and responsibilities
effectiveness of the intervention (16, 66). The optimal amount with other types of health workers working in the context
and type of training required by CHWs must be understood in of integrated primary health care teams. Training duration
relation to the health system context, the CHWs’ pre-existing should be feasible, acceptable and affordable in the context
skills and experience, the status of CHWs, and the roles that of a specific jurisdiction, while long enough to ensure that
they are expected to play (17). the desired level of competencies and expertise is achieved.
As these vary substantially based on the role that CHWs play,
The stakeholder perception survey identified a generic longer it is expected that CHWs with a polyvalent role and working
duration of training to be acceptable and feasible (without on a full-time or regular basis (that is, those delivering more
mentioning a specific cut-off point to define longer training). complex interventions or a wide range of primary health care
services) would require longer training than those providing
7.2.4 I nterpretation of the evidence and other a single focused service on a more occasional basis. Table
considerations by the GDG 3 provides selected examples of pre-service education that
The scope and roles of CHWs are varied, hence it is not is considered by national policy-makers to be of appropriate
appropriate to define in quantitative terms at global level a duration (typically several months) in relation to the learning
minimum duration of pre-service training. Training duration objectives of CHWs with a polyvalent role. CHWs with a more
limited set of responsibilities have a shorter pre-service The length of the training might also need to reflect the need
education (for example, 23 days for accredited social health for and appropriateness of phased training based on different
activists in India) (67). modules delivered after some intervals of practice. Besides
length of training, the adoption of relevant adult learning
In determining the most appropriate length of training, the practices and the appropriate design of the training programme
role and importance of cross-cutting skills (for example, may be equally or even more important in determining the
patient communication, community engagement) should be effectiveness of pre-service education. The education approach
factored in, avoiding too narrow a focus on the transfer of should be seen holistically as part of a broader set of strategies
only diagnostic and clinical skills. that include also appropriate quality, frequency and relevance
of supportive supervision and opportunities for periodic
retraining and continuous professional development.
Table 3: Duration of training for CHWs with a polyvalent role

Country Local name of CHWs Role Duration of
pre-service
training
Ethiopia Community health extension workers Promotive and preventive activities; diagnosis, basic treatment 12 months
and referral services for most prevalent conditions; essential (30% theoretical,
behaviour change communication; administrative duties, including 70% practical)
health record keeping, organization of services at community level,
management of essential medical supplies
Mozambique Agentes polivalentes elementares Illness prevention and health promotion activities; nutritional 4 months
and vaccination surveillance; diagnosis, treatment and referral (approximately 50%
of common conditions; family planning, pregnancy and newborn theoretical, 50%
follow-up; HIV and TB adherence; health data reporting practical)
Pakistan Lady health workers Provide primary health care services, with special emphasis on 15 months
reproductive, maternal, newborn, child and adolescent health, and (20% theoretical,
organize communities by developing women’s groups and health 80% practical)
committees in the catchment areas
Source: Adapted from Bhutta et al. (13).
Recommendation 3: C
ompetencies in curriculum for pre-service training
Recommendation 3
WHO suggests including the following competency domains for the curriculum for pre-service training of CHWs, if their expected role
includes such functions.
Core:
• promotive and preventive services, identification of family health and social needs and risk;
• integration within the wider health care system in relation to the range of tasks to be performed in accordance with CHW role, including referral,
collaborative relation with other health workers in primary care teams, patient tracing, community disease surveillance, monitoring, and data
collection, analysis and use;
• social and environmental determinants of health;
• providing psychosocial support;
• interpersonal skills related to confidentiality, communication, community engagement and mobilization;
• personal safety.
Additional:
• diagnostic, treatment and care in alignment with expected role(s) and applicable regulations on scope of practice.
Certainty of the evidence – moderate. Strength of the recommendation – conditional.
37
7.3.1 Background to the recommendation additional specific curriculum topics within community
Ensuring CHWs have the necessary skills to fulfil their role mobilization, basic newborn care and group counselling.
within the community is essential to making sure they have Consistent findings were reported across the included
a positive effect on population health outcomes. However, trials: the addition of training with specific curricula
currently there are no standards as to how CHWs should be components improved CHW provision of several postnatal
trained or how the adequacy of their skills should be assessed care practices (proportion of births) in line with evidence-
(54). Consequently, there is wide variation in the content of based recommendations, and reduced stillbirth and neonatal
training programmes and the assessment of CHWs (52). mortality rates. The findings provide some evidence to
support the inclusion of additional specific curricula as part
Despite the importance of the competence of CHWs, the of CHW training, at least in the community contexts in which
relative benefit of more broad or specific competencies these studies were undertaken. The overall certainty of the
as part of CHW training is unclear. A broad set of core evidence was rated as moderate.
competencies may ensure that all CHWs have the basic
skills necessary to adequately carry out their role. However, The systematic review of reviews found that training should
keeping training and assessment flexible and based on the seek to impart both technical competencies and socially
specific needs of the target community may help to tailor the oriented capacities, such as skills in communication and
skills of CHWs to their context (68). counselling, as well as awareness of the importance of
confidentiality (5, 17, 53). Awareness of the social and
7.3.2 Rationale for recommendation political determinants of health (72) and problem-solving
The GDG recognized that the heterogeneity of roles played skills were also identified as being important (51).
by CHWs requires and benefits from considerable flexibility
in determining the contents of curricula for pre-service The stakeholder perception survey identified high levels
education. The logic underpinning the recommendation of acceptability and feasibility of different components of
was that while roles – and thus competencies required – CHW training, such as preventive and promotive behaviours,
may vary, the general principle, supported by some limited community engagement, and integration into health systems,
evidence, is that the addition of specific competencies but variable and uncertain levels of the acceptability and
and skills to the curriculum improves the capacity and feasibility of including a medical orientation to some elements
performance of CHWs to perform the corresponding task(s). of the curriculum through the inclusion of diagnostic and
The recommendation was framed as a conditional one, curative competencies.
recognizing both the importance of adapting it to national and
local context and the moderate certainty and very 7.3.4 Interpretation of the evidence and
limited scope of the underpinning evidence. other considerations by the GDG
The scope and roles of CHWs vary substantially across
7.3.3 Summary of evidence countries and CHWs, hence it is not possible to standardize
The systematic review (Annex 6.3) conducted on the the scope of pre-service education and contents of curricula.
question – “For community health workers (CHWs) receiving This is already reflected by the wide variations in the content
pre-service training, should the curriculum address specific of training curricula across countries (Table 4), with some
versus non-specific competencies?” (69) – identified countries emphasizing predominantly competencies relating to
two eligible studies, namely a pilot quasi-experimental reproductive, maternal, newborn and child health and others
(non-randomized) trial (70) and a larger cluster RCT (71) taking a broader approach. Some curricula, for example,
conducted in rural villages in Pakistan in 2008 (pilot) and focused exclusively on preventive and promotive interventions,
2011 (full trial). The study included lady health workers while others also included diagnostic and curative
(pilot N = 96, full trial N = 288) providing basic antenatal competencies. The evidence identified through the systematic
care services. In both trials, training in the intervention review, while of moderate certainty, refers to a single type of
communities consisted of the standard curriculum plus CHW in a single country, hence it is of limited generalizability
and applicability. The inclusion of competencies in curricula competencies listed in the recommendation, should also
should therefore be guided by requirements in the national acquire, as a result of their training, an understanding of
context, while also reflecting international best practices, as the importance of working within the scope of their role and
also reflected in other WHO guidelines. competencies. Specific circumstances, such as emergencies,
may trigger the need to add further competencies in addition
7.3.5 Implementation considerations to the core ones. In addition to determining the most
The most appropriate contents of CHW training should appropriate contents of training, due attention should be
be established at the country level (either in a national given to factors such as the availability of quality faculty,
or subnational context) on the basis of local needs and training materials and appropriate training infrastructure.
circumstances. CHWs, in addition to the specific technical
Table 4: Variations in contents of pre-service training curriculum for CHWs

Clinical, diagnostic and Disease prevention, Counselling, motivation Community Management
curative services health promotion and and referral skills mobilization and
rehabilitation administration
Bangladesh Treatment for 10 essential Family planning and Counsel mothers and Encourage people
diseases: anaemia, cold, prevention of arsenic caregivers for newborn care to seek care, home
diarrhoea, dysentery, fever, poisoning, tetanus toxoid (TT) management. Counselling visits
goitre, intestinal worms, immunization for women, child skills for encouragement
ringworm, scabies and growth monitoring, family of breastfeeding. Prenatal
stomatitis. Treatment of planning, breastfeeding, caring and postpartum counselling.
tuberculosis through Directly practices, personal hygiene Verbal referral skills
Observed Therapy (DOT). and use of iodized salt
Delivery services and newborn
resuscitation. Take obstetric
history, observe the process of
labour, examine neonates, and
record findings. Visual training
for neonatal signs. Case
management of pneumonia in
children, including neonates
Bhutan First aid treatment for Outbreak notification, health Referral services Immunization
emergencies and minor illness education for family planning outreach, community
development
activities
Brazil Use of oral rehydration salts Promotion of breastfeeding, Home visits, social Data collection
for diarrhoea, management healthy family practices mobilization, linking including
of pneumonia and growth families to health demographic,
monitoring. Prenatal care services epidemiological
including laboratory tests, and
clinical exams, breastfeeding socioeconomic
counselling and iron information of
supplementation families
Burkina Child delivery, asepsis
Faso and simple obstetrical
manipulations
China Prenatal maternal care services
to mothers at grass-roots level,
prescription of antibiotics and
minor surgical interventions
(continued)
39
Table 4: Variations in contents of pre-service training curriculum for CHWs (continued)

The Gambia Home births, antenatal and Malaria chemoprophylaxis Referrals to health facility
postnatal care
Ghana Care during antepartum,
intrapartum and postpartum
period
Guatemala Detection of obstetric Teaching women to recognize Referral for obstetric
complications danger signs in pregnancyㅇ complications, encourage
women to go for antenatal
care
India Provide antenatal, natal Family planning services Nutrition counselling, Community Registration and
and postnatal care, provide assessment and referrals of mobilization, home follow-up of
maternity kits. Provide tetanus sick newborns to hospital, visits and household pregnant women
toxoid (TT) immunization, identification of high-risk registration
primary health care services pregnancies
Islamic Maternal and child Family planning, case finding, Follow-up of diseases
Republic health care environmental health and
of Iran occupational health
Kenya Using simplified integrated Promotion of family planning,
management of childhood immunization and HIV
illness guidelines to classify prevention
and treat malaria, pneumonia
and diarrhoea/dehydration
concurrently, and use
flowsheets to assist in the
application of these algorithms
Malaysia Simple hygienic procedures,
cleanliness and basic nutrition
education
Mali Antimalarial treatment for Counselling on disease Referral services for acute Community ,
patients of all ages, zinc and prevention, health promotion, severe symptoms such mobilization, liaison
oral rehydration therapy for and family planning as difficulty in breathing with community
diarrhoea (children), amoxicillin and convulsions, as well volunteers, support
for treatment of pneumonia as prenatal, postnatal, and for mass distribution
(children), treatment of neonatal monitoring and campaigns (bednets,
acute malnutrition without referral deworming)
complication, provision of
contraception
Nepal Interventions including iron Health education
and folate supplementation,
deworming and TT vaccination,
recognition of danger signs,
skilled birth attendance,
emergency obstetrical care and
essential newborn care
Pakistan Safe motherhood, education on Raising awareness
danger signs of pregnancy regarding primary
health care, including
reproductive health
(continued)
Table 4: Variations in contents of pre-service training curriculum for CHWs (continued)

Peru Case management of diarrhoea Refer cases needing care to Map out population,
and pneumonia higher facilities identify and track
households with
young children and
pregnant women
Uganda Antimalarial treatment Counselling on disease Referral services for acute Community Registration
for malaria, zinc and oral prevention, health promotion, severe symptoms, such mobilization, support of households
rehydration therapy treatment and family planning as difficulty in breathing for mass distribution in their
for diarrhoea, amoxicillin and convulsions, as well campaigns (bednets, catchment area.
for treatment of pneumonia, as prenatal, postnatal, and deworming) Support and
screening of newborns and for neonatal monitoring and engagement with
acute malnutrition referral village health
committees
West Pap smears and breast Health promotion of Counselling and services Postpartum
Bank, Gaza examination contraception and breast and tailored to the needs of home visits
Strip and cervical cancer awareness low-parity women
Palestine and prevention
Source: Adapted from Bhutta et al. (13).
Recommendation 4: Modalities of pre-service training

Recommendation 4
WHO suggests using the following modalities for delivering pre-service training to CHWs:
• balance of theory-focused knowledge and practice-focused skills, with priority emphasis on supervised practical experience;
• balance of face-to-face and e-learning, with priority emphasis on face-to-face learning, supplemented by e-learning on aspects on which it is
relevant;
• prioritization of training in or near the community wherever possible;
• delivery of training and provision of learning materials in language that can optimize the trainees’ acquisition of expertise and skills;
• ensuring a positive training environment;
• consideration of interprofessional training approaches where relevant and feasible.
7.4.1 Background to the recommendation While face-to-face didactic classroom teaching was the
Meeting the various needs of a community entails CHWs dominant training modality until the early 1990s, web-based
having the required core competencies in relation to their learning is increasingly used for training purposes (76).
role (73). Such competencies and attributes can be built and Although e-learning is still restricted to geographical settings
honed through proper and adequate training (74). In some with higher connectivity to web-based portals, increased
cases, access to training has been an important factor in access to the Internet and rapid growth in technology are
CHW retention (75). providing enhanced opportunities to develop health care
worker training programmes, upgrade health care services
There are several approaches for the training of CHWs, and strengthen health care systems (77).
including short-term courses, long-term certificate
programmes and distance learning, all of which use different The broader policy discourse on education of other health
delivery modalities, from didactic face-to-face classroom workers in recent years has identified a number of issues
teaching to web-based online courses for self-guided learning. contributing indirect evidence that can be considered
41
also in the education of CHWs, including the potential for These studies point to training leading to indirect and
broadening the focus of health education to enable health developmental outputs for CHWs in the form of increased
workers to be change agents in the communities they serve knowledge, advancement, self-efficacy and esteem,
(78); the opportunities opened by interprofessional education confidence and morale. However, the material contains no
approaches (79); and the link between locating education clear indications of specific training modalities being more
institutions and training in underserved areas and the retention effective than others.
of health workers in these settings (80).
Moreover, CHW perceptions of the value and relevance
7.4.2 Rationale for recommendation of different training modalities vary. While CHWs valued
The GDG intended to provide guidance to inform decisions the flexibility of web-based training, they also highlighted
on appropriate delivery modalities for pre-service education. in-person and classroom-based training as helpful and
The findings of the systematic review were limited in scope, meaningful. The systematic review team rated the overall
and did not directly compare alternative modalities for certainty of the evidence as very low.
the delivery of pre-service education. Therefore, the GDG
considered as a basis for the recommendation also the The systematic review of reviews found that CHW training
broader evidence emerging from the review of reviews and should include a mix of approaches (knowledge and skills
indirect evidence on health worker education, recognizing based) (17, 86, 87).
the limitations and caveats of applying it to CHWs as well.
7.4.4 Interpretation of the evidence and
7.4.3 Summary of evidence other considerations by the GDG
The systematic review (Annex 6.4) addressing the question The broader literature on effective training approaches
– “For CHWs receiving pre-service training, should the published in other sectors points to one-off theory and
curriculum use specific delivery modalities versus not?” discussion-based trainings as being only moderately helpful
(81) – identified five eligible studies (one quantitative, four in increasing the knowledge of practitioners, and they are
qualitative). Two studies were located in South Africa, two generally ineffective in practical skill building that is of
in the United States, and one in the Islamic Republic of Iran. measurable benefit in real-world practice settings (88).
The quantitative study was an RCT comparing the benefits of Substantial changes in practice behaviour could first be
training CHWs in person or through web-based methods with observed when on-the-job coaching and continuous feedback
a training approach based on mailing training materials to was used to support practitioners. This broader literature may
CHWs, finding no differences in outcomes (82). be of value when considering the development of practice
guidelines for CHWs in this area (89, 90). The GDG considered
The remaining four studies (75, 83–85) included were that the evidence base from other health occupational groups
qualitative and utilized a pre-post evaluation design examining – showing that a balance between theoretical and practical
whether a particular training intervention could enhance the training is associated with positive outcomes – can be
knowledge and competencies of community health workers. assumed to apply also to CHWs. Similar considerations apply
to the evidence supporting a “rural pipeline” approach, with
The modalities in which trainings were delivered varied across health education institutions established preferentially in rural
studies. They included: areas and opportunities for practical training in rural areas
• in-person and web-based training for brief intervention (91). Efforts should also be made to ensure that digital health
methods; education approaches complement, rather that replace,
• face-to-face classroom-based didactic teaching; traditional face-to-face instructional modalities (92).
• interactive teaching elements such as practice
demonstration and role play;
• experiential teaching elements such as on-the-job
training, expert feedback and supervision.
7.4.5 Implementation considerations subsequent practical training to ensure that the theoretical
Countries will need to identify the appropriate balance in their knowledge has been internalized and can be successfully
context between theoretical and practical training, taking applied in the work setting.
into account a variety of factors, including the pre-existing
literacy and educational attainment of trainees. The use In relation to the location of training, in many contexts the
of dynamic teaching methodologies, as well as the use of initial theoretical training may be most conveniently offered in
multimedia resources, have the potential to make the training a central location, which should nevertheless be as close as
more attractive and effective. The role of simulated practice possible to the intended catchment area. For practical parts
may be considered for skills development and in areas where of the curriculum efforts should be made, where logistically
exposure to practical training in communities or health feasible, to offer the training within the communities and
facilities may present logistical or operational challenges. facilities where CHWs are expected to eventually serve.
Rather than prescribing a specific formula for allocation of The faculty for the training of CHWs should ideally include
time for pre-service training, it is important that trainees are other health workers so as to facilitate subsequent
required to demonstrate, as part of the testing or certification integration of CHWs as members of multidisciplinary primary
process, to have acquired the practical skills required for health care teams. It should also include the health workers
their role and to be competent to practice. It is equally who have the responsibility for supervising CHWs.
important to reinforce the skills acquired through pre-service
education and through appropriate links with subsequent The importance of a positive and conducive learning
mentoring and supportive supervision. environment cannot be overemphasized. Some of its
elements include the safety of and respect for trainees; a
Most typically, the initial main pre-service training for CHWs positive and supportive attitude by faculty; attention to the
takes place through face-to-face instructional modalities. specific requirements of women and trainees from minorities
Online-based training is increasingly being considered for or vulnerable groups; availability of adequate infrastructure
follow-up and refresher training, based on the availability and trainers; development of training materials; and the
of the required technology infrastructure. E-learning delivery of training reflecting the linguistic abilities and
methodologies should be coupled with and followed by requirements of trainees.
Recommendation 5: Competency-based certification

Recommendation 5
WHO suggests using competency-based formal certification for CHWs who have successfully completed pre-service training.5
7.5.1 Background to the recommendation been identified as “community volunteers” and are casually
A key component of quality health care delivery is workforce trained to provide services in the community without any
standards. This implies defining professional roles, scope clear mechanism for certification. In some countries, however,
of work, responsibilities and tasks, along with educational standards and procedures for CHW certification exist.
standards and minimum competency requirements for
different health service positions. Credentialing provides a For CHWs, certification programmes might have some
formal recognition awarded to those meeting predetermined theoretical benefits: certification may increase their
standards (93). The availability of and requirements for CHW motivation, sense of self-esteem and respect from other
certification vary across countries. In many cases, CHWs have health workers. Certification that describes the learning
5
Certification is defined in this context as a formal recognition awarded by relevant authorities to health workers who have successfully completed
pre-service education and who have demonstrated meeting predetermined competency standards.
43
achieved enables transferability to other settings, thus summarized certification experience from New York City (97).
reducing the need to repeat training if the worker moves A national view on certification was also included in a study
location; or it can be used as evidence as part of admission from the Islamic Republic of Iran, where certification is the
criteria for further education. In some countries, certification norm and is required to achieve employment as a CHW (75).
can legitimize the work of CHWs and provide opportunities In a fourth study, from Ethiopia, certification was one among
for the reimbursement of CHW services (94). From the many topics discussed with interviewees who represented a
perspective of citizens and communities, formal certification scoped community mobilization project (98).
may protect the public from harm resulting from the provision
of inappropriate care rendered by providers lacking any The evidence included in these studies points to potential, but
training but purporting to be qualified (95). untested, benefits from certification processes related to the
motivation, morale and self-esteem of CHWs, as well as their
To reduce CHW drop-out rates and to ensure a sense of retention, professional development and advancement. The
commitment to service, an earlier review suggested that process of credentialing was perceived by CHWs as offering
CHW programmes should set up clear appointment and opportunities to gain increased knowledge, credibility and
deployment strategies for CHWs who pass the final exam recognition, potentially improving the collaboration between
at the end of a training and receive a certificate of course CHWs and their communities.
completion (13). However, there is little formal evidence that
suggests that certification improves outcomes. In this section, The literature also points to possible barriers to the
the guideline explores the evidence and provides policy implementation of credentialing, in that certification
guidance on competency-based, formal certification for CHWs requirements may impose direct and indirect costs
who have successfully completed pre-service training. and resource demands on CHWs, as well as legal and
administrative barriers, limiting the accessibility of
7.5.2 Rationale for recommendation community health service positions for volunteers who are
The GDG noted that the very limited evidence points to interested in working in the sector but are not eligible or
a positive, though largely untested, potential of formal suited for certification. This paucity of quality research linking
credentialing of CHWs. While credentialing may in theory credentialing to outcomes is aligned with a previous review
negatively impact equity (by limiting the number of CHWs that examined such linkages across a broad range of public
authorized to practise to those awarded a formal licence, health, health care and teacher education literature (99). The
thereby restricting access to services), in many contexts systematic review team rated the overall certainty of the
it can be a pathway to greater competency of CHWs (and evidence as very low.
hence improved patient safety through better quality of
care). Further, it can enhance credibility, recognition and The systematic review of reviews found no evidence of direct
employability of CHWs. On this basis, the GDG supported a relevance to accreditation and certification.
conditional recommendation in favour of formal certification.
The stakeholder perception survey identified certification of
7.5.3 Summary of evidence CHWs as both acceptable and feasible.
The systematic review (Annex 6.5) addressing the question
– “For community health workers who have received 7.5.4 Interpretation of the evidence and
pre-service training, should competency-based formal other considerations by the GDG
certification be used versus not?” (96) – identified four Despite the paucity of evidence, the GDG considered that a
eligible qualitative studies that reported on how certification form of credentialing of CHWs could be an important element
processes were perceived by small, non-representative for the progressive formal acceptance of these health
samples of CHWs. Two studies were conducted in the United workers. In some countries this could also be a
States, one of which reported on state-based credentialing requisite for authorization of practice, and the pathway to
of CHWs occurring in four states (68), while the other formal contracting, remuneration, and the availability of
opportunities for career progression, which are the subject rendering better quality of care to the population, as well
of some of the recommendations in the subsequent sections as facilitating the career mobility and advancement
of this guideline. The recommendation on certification opportunities of CHWs.
therefore has important ramifications for the broader aspect
of social mobility of CHWs. Depending on the context, certification could range
from a certificate provided by the training institution to
The GDG recognized that alternative terminology might jurisdiction-level certification by an independent third party.
apply in different contexts, including certification, licensing,
credentialing and recognition, with varying levels of legal The certification process should entail verifying and attesting
recognition and different institutional arrangements regarding that the CHWs have not only successfully completed
the certifying bodies. In the context of this recommendation, their pre-service education, but have also demonstrated
the GDG recommended formal certification based on possessing the technical and soft skills required to practise
attainment of certain predetermined competencies following according to their role. Attention should be devoted to
successful completion of pre-service training. ensuring that the introduction of a formal certification
process does not result in unintended adverse equity effects.
7.5.5 Implementation considerations The certification requirements, process and institutional
Certification is of particular relevance to CHWs undergoing arrangements should explicitly and deliberately include a
a longer period of pre-service education. Efforts should focus on mitigating potential adverse equity effects.
be made to standardize within a jurisdiction quality and
content of training through formal accreditation of education Adequate resources should be invested in ensuring
institutions and training courses, so as to improve and align appropriate capacity for quality certification processes,
the competencies of CHWs, which can be instrumental in including sufficient human resources and materials to test
key CHW skills and competencies in practice.
Recommendation 6: Supportive supervision
Recommendation 6
WHO suggests using the following supportive supervision strategies in the context of CHW programmes:
• appropriate supervisor–supervisee ratio allowing meaningful and regular support;
• ensuring supervisors receive adequate training;
• coaching and mentoring of CHWs;
• use of observation of service delivery, performance data and community feedback;
• prioritization of improving the quality of supervision.
7.6.1 Background to the recommendation A typical challenge however is a lack of resources to provide
The importance of adequate supervision of CHWs is well a supportive supervision and environment to optimize the
recognized. International evidence suggests that regular and capacity of CHWs (21, 105, 106). It is essential to streamline
systematic supervision, with clearly defined objectives, can the supervision process by identifying effective strategies and
improve the performance of CHWs involved in primary health including them in the implementation of interventions.
care (100–102). Supportive supervision that targets and
measures knowledge and skills, motivation, and adherence 7.6.2 Rationale for recommendation
to correct practices provides incentives that positively The evidence retrieved and analysed for the purpose of this
impact performance (103). There is also emerging evidence guideline reiterated the importance of supportive supervision
suggesting that employing mobile phones, including for better and identified a number of supervision strategies in the
supervision, can improve health care delivery in resource- context of different programmes and initiatives. However,
limited settings (104). the studies typically did not compare specific supervision
45
strategies against others in terms of effectiveness, costs, The stakeholder perception survey identified most supportive
acceptability, feasibility or other outcomes. The GDG therefore supervision strategies (including coaching, observation at
provided indications on core approaches (reflected in the community and facility, community feedback, and supervision
recommendations) and additional strategies (mentioned by trained health workers) to be acceptable and feasible,
under the implementation considerations) based on their but lower levels of acceptability and especially of feasibility
expertise, and taking into account the models that emerged were identified for direct supervision of service delivery and
from the review of the evidence. In light of the very low supervision conducted by other CHWs.
certainty of the evidence and the need to adapt supervisory
strategies to the requirements of different contexts, this 7.6.4 Interpretation of the evidence and other
recommendation was a conditional one. considerations by the GDG
Supportive supervision was consistently found to be effective
7.6.3 Summary of evidence in improving the performance of CHW programmes, and was
The systematic review (Annex 6.6) on the question – “In appreciated by CHWs. At the same time, very limited information
the context of community health worker programmes, what was available to compare specific supervision strategies. In
strategies of supportive supervision should be adopted over light of the lack of specific evidence and the low certainty
what other strategies?” (107) – identified 13 eligible studies: of the available evidence, the GDG opted for a conditional
nine quantitative, of which five were RCTs, and four qualitative. recommendation in favour of different supervisory strategies.
The studies came from India (three studies), Ethiopia, Kenya,
and Uganda (two studies each), and Lao People’s Democratic Supervision should be supportive, striking the right balance
Republic, Malawi, Pakistan, and the United Republic of between its function to ensure monitoring and accountability
Tanzania (one study each). Various approaches and modalities and the aim of accompanying the CHW in a path of
of supervision were found to be effective in improving various progressive professional growth and development through a
aspects of CHW programme performance (108–114), in some mentorship approach. Supervision may be carried out by both
cases also showing a dose–gradient response (115), while on dedicated supervisors and other health workers as part of
limited occasions there was no measurable difference on some a broader set of responsibilities. The application of different
outcomes between the study arm receiving the supervision approaches will depend on context.
intervention and the study arm that did not (116, 117). The
qualitative studies found evidence that different supportive 7.6.5 Implementation considerations
supervision strategies were deemed helpful and reinforced In addition to the supportive supervision approaches
motivation by the CHWs themselves (116, 118–120). mentioned in the recommendation, additional options, to be
considered as relevant to the local context, might include:
The systematic review team rated the overall certainty of the • use of supervision tools such as task checklists as part
evidence as very low. of a coaching process, while ensuring they also allow
qualitative monitoring and interpersonal engagement;
The systematic review of reviews found several studies • peer support and supervision by senior, experienced CHWs;
confirming the critical importance of supportive supervision • expert support and supervision conducted by a
to enhance CHW quality, motivation and performance (13, 51, multidisciplinary team, incorporating as relevant
121–125). However, it similarly found very limited evidence mechanisms for community feedback.
on which supervisory approaches work best. Supervision that
Supervision content and approach are related to the complexity
focuses on supportive approaches, quality assurance and
of roles and tasks; the optimal supervision mechanisms would
problem solving may be most effective at improving CHW
also differ based on whether the CHWs are full-time and
performance (as opposed to more bureaucratic and punitive
formally employed by the health system or, conversely, part-
approaches) (17, 105, 126).
time volunteers. Supervision should be seen in an integrated
Improving supervision quality has a greater impact than way with other functions, including broader peer support,
increasing frequency of supervision alone (105). in-service training and continuous professional development,
and take into account the standards and expectations of other
health workers and health professionals in relation to their should be familiar with both the technical content of care
supervisory responsibilities. Integration at service delivery delivery and more general aspects regarding quality of care
level will help ensure systematic engagement of both the improvement and methodologies for exerting a positive influence
facility staff and the CHWs. In the design and operationalization on the behaviour of practising CHWs. Gender factors should
of appropriate supervisory strategies, adequate investment be considered in selecting supervisors: for instance, having
and attention should be dedicated to building the capacity of mostly male supervisors for mostly female CHWs may be
supervisors. Supervision may be carried out by both dedicated inappropriate, reinforce gender barriers, and limit acceptability
supervisors and other health workers as part of a broader and effectiveness of supervision. The quality and results of the
set of responsibilities; irrespective of the set-up, supervisors supervision should be themselves regularly assessed.
Recommendation 7: Remuneration
Recommendation 7A
WHO recommends remunerating practising CHWs for their work with a financial package commensurate with the job demands, complexity,
number of hours, training and roles that they undertake.
Recommendation 7B
WHO suggests not paying CHWs exclusively or predominantly according to performance-based incentives.
7.7.1 Background to the recommendation support CHW payment in ways that are beneficial (128),
The use of incentives for CHWs has been proposed as a means and policies and practices vary considerably in this respect
of improving health outcomes, and varying combinations of across and within countries.
monetary and non-monetary incentives have been explored in
different settings with varying degrees of success (127). 7.7.2 Rationale for recommendation
The GDG approached this question from the perspective
The provision of incentives has a direct impact on the of exploring whether practising CHWs should be offered
effectiveness and sustainability of a health programme. It is a financial package for their work and, if so, of which type.
normally assumed that it improves service delivery through
enhanced employee motivation and reduced attrition (127). Despite the overall assessment of very low certainty of the
Choosing effective incentives for CHWs represents a long- evidence, the majority of reviewed studies were supportive
standing policy issue within the field of primary health care; of providing CHWs with a financial package. The GDG
incentives can vary from providing a salary or other financial considered in its decision-making process also broader
remuneration, such as performance-based incentives, to criteria, including best practice in relation to labour rights
provision of non-financial incentives (87). To determine and legislation. This is crucial to align health policy to the
the best approach, it is important to understand both CHW broader international agenda on decent work, which entails
and supervisor perspectives about the factors, financial opportunities for work that is productive and delivers a fair
or otherwise, that best motivate CHWs, as well as broader income; security in the workplace and social protection
aspects, including duration and scope of CHW training, for families; better prospects for personal development
and level of effort in their role. Decisions on provision of and social integration; freedom for people to express their
incentives have to be consistent with broader employment concerns, organize and participate in the decisions that
and labour legislation and principles. However, there appears affect their lives; and equality of opportunity and treatment
to be no clear agreement on which strategies would best for all women and men (129). The GDG was particularly
47
concerned that models that rely on voluntary CHW work are to compensate for this was reported to be most important. The
inconsistent with the international agenda on decent work, reputation of the CHW, as based on trust and respect from the
and particularly with Sustainable Development Goal (SDG) community, can be negatively impacted by performance-based
8, promoting decent work and economic growth. As most incentive schemes, which were described as at times being
CHWs globally are female, the GDG was also concerned too narrowly focused on pre-identified indicators, leading
that continued reliance on voluntary work could perpetuate to activities and efforts not linked to these indicators being
gender disparities in access to employment and income ignored and unacknowledged. Performance-based incentives
opportunities, and be inconsistent also with SDG 5 – “Achieve encouraged uneven focus on certain activities due to their
gender equality and empower all women and girls” (130). association with higher incentives, especially when CHWs
On this basis, the GDG voted by an overwhelming majority had no basic remuneration, leading to the neglect of other
(18 to 1) in favour of a strong recommendation to provide a important activities or responsibilities. Other CHWs expressed
financial package to practising CHWs, despite the recognition dissatisfaction with performance-based incentive models in
of the very low certainty of the evidence. relation to amounts paid and inconsistent and incomplete
payment of incentives (45, 143). The systematic review team
The GDG did not recommend a specific form of remuneration rated the overall certainty of the evidence as very low.
(see sections below), but since evidence regarding a specific
form of financial package (performance-based incentives) The systematic review of reviews found that monetary
identified some evidence of potential harm, it also made remuneration (such as salaries, financial incentives, or income
a conditional recommendation against adopting financial from selling commodities) and non-monetary incentives (such
packages based exclusively or predominantly on this as respect, trust, recognition, and opportunities for personal
particular form of incentive. growth, learning, and career advancement) are important
motivators for CHWs and can reduce attrition (17, 51, 121,
7.7.3 Summary of evidence 123, 144, 145). CHW rights and the need of CHWs for reliable
The systematic review (Annex 6.7) addressing the question financial remuneration was discussed in only one review,
– “In the context of CHW programmes, should practising which highlighted the consistent (and unmet) demand of CHWs
community health workers be paid for their work versus for salaried positions (146).
not?” (131) – identified 14 eligible studies (five quantitative,
nine qualitative), conducted in India (five studies), Ethiopia, The stakeholder perception survey identified a good level
Kenya and Nepal (two studies each), and Bangladesh, Ghana, of feasibility and acceptability of providing CHWs with both
the Islamic Republic of Iran, Mozambique, Nigeria, Pakistan, financial and non-financial incentives, but the assessment
Rwanda and Uganda (some studies included evidence from of the feasibility of paying CHWs a minimum wage bordered
more than one country). Quantitative studies provided some between feasible and uncertain.
evidence that financial incentives may lead to improved
CHW performance (117, 132–134), although in the case of 7.7.4
Interpretation of the evidence and
performance-based incentives a concern was raised related other considerations by the GDG
to neglecting tasks that are not incentivized (135). CHWs are in some contexts essential service providers at the
forefront of the health system. Their integration into formal
Qualitative studies were included to provide insights with health systems may mean that they need to be recognized
respect to the perceived consequences of various payment and and paid. Payment mechanisms and compensation measures
remuneration approaches. Most qualitative studies described may differ depending on whether they are full-time or part-
positive attitudes towards financial payments (136–142). time, polyvalent or monovalent.
Financial incentives in general appear to be well accepted,
provide motivation and recognition, and may bring a sense of The GDG noted that the recommendation to provide a
financial independence and self-confidence to CHWs. CHWs financial package to practising CHWs applies to CHWs of
can incur out-of-pocket expenditures for communication and different types and capacities, but that it should not rule out
transport; ensuring timely and complete payment of incentives a priori the continued existence of dedicated volunteers that
willingly perform their roles on a pro bono basis, in addition As most of the concerns emerging from the literature
to having as individuals a different, main source of livelihood. regarding payment of CHWs referred in reality to one
It may sometimes be difficult to draw a clear line between particular form of payment (performance-based incentives),
volunteers who wish to remain volunteers (for instance the GDG opted for isolating this particular form of payment
because they have a different full-time job, and only dedicate from the overall recommendation and having a dedicated
a few hours per month to voluntary community service), recommendation focused on it.
and the CHWs without an alternative source of livelihood
who are currently not receiving any financial package for 7.7.5 Implementation considerations
their work. Recognizing the sometimes blurred boundaries The provision of a financial package to CHWs could take
between these different situations, the GDG framed the different forms (salary, stipend, honorarium, monetary
recommendation as a financial package commensurate with incentives), in accordance with the employment status and
the role, capacity, level of effort and hours of work of CHWs. applicable laws and regulations in the jurisdiction.
Delineating more specifically this distinction should remain
the prerogative of authorities within specific jurisdictions. Countries should consider the financial package to
remunerate CHWs as a part of the overall health system
The GDG noted that, irrespective of direct provision of a planning, and adequate resources should be made available
financial package for their work, all CHWs and volunteers to implement this recommendation through the mobilization
should be compensated to cover expenses incurred in and prioritization of the required resources.
delivering services according to their roles.
In addition to the financial package, the provision of
The GDG noted the importance of non-monetary incentives, non-monetary incentives should also be considered to
but noted also that they should not be seen as a substitute improve the performance of CHW programmes.
for the provision of a financial package, and, conversely, that
the provision of a financial package should not be seen as a While the GDG cautioned on the adoption of performance-
substitute for non-financial incentives, such as a conducive based incentives as the only or predominant mechanism
and respectful work environment, and opportunities for of payment for CHWs, its continued application in contexts
professional development and career advancement. where it is well established and found to be effective could
be accompanied by dedicated efforts to mitigate the known
and potential shortcomings of these mechanisms.
Recommendation 8: Contracting agreements
Recommendation 8
WHO recommends providing paid CHWs with a written agreement specifying role and responsibilities, working conditions, remuneration
and workers’ rights.
7.8.1 Background to the recommendation have the potential to explicitly and formally determine the
Because CHWs work at the interface of community and responsibilities that CHWs should fulfil, as well as the rights
formal health care systems, their role and identity within the and benefits they are entitled to, and they could represent
health care structure has historically lacked clarity (21). The a tool to more formally integrate CHWs into the health care
importance and impact of CHWs with regard to health care system. Formal contracts in this context are defined as
delivery are generally well recognized and acknowledged written agreements specifying CHW working conditions
within the sector. However, contracts and agreements and rights, job responsibilities, duration of employment and
remuneration terms.
49
It is assumed that contracts can serve as an incentive The systematic review of reviews found no evidence of
and contribute to job stability and security, and enhance direct relevance to the policy option under consideration
occupational protection and safety. Furthermore, formal in this question.
contracts set the groundwork for professional development,
as they typically require or encourage employers to support The stakeholder perception survey found that formal
professional development opportunities and supervise contracting of CHWs by the health system was both
workers (147). The advantage for the health system is acceptable and feasible.
provision of a basis for CHW accountability.
7.8.4 Interpretation of the evidence and
7.8.2 Rationale for recommendation other considerations by the GDG
The GDG noted the limited evidence supporting the The GDG interpreted the limited evidence supporting the
effectiveness of formal contracts in improving the effectiveness of contractual arrangements to formalize
performance of CHW programmes. While the evidence was the role of practising paid CHWs in the broader context of
of very low quality, the GDG considered that some form of the significance and implications of formal agreements for
written agreement is essential in upholding workers’ rights labour relations and workers’ rights. The GDG also concluded
and is a key component of the Decent Work Agenda. On that formal contracts for paid CHWs could be instrumental
this basis the GDG voted by an overwhelming majority (17 in improving motivation and retention.
to 1; one did not participate in the voting) to adopt a strong
recommendation despite the very low-quality evidence. The GDG also noted the importance of consistency of the
guideline, externally with broader labour rights frameworks,
The GDG only applied this recommendation to paid CHWs, and internally among different recommendations; in particular,
as applying it to volunteers would entail an obligatory nature the formalization of rights, responsibilities and working
(by virtue of the contract) of the relation between the health conditions covered by this recommendation reinforces and
system and the volunteer. This would possibly represent a is complementary to the recommendations on certification
violation of basic labour rights, and would be inconsistent (recommendation 5), remuneration (recommendation 7)
with the principle of volunteer work, which is by definition of and career advancement (recommendation 9).
non-compulsory nature (148).
7.8.5 Implementation considerations
7.8.3 Summary of evidence This recommendation only applies to paid practising CHWs.
The systematic review (Annex 6.8) on the question – “In Formal contracts or any type of binding agreements should
the context of community health worker (CHW) programmes, not be adopted in the case of volunteer CHWs.
should practising CHWs have a formal contract versus
not?” (149) – identified two quantitative eligible studies: a The contractual arrangements, which may apply to both
cross-sectional study exploring the factors that influence public sector and private employers, should reflect applicable
the performance of CHWs delivering a malaria programme in regulatory and legislative frameworks in the jurisdiction.
Uganda (150), and an RCT assessing the impact of different In particular, the precise terminology may need adaptation,
types of contracts for CHWs on provision of immunization considering that the term “contract” entails specific obligations
services in Pakistan (135). The existence of a contract or in some contexts that could inadvertently hinder or deter the
the receipt of an appointment letter were among the factors institutionalization of CHWs. Ultimately the application of the
associated with higher performance (measured in terms of recommendation will be beneficial as long as a binding written
service delivery outputs). The systematic review team rated agreement specifies roles, responsibilities, rights and working
the certainty of the evidence as low. conditions, including remuneration, of CHWs.
Recommendation 9: Career ladder
Recommendation 9
WHO suggests that a career ladder should be offered to practising CHWs, recognizing that further education and career development
are linked to selection criteria, duration and contents of pre-service education, competency-based certification, duration of service and
performance review.
7.9.1 Background to the recommendation framework versus not?” (154) – identified one eligible study,
Providing health workers with a career ladder (that is, an RCT conducted in Zambia, which compared the impact of
opportunities for progressive advancement to higher-level exposure to different recruitment posters that emphasized
positions in a health system, or upgrading skills and career opportunities to those attracted by posters that
expanding roles) is universally seen as a good practice to emphasized civil service and social identity as incentives (151).
reinforce both motivation and retention. This policy issue is The results demonstrated that providing career progression as
particularly relevant for CHWs (151), as retention of these an incentive for recruitment of CHWs increased the recruitment
workers is problematic due to a variety of factors (152, 153). of higher-calibre and more ambitious CHWs, who had a
The policy question revolves around whether providing career statistically significant better performance in terms of clinic
opportunities for CHWs to retrain or upskill can enable them utilization, home visits, household behaviours and child health
to more effectively meet community health needs and can outcomes. There was no difference in retention at 18 months
positively influence job satisfaction and retention. between the two groups.
7.9.2 Rationale for recommendation The systematic review of reviews found that opportunities
The GDG, despite the minimal evidence directly addressing for career advancement are one of several important
this question, provided a recommendation based primarily non-financial incentives that can improve CHW motivation,
on its members’ expertise and on broader good practice in although this was most often a conclusion of the authors of
human resources and health workforce management. the reviews rather than a statement based on evidence of
effectiveness (17, 51, 121, 123, 144, 145).
The GDG was of the view that the benefits of offering CHWs
a career ladder after some years of satisfactory service can The stakeholder perception survey found that offering CHWs
potentially include improved motivation and job satisfaction, a career ladder opportunity is acceptable, but its feasibility
contributing to increased retention and reduced attrition. might be variable across different contexts.
The GDG concluded that these benefits outweigh potential
shortcomings linked to depleting the pool of practising 7.9.4 Interpretation of the evidence and
CHWs, and, on the contrary, that career ladder schemes and other considerations by the GDG
frameworks can contribute in a positive way to upward social The GDG interpreted the lack of evidence on this aspect
mobility aligned to the Decent Work Agenda. as a reflection of the limited availability of career ladder
opportunities for CHWs in most settings, resulting,
On this basis, while considering the minimal supporting correspondingly, in the absence of formal evaluation of
evidence, the GDG adopted a conditional recommendation in such (non-existing) schemes. The broader evidence from
favour of providing CHWs with a career ladder framework. the systematic review of reviews, and the high level of
acceptability according to the stakeholder perception survey,
7.9.3 Summary of evidence should be interpreted as a strong interest by policy-makers
The systematic review (Annex 6.9) addressing the question – and CHWs to better align CHW policies with best practices
“In the context of community health worker (CHW) programmes in human resources management, including through the
should practising CHWs have a career ladder opportunity/ provision of career advancement opportunities.
51
The different educational attainment levels, qualifications, If compatible with the pre-existing education level, offering
certification status and roles of CHWs imply, however, varying CHWs a career ladder might entail a route to progress to
levels of feasibility of adoption of this policy option. other health qualifications, subject to completion of required
additional training. In the case of lower level of educational
7.9.5 Implementation considerations attainment than the minimum required for training for other
The availability and definition of career ladder opportunities health professions, alternative modalities of career ladder
should be embedded in CHW programme design from the might entail progressing to CHW managerial posts (for
outset. The prerequisites for eligibility for further education example, senior and well performing CHWs advancing to
and career development may need to be linked with roles that entail contribution to education, supervision and
selection criteria for entry into pre-service education (see management of less experienced CHWs).
recommendation 1), duration and content of pre-service
education (recommendations 2 and 3) and formal Regulatory and legal barriers to CHW career ladders should
competency-based certification (recommendation 5). be considered when designing an appropriate scheme,
which should be compatible with the applicable normative
environment in a given jurisdiction.
Recommendation 10: Target population size
Recommendation 10
WHO suggests using the following criteria in determining a target population size in the context of CHW programmes.
Criteria to be adopted in most settings:
• expected workload based on epidemiology and anticipated demand for services;
• frequency of contact required;
• nature and time requirements of the services provided;
• expected weekly time commitment of CHWs (factoring in time away from service provision for training, administrative duties, and other
requirements);
• local geography (including proximity of households, distance to clinic and population density).
Criteria that might be of relevance in some settings:
• weather and climate;
• transport availability and cost;
• health worker safety;
• mobility of population;
• available human and financial resources.
7.10.1 Background to the recommendation CHWs should be assigned a targeted population size and how
Prominent among the many challenges that may result in poor this population size might impact CHW productivity, coverage
CHW performance is an excessive workload, often indirectly and health outcomes.
linked to an increased population size served by each CHW
(155, 156). The factors in question are the optimal population 7.10.2 Rationale for recommendation
size or caseload that maximizes the effectiveness of commu- The GDG recognized the importance of determining an
nity health workers. While many factors have been highlighted appropriate target population size to maintain a realistic
as influencing CHW performance, few studies have actually workload and optimize CHW performance. Given the wide
tested which intervention works best to manage CHW workload variance in CHW roles, the GDG felt the recommendation
and improve CHW performance, and how such interventions should focus on the factors that should be taken into account
should be implemented. Closely related to this interest in at the national level in setting the optimal target population
understanding how to balance the workload of community size. The certainty of the evidence was very low, hence the
health service staff is the interest in determining whether conditional recommendation.
7.10.3 Summary of evidence catchment population per CHW was smaller (66). Another
The systematic review (Annex 6.10) on the question – “In related finding was that a high workload could lead to
the context of practising community health worker (CHW) CHW demotivation (121).
programmes, should there be a target population size
versus not?” (157) – identified five eligible quantitative 7.10.4 Interpretation of the evidence
studies, conducted in Bangladesh, India, South Africa and and other considerations by the GDG
Uganda (two studies). The included studies suggest that The variability of the evidence points to widely differing
CHW performance is influenced by the population size or practices in determining the target population size and
workload that is assigned to them. However, the evidence workload of CHWs, resulting in some programmes already
on optimal population size for CHWs was ambiguous. On the stretching CHW capacities to their limits, while in other
one hand an excessive workload could result in decreased settings an additional workload can be accommodated
motivation and ultimately lower performance by CHWs (158), without compromising quality and, conversely, improving
with the CHW–population ratio identified as an influence on cost-effectiveness. This variability in baseline situations,
CHW performance, and with some evidence suggesting that as well as in roles, responsibilities and levels of effort of
a small population coverage was preferable (159, 160); on CHWs, prevents setting global benchmarks on workload
the other hand, other evidence suggests that an additional or appropriate population targets. Rather, the evidence
workload could be integrated into existing CHW duties points to the need to identify realistic and context-specific
without significantly impacting performance, and at times benchmarks.
may improve health outcomes (161). Furthermore, increasing
the workload of CHWs was found to be cost-effective if In doing so, some criteria will be universally relevant (such
coupled with sufficient support and supervision (162). Limited as expected caseload based on local epidemiology, frequency
evidence in the included studies pointed to the acceptability of contacts required, level of time commitment by CHWs)
and feasibility of setting a target population size for practising (163), while others will be particularly relevant only or mostly
CHWs. The systematic review team rated the overall certainty in certain contexts (such as factors relating to geographical
of the evidence as very low. accessibility of the catchment area, availability of transport,
distance to clinic, and population density).
The systematic review of reviews found that decisions about
catchment area population should be based on a variety
of considerations: frequency of contact required; nature of Planning for catchment areas for CHWs, including the optimal
the services provided; expected weekly time commitment size and geographical distribution of their target population,
from the CHW; and local geography (including proximity of should occur as part of an approach considering the health
households), weather and transport availability (16, 17, 124). workforce as a whole, and in alignment with overarching
One review found that for interventions consisting of home national health strategies (1). Adaptations to routine
visits only, there was no consistent effect of the size of the staffing standards and structures may become necessary
catchment population on neonatal mortality. However, when in the situations or context of acute onset or protracted
the interventions involved community mobilization as well, emergencies, as these may influence both population demand
the reduction in neonatal mortality was greater when the and need for services, as well as the capacity of other health
workers to provide them.
53
Recommendation 11: Data collection and use
Recommendation 11
WHO suggests that practising CHWs document the services they are providing and that they collect, collate and use health data on
routine activities, including through relevant mobile health solutions. Enablers for success include minimizing the reporting burden and
harmonizing data requirements; ensuring data confidentiality and security; equipping CHWs with the required competencies through
training; and providing them with feedback on performance based on data collected.
7.11.1 Background to the recommendation policy option under consideration. Recognizing the potential
While the collection of data by CHWs can serve a variety pitfalls of overburdening CHWs with data collection tasks,
of purposes – for example, surveillance or research – the GDG focused on identifying enablers for successful CHW
a key objective of routine data collection is service delivery contributions to data collection, collation and use.
improvement. Data collection and use is an integral part
of continuous quality improvement approaches that have 7.11.3 Summary of evidence
proven effective in improving outcomes across a range The systematic review (Annex 6.11) on the question – “In
of settings (164–167). Within practice improvement, data the context of community health worker (CHW) programmes,
generated through CHW practice are collected for several should practising CHWs collect, collate, and use health data
purposes, including: versus not?” (168) – identified as eligible for inclusion eight
• for monitoring service delivery to enable adjustments and quantitative, four qualitative and two mixed methods studies,
identify programme requirements (for example, stock- conducted in seven sub-Saharan African countries and Brazil,
outs, epidemiological trends, human resource needs) so Cambodia and the United States.
that the service meets the needs of recipients;

Across these studies, findings associated with CHWs involved
• for engaging communities in finding local solutions to
in data collection processes were shown to contribute to
identified problems;
improvements in CHW programme performance across several
• for supervising and supporting CHWs to build their
outcome measures: reduced absenteeism (169) and attrition
knowledge, competencies and skills for the benefit of
(170), service delivery improvements (150, 171–173), changes
service recipients.
in health system functioning, changes in the knowledge,
For the latter purpose, the inherent assumption is that self-efficacy and esteem of CHWs, and improved productivity
enhanced expertise and skills will translate into improved (173, 174). Some studies highlighted the burden of data
service delivery, thereby improving the outcomes of collection in terms of greater CHW workload.
community health interventions. Data collection by CHWs is
a potentially meaningful yet still underresearched pathway In addition, changes in community health (175) and credibility
towards improving community health services (14). This were explored, together with data collection processes
potential should be balanced with data ownership, access that potentially influenced decreased mortality (172) and
and individual patient confidentiality issues. morbidity (176).
7.11.2 Rationale for recommendation Many of the included studies examined the role of data
The GDG noted that most published evidence supports a collection through a mobile health (mHealth) application.
role for CHWs in data collection and use, and this finding is In these studies, mobile technologies were generally found
consistent with the broader literature on health information to improve CHW programmes (169, 171–174, 177) with
systems and quality improvement. As the evidence base is some exceptions: for example, no differences in CHW job
characterized by a low level of certainty and considering that satisfaction between groups could be measured in an RCT
the most appropriate strategies may vary by context, the conducted in Sierra Leone to evaluate the impact of an
GDG adopted a conditional recommendation in favour of the mHealth-based data collection programme (178).
Little information was provided on how data collection creating the right conditions and enablers for the success of
processes were integrated into supervision, coaching and such initiatives, including prioritizing a standardized set of
comparable activities aiming to support CHWs in their work. data requirements and indicators that CHWs in a programme
or jurisdiction should focus on, and ensuring appropriate
Interviews with international experts and stakeholders data use and feedback loop mechanisms. As the certainty
concluded that retention and attrition of CHWs could of the evidence was very low, and recognizing the need
potentially improve if they more meaningfully engaged with to adapt to different contexts, the GDG adopted the
the data they collect. The researchers suggest that this could recommendation as conditional.
involve CHWs collecting and analysing data and applying it
to their work environment, CHW supervisors providing more 7.11.5 Implementation considerations
support for the data collected by CHWs to be actively used in The health management information systems in most countries
professional development, and letting the data collection feed include very little or no information collected by CHWs,
into tools for use by the community (170). although their potential to contribute substantially to data
collection has already been proven: for instance, in WHO’s 2017
The systematic review team rated the overall certainty of the round of global TB data collection, 53 countries reported data
evidence as very low. about the contribution of CHWs to TB notifications or treatment
support. This represents a more than threefold increase in
The systematic review of reviews identified one review
reporting since 2013, when data were first collected (179).
suggesting that there were cost savings of 24% when CHWs
But there may not always be quality assurance systems to
collected data using personal digital assistants compared to
support expanding the data collection process. Factors that
when they used traditional manual methods of data collection
should be considered when designing and operationalizing
and transmission (104).
policies for the contribution of CHWs to health data collection
and utilization include having in place the appropriate quality
The stakeholder perception survey found involvement of CHWs
control mechanisms, channels of processing the information
in data collection and use to be both acceptable and feasible.
upstream, interoperability of data mechanisms fed by CHWs
7.11.4 Interpretation of the evidence and with the broader health management information system, and
other considerations by the GDG mechanisms to provide feedback loops, so that CHWs also
Taken together, the findings of these studies point to benefit from the data they collect and collate.
potential community health service benefits – across a
At the same time, it is important to recognize that reliable
broad range of outputs and outcomes – associated with
data collection requires both specific skills and time. The
data collection by CHWs.
required competencies should inform the development
The GDG was aware of potential drawbacks not highlighted of the curriculum for pre-service education of CHWs and
by the literature, including distracting CHWs from their subsequent in-service training activities. In addition, the
service delivery, illness prevention and health promotion requirements for data collection should be standardized
tasks; generating data collection fatigue if collected data and harmonized across different types of providers for
are not utilized and understood; risks to confidentiality and the same services, and kept minimal to ensure that the
data security; and the risk of moral hazard and misreporting workload of CHWs stays at reasonable levels and maintains
or overreporting when data production and provision an appropriate balance between service delivery, illness
are linked to performance-based incentives and other prevention and health promotion activities on the one hand,
income-generating activities. and the administrative and clerical tasks (including record
keeping) on the other hand. Collecting data about citizens’
Overall, the GDG concluded that there may be more benefits satisfaction with services rendered by CHWs themselves may
than harms in strengthening and systematizing the role of require the involvement of a neutral, objective third party,
CHWs in data collection, and the policy focus should be on such as the supervisors of the CHWs.
55
Harnessing the promising potential of mHealth applications software development, continuous CHW training, and the
requires considering factors such as sustainable access to consideration of patient privacy and safety concerns.
mobile phones and mobile network coverage, locally tailored
Recommendation 12: Types of CHWs

Recommendation 12
WHO suggests adopting service delivery models comprising CHWs with general tasks as part of integrated primary health care teams.
CHWs with more selective and specific tasks can play a complementary role when required on the basis of population health needs,
cultural context and workforce configuration.
7.12.1 Background to the recommendation as first point of contact of the health system possess a
The effective delivery of primary health care services can relatively broad set of skills to enable them to better respond
benefit from multidisciplinary and interdisciplinary teamwork, to population needs and demands for services, or refer them
making it necessary for health care professionals to work in to the appropriate level of care when they are unable to do so
well functioning teams and according to an optimal distribution directly. On this basis, the GDG recommended that, in settings
of roles and tasks in relation to skills (1, 180). where the health workers operating at the front line of service
delivery are CHWs, they should possess a polyvalent profile,
CHWs are often trained unimodally to specialize in the care enabling them to deliver a range of priority primary health
of a single patient condition, such as diabetes or HIV (181, care services. Recognizing that some settings may present
182). There are examples where CHWs have been integrated, particular epidemiology situations, cultural contexts or health
using various approaches and with varying levels of success, system requirements, the addition of more specialized CHWs,
in primary care teams to deliver a broader range of services, with clear division of roles vis-à-vis polyvalent CHWs, should
though often with a predominant focus on reproductive, be considered when aligned with public policy objectives and
maternal, newborn, child and adolescent health services instrumental to the attainment of population health goals.
(183–186).
The lack of underlying evidence on types of CHWs and the
7.12.2 Rationale for recommendation need for adapting related measures to country contexts led
This policy question stood out for the lack of eligible the GDG to the adoption of a conditional recommendation.
evidence in both the specific systematic review addressing
this question and in the systematic review of reviews. The 7.12.3 Summary of evidence
GDG had therefore to rely exclusively on indirect evidence Neither the specific systematic review (Annex 6.12)
emerging from other reviews and the broader literature, and addressing this question – “In the context of community health
the expertise and capacity within the GDG. worker (CHW) programmes, should practising CHWs work in
a multi cadre team versus in a single cadre CHW system?”
The GDG noted the availability of evidence demonstrating the (188) – nor the systematic review of reviews, found any studies
effectiveness of both models – one in which polyvalent CHWs eligible for inclusion of direct relevance to this question.
perform a relatively broad range of functions, and another
where CHWs have been trained to deliver a single service 7.12.4 Interpretation of the evidence and
or a set of preventive, promotive, treatment or care services other considerations by the GDG
related to a single disease or cluster of diseases. The GDG noted that the lack of evidence on this policy question
can be understood in the context of studies typically focusing
Adopting an integrated and person-centred approach on analysing the experience of a CHW programme or initiative
to primary health care (187), however, requires a health (be this national in scope or a small pilot), but rarely comparing
workforce configuration whereby health workers operating different initiatives as alternative models against one another.
Evidence of effectiveness exists on both monovalent CHWs and CHWs operating on a volunteer basis or those drawn from
polyvalent CHWs delivering a broader range of primary health patient groups to provide services to people affected by the
care services. The GDG was also aware that overburdening same condition may more commonly serve as CHWs focusing
CHWs with an unrealistic set of expectations might lead to on a single or few service area(s).
deteriorating quality of services and attrition due to burnout.
With the objective of supporting an integrated service delivery The definition of the role and typology of CHWs should be part
model responsive to population expectations, the GDG was of of a broader public policy perspective considering the health
the view that the default option for policy-makers in settings system and health workforce planning as a whole. The entry
where CHWs are expected to play a significant role in service point for exploring policy options around which typologies of
provision is to adopt a model of polyvalent CHWs, who can CHWs may be more appropriate in a given context should be
understand community needs and provide services according a population and health workforce needs assessment. The
to a holistic perspective and a well defined set of roles and process to define the need and opportunity for CHWs as part
tasks. Conversely, a model based exclusively on specialized of the primary health care team should also take into account
CHWs might carry risks of fragmentation of care, resulting in acceptability by communities that will be served, as well as by
gaps in service provision and inefficiency. other professional and associate professional health workers.
CHWs specialized in the delivery of a single task or narrower The definition of the roles and typology of CHWs is an
set of functions should be considered as an addition to a essential planning function, which should in turn inform other
primary health care team comprising polyvalent CHWs in elements covered by recommendations in this guideline,
settings where the epidemiology and local service delivery and including population target size, selection criteria, education
workforce configuration make such a policy choice appropriate. and accreditation requirements.
Recommendation 13: Community engagement
Recommendation 13
WHO recommends the adoption of the following community engagement strategies in the context of practising CHW programmes:
• pre-programme consultation with community leaders;
• community participation in CHW selection;
• monitoring of CHWs;
• selection and priority setting of CHW activities;
• support to community-based structures;
• involvement of community representatives in decision-making, problem solving, planning and budgeting processes.
Certainty of the evidence – moderate. Strength of the recommendation – strong.
7.13.1 Background to the recommendation range of health-related goals, with a positive impact on
Community engagement is increasingly recognized and health behaviours, health literacy, self-efficacy and perceived
supported by policy-makers as a valued component of health social support for vulnerable populations (189–191).
programmes. The term “community” may refer to the general
population living in a defined geographical area (whether However, the lack of a standard and agreed-upon definition
rural or urban), or to a specific population subgroup requiring (including of what constitutes a community in urban settings),
targeted support (for example, people with a certain health and the wide spectrum of activities that constitute community
condition or breastfeeding mothers). Community engagement engagement, create challenges for operationalizing and
interventions have been deemed effective in achieving a assessing the effectiveness of community engagement more
57
broadly (189, 192, 193). This in turn creates substantial very important. Moreover, the GDG could not identify any
challenges for comparing community engagement and its meaningful risk or drawback of community engagement
effectiveness across different health outcomes and contexts; activities. Therefore, the GDG adopted unanimously a
particular forms and mechanisms of community engagement strong recommendation in favour of adopting community
may be more or less effective depending on the focal outcome engagement in CHW programmes.
to be achieved, the population, and the sociostructural
context. In addition, there are known risks that the voice of 7.13.3 Summary of evidence
a community, however defined, is captured by some interest The systematic review (Annex 6.13) on the question – “In
groups or individuals pursuing personal interests. the context of practising community health worker (CHW)
programmes, are community engagement strategies effective
7.13.2 Rationale for recommendation in improving CHW programme performance and utilisation?”
The GDG considered the benefits and harms of having (194) – identified 43 eligible studies (12 quantitative, 25
community engagement activities as part of CHW qualitative and six with mixed methods) from all six WHO
programmes. Based on evidence available and its own regions, but with a predominance of studies from the African
expertise, the GDG consensus view was that community and South-East Asia Regions, and only one study each from
engagement is a key community health intervention that the Region of the Americas and the European Region.
should be part of CHW practicum and activities.
A variety of community engagement strategies were
The certainty of the evidence was found to be moderate by employed across studies, with many studies using more than
the systematic review team, but the potential impact, one strategy. Table 5 presents a categorization of strategies
including on reduction in inequalities, was considered identified in the literature.
Table 5: Categories of community engagement strategies

Community engagement strategies
Pre-intervention consultation
Pre-programme consultation with community leaders
Meetings to sensitize community to an impending intervention, led by community leaders or community members
CHW selection
Engaging community in developing CHW hiring criteria
Engaging community in nominating community members for CHW positions
Community leaders involved in selecting and hiring CHW
CHW training
Involving selected community members or organizations in developing CHW training
CHW programme implementation
Enrolling community as members in organization/collaboration associated with CHW intervention
Engaging community members in retaining CHW
Involving community leaders in CHW activities
Engaging community members in intervention implementation
CHW project evaluation and oversight
Involving community members in decision-making, quality improvement and evaluation, e.g. participatory evaluation meetings
Establishment of a village health committee for project and CHW oversight
Evidence shows that community engagement strategies may marginalization of women, lack of access to health care, and
be effective in improving CHW performance and utilization. programme funding limitations. Several qualitative studies
Most quantitative, qualitative and mixed methods studies specifically indicated the negative impact of barriers to fair
indicated that a range of community engagement strategies and equitable CHW selection processes on CHW performance
have beneficial impacts on CHW performance outputs, and utilization; these appear to operate both internally through
including CHW motivation, commitment, satisfaction and undermining CHW commitment and satisfaction, and externally
retention (39, 134, 195–206). Community engagement through undermining community trust in CHWs and CHW
strategies were also found to have beneficial impacts on CHW programmes. Thus while 10 studies involved community
performance outcomes, including community trust of CHWs leaders in selecting and hiring CHWs, this should probably
and community awareness, support and sense of ownership be interpreted as a different intervention than involvement of
of CHW programmes. Three RCTs indicated that community community members in the CHW selection process (11 studies)
engagement strategies are effective in increasing CHW – though some studies report both. Cautionary evidence
programme impact at the population level, all in the domain of emerged with respect to the potential for this mechanism of
maternal and child health outcomes among rural communities community engagement to create tension with and within local
in low- and middle-income countries (70, 71, 207). authorities and other stakeholders.
Some community engagement strategies employed were Finally, the systematic review identified evidence suggesting
implemented before programme development and roll-out, that community engagement strategies support increased
including pre-programme consultation with community health equity, with improved child and maternal health
leaders (43, 208–212) and meetings to sensitize the outcomes among vulnerable populations in low-income
community about an impending intervention, led by settings, and beneficial effects of community engagement
community leaders or members (213–215). Other strategies strategies in CHW programmes specifically designed for
were implemented throughout the programme in engagement vulnerable populations (for example, ethnic minorities,
of community members in implementation (216–221) or immigrants, poor and rural communities) that experience
represented an ongoing evaluation and oversight of the health disparities.
CHW programme (222–225).
The systematic review of reviews showed that community
Across all studies, the single most prevalent community embeddedness is an important enabler of CHW retention,
engagement strategy described was community participation motivation, performance, accountability and support,
in nomination or selection of CHWs (see also recommendation and ultimately of the acceptability and uptake of the
1), which emerged across multiple studies as a factor health-related work of CHWs. It identified four reviews
in improving CHW performance and utilization (46, 133, documenting specific approaches to foster community
226–230). embeddedness (17, 51, 87, 124):
• community members being involved in CHW selection
The community engagement strategies also emerged as and selecting a locally admired and trusted person;
reflecting different levels of power afforded to community • community having a clear understanding of and
members, though it was difficult to assess this dimension reasonable expectations for their CHW;
from the descriptions provided in the majority of studies. • community monitoring of CHWs;
Limited evidence suggests that addressing existing social • community ownership of the CHW programme;
and gender hierarchies, and taking into account health • community involvement in selection of activities and
care system limitations, may support the effectiveness of priority setting of CHW work;
community engagement strategies in CHW programmes. • health system back-up of the CHWs with supervision,
Social and structural obstacles that may impede or undermine supplies and support, which in turn helps to maintain
the effectiveness of community engagement in improving community trust in CHWs.
CHW programme performance include stigma, poverty,
59
The systematic review of reviews also identified one review thereby reinforcing inequitable power relations and
suggesting that CHW embeddedness can lead to CHWs being alienating local communities. Proactively seeking
caught in tensions between the community and the health large participation, inclusive of all components of
system (231). the community, with specific activities targeting
disadvantaged groups, should therefore be considered.
The stakeholder perception survey found that community • In the case of highly stigmatized diseases (such as
engagement strategies had both high acceptability HIV), community engagement interventions may pose
and feasibility. perceived threats of inadvertent status disclosure in
local communities (for example, calling attention to HIV
7.13.4 Interpretation of the evidence in the household). Community engagements strategies
and other considerations by the GDG need to be adapted to ensure non-discrimination of
The GDG was of the view that community engagement is a the target group as a result of the activity. In order to
priority in CHW programmes. However, the GDG considered that avoid discrimination, mainstreaming key community
the diversity of community engagement strategies means that engagement strategies as part of regular CHW work
programme planners and policy-makers should pay specific might be required in some situations.
attention to the variety of options available. Policy-makers • Community engagement strategies may increase CHW
and planners should select the ones that are most relevant in programme utilization and perceived benefits beyond
relation to the scope and nature of the CHW programme under what available health system infrastructures can
consideration. Different community engagement strategies that support. Investments in CHW programmes that comprise
had supporting evidence bases were discussed by the GDG and community engagement strategies need to be planned as
included in the final recommendation. part of a comprehensive and participative health system
strengthening approach at community level.
These challenges underscore the importance of adapting
The systematic review found a broad range in the type,
policies on community engagement in CHW programmes
intensity and scale of community engagement strategies,
as a particular form of health intervention; and, secondly,
suggesting these interventions are feasible to implement.
the importance of assessing possible variability in the
However, it also identified qualitative studies pointing to
effectiveness of community engagement in CHW programmes
possible challenges that warrant specific mitigation strategies.
as a function of the focal health conditions, populations and
• Attempts to implement community engagement
contexts of these programmes.
strategies may be subverted by local stakeholders
during the CHW nomination and selection process,
Recommendation 14. Mobilization of community resources

Recommendation 14
WHO suggests that CHWs contribute to mobilizing wider community resources for health by:
• identifying priority health and social problems and developing and implementing corresponding action plans with the communities;
• mobilizing and helping coordinate relevant local resources representing different stakeholders, sectors and civil society organizations to address
priority health problems;
• facilitating community participation in transparent evaluation and dissemination of routine community data and outcomes of interventions;
• strengthening linkages between the community and health facilities.
7.14.1 Background to the recommendation One study (239) reported on the quantity of mobilization
CHWs are most frequently members of the communities they activities delivered among CHWs who received a health
serve, and therefore have deep knowledge and experience leadership training intervention, finding that CHWs who
of their community cultures and languages (232). Given participated in the training self-reported that they engaged
their in-depth knowledge of local systems, CHWs are in a in a “change agent role” at a significantly higher level across
unique position to act as agents of change by mobilizing multiple mobilization activities than non-trained CHWs in a
communities and additional resources for action to address national sample. For example, trained CHWs were more likely
health issues. Previous authors have conceptualized the CHW than non-trained CHWs to report that:
role as that of “change agents, empowering individuals, their • CHWs engaged community members to identify people
community, and themselves” (233). who influence change;
• community-engaged interventions had an impact on
Community mobilization is a process of raising a community’s local health and social parameters;
awareness of an issue and involvement in identifying and • CHWs and the community engaged in sustainability
activating resources and leadership to address it. Community efforts.
mobilization has long been recognized as a critical strategy However, trained CHWs were no more likely that non-trained
for improving health outcomes, and there exists a rich body CHWs to report that they engaged the community in initial
of literature evidencing successful mobilization on a range problem identification efforts.
of health issues (234–237). CHWs are uniquely suited to
engage communities and lead community mobilization efforts The other study (240) used ethnographic data to compare
by identifying and recruiting additional resources for health, a CHW programme at two points in time: first, when it was
working with communities to identify health priorities, and initially implemented by a nongovernmental organization
mobilizing key stakeholders. However, previous reviews of through CHWs who had a role in community mobilization;
literature examining the tasks that CHWs perform provide and second, after intervention management was transitioned
little evidence of CHWs being conceptualized as community to government, and the role of CHWs was reframed as peer
mobilizers (17). educators. The loss of the community mobilization role led
to diminished credibility with the community and loss of
7.14.2 Rationale for recommendation motivation by CHWs.
The GDG noted that the evidence found on this question
suggests, but does not provide conclusive evidence of, a The systematic review team rated the overall certainty of the
positive potential for a role for CHWs in mobilizing community evidence as very low.
resources for health. No known or theoretical risks arising
from such activities were identified through the review of The systematic review of reviews found no reviews of direct
the evidence and the GDG discussions. As the evidence was relevance to this policy question.
extremely limited in volume and scope, and characterized by
a very low level of certainty on the effects, the GDG adopted The stakeholder perception survey found CHW activities in
a conditional recommendation in favour of the policy option mobilization of community resources to be both acceptable
under consideration. and feasible.
7.14.3 Summary of evidence 7.14.4 Interpretation of the evidence and

The systematic review (Annex 6.14) on the question – “In other considerations by the GDG
the context of community health worker (CHW) programmes, The general lack of specificity regarding the role of CHWs
should practising CHWs mobilize wider community resources in mobilizing communities poses difficulties in determining
for health versus not?” (238) – identified as eligible for which activities are considered as “mobilization”. For the
inclusion two studies (one quantitative, one qualitative), purposes of this guideline, “mobilization” is interpreted as
conducted in India and the United States. a two-way process of empowering communities to take
61
action for health, and community involvement is therefore design and implement community mobilization tasks,
seen as a key criterion (241, 242). The resulting paucity they must evidence leadership skills and the ability to
of specific evidence limited the conclusions that could be strategically champion cooperation between communities
drawn. Therefore, this recommendation is based, to a large and stakeholders. Most typically, CHWs would perform these
extent, on the GDG’s view on the potential benefits of CHW functions by contributing to wider efforts by multidisciplinary
involvement in community mobilization efforts. primary care teams.
7.14.5 Implementation considerations Successful implementation of community mobilization

Evidence from the two studies indicates that community activities requires forging collaborative relations with local
mobilization activities require a unique skill set that leaders and authorities and recognition by other health
is substantively different from that of providing health workers of the role of CHWs in these tasks.
promotion and clinical services. For CHWs to proactively
Recommendation 15. Availability of supplies

Recommendation 15
WHO suggests using the following strategies for ensuring adequate availability of commodities and consumable supplies, quality
assurance, and appropriate storage, stocking and waste management in the context of CHW programmes:
• integration in the overall health supply chain;
• adequate reporting, supervision, compensation, work environment management, appropriate training and feedback, and team quality
improvement meetings;
• availability of mHealth to support different supply chain functions.
7.15.1 Background to the recommendation 7.15.3 Summary of evidence

Supply chain bottlenecks affect the access of CHWs to The systematic review (Annex 6.15) conducted for the
essential supplies and medications, placing vulnerable client question – “In the context of practising community health
populations at further risk. Poor supply chain management, worker (CHW) programmes, what strategies should be
including limited or non-existent stock control and fore- used for ensuring adequate availability of commodities and
casting, means that even though drugs may be available consumable supplies over what other strategies?” (243) –
centrally, there can be frequent stock-outs at the community identified as eligible for inclusion two quantitative and seven
level. Various strategies have been adopted to better train mixed methods studies, all conducted in six sub-Saharan
and equip CHWs to ensure availability of supplies. However, African countries.
despite various strategies to improve stock supply, there are
many challenges, such as community remoteness and erratic Factors associated with improved supply systems according
data management. to the included studies were as follows.
• Adequate supervision. Supervisors were noted to have
7.15.2 Rationale for recommendation additional duties involving the review of CHW registers
The GDG noted that the included studies identified several and cross-checking of drug inventories in order to make
strategies likely to be associated with improved supply sure supplies are routinely and adequately replenished.
chain management processes and outputs. As the certainty This helps reinforce CHW competencies regarding
of the evidence was low, the GDG adopted a conditional drug use (244).
recommendation in favour of these strategies. • Correct prescriptions. Having appropriate prescriptions
leads to a more accurate and reliable drug resupply for
CHWs (244).
• Regular reporting. CHWs received a more regular 7.15.4 Interpretation of the evidence
replenishment of drugs when they submitted monthly and other considerations by the GDG
drug reports on time compared to those who did not The GDG recognized that an effective supply chain for CHWs
submit reports on time or at all (245, 246). is one of the critical factors that represent a precondition
• Diagnostic tool availability. Availability of diagnostic for effective service delivery. It also noted the absence of
tools for CHWs also improved drug resupply (247). waste management from the literature identified. The GDG
Broader strategies identified across these studies as enablers was of the view that extending to CHW programmes the
to improve the availability of commodities and supplies national supply chain (as opposed to setting up a separate
included adequate compensation, appropriate training and independent one) represents a key element of health system
feedback, team quality improvement meetings and integration and sustainability.
an enabling work environment.
Evidence from several mixed methods studies showed that To ensure appropriate implementation of the identified
mHealth was well supported and effectively used by CHWs. strategies, and to avoid fragmentation into parallel competing
Phone-based systems improved communication, enhanced supply chains, relevant CHW commodities should be included
supply chain management, and enabled sharing of medicines in the national pharmaceutical supply plan or equivalent
between CHWs (248, 249). MHealth was also found to national supply chain plan. Mechanisms to replenish and
contribute to more timely and complete reports and to aid replace the equipment and supplies of CHWs vary, but any
supervision of CHWs (155, 177, 250). The systematic review national distribution systems of commodities should address
team rated the overall certainty of the evidence as low. the needs of CHWs on the ground, based on reliable data
and forecasting.
The systematic review of reviews found evidence suggesting
that regular provision of logistical support and supplies (such Simplified stock management tools and visual job aides for
as drugs and educational materials) is essential to maintain CHWs that accommodate low literacy with minimum data
CHW programme effectiveness, productivity, and respect for points may be instrumental to facilitate recording of data,
CHWs by the community. In addition, mHealth was found to adequate storage (including keeping perishable supplies at
be a potentially valuable job aide for noting drug adverse the right temperature), mapping and monitoring for early
effects, confirming dosage amounts and improving medical warning and resupply.
knowledge (13, 17, 124, 251–253).
The pre-service education curriculum for CHWs should
The stakeholder perception survey found various strategies include, beyond diagnostic and clinical competencies for
for strengthening the supply chain for CHWs to be both correct prescriptions, capacity for basic storage, stocking,
acceptable and feasible, with the exception of the use of quality assurance and waste management for essential
social media distribution aid, for which the acceptability and medicines and supplies, including basic elements of personal
feasibility were rated as more uncertain. safety when handling hazardous supplies (for example, to
prevent needle-stick injury).
63
8
Research priorities and
guideline update
Every effort has been made to ensure that the policy to the evidence base on the effectiveness of CHWs in
recommendations contained in this guideline are informed the delivery of specific preventive, promotive, curative
by an up-to-date appraisal of the published evidence, or care interventions.
complemented by assessments of feasibility and
acceptability. Overall, evidence was identified to provide In general terms, in some areas the research activities
policy recommendations for most areas. However, in several undertaken in support of this guideline found a near-
instances important gaps in both the scope and certainty absolute absence of evidence (for example, on certification
of evidence emerged from the systematic reviews, which or contracting and career ladders for CHWs, appropriate
provides an opportunity to outline priorities for a future typology and population target size); in most policy areas
research agenda on CHWs. considered, however, there is some evidence (in some cases
substantial) that broad strategies (such as competency-
The research priorities outlined in this document have been based education, supportive supervision and payment) are
extracted mainly from the systematic reviews and review of effective. However, this evidence is typically not sufficiently
systematic reviews conducted for the intervention areas of granular to allow recommendation of specific forms of
the CHW guideline. The prioritization of the CHW research these interventions, for example which education approaches,
needs is organized as much as possible to align thematically which supervision strategies, or which bundle of financial
with the intervention areas of the CHW guideline whilst and non-financial incentives are most effective or more
considering relevance and context. Like the guideline, the effective than others. Other cross-cutting considerations
research priorities identified relate only to the cross-cutting include the absence of economic evaluations of the various
policy and system enablers to optimize design and interventions under consideration, and the dearth of evidence
performance of CHW programmes, and they do not refer tracking policy effectiveness over time through longer-term
longitudinal studies.
8.1 Selection, education and certification

To improve CHW selection strategies, more research is needed Given the variability in the quantity, quality and duration of
that specifically assesses which recruitment criteria are most CHW training across different settings, further research is
effective for producing improved outputs and outcomes. required to assess optimal levels of education required to
Rigorously testing of whether and how community selection effectively perform CHW tasks. There is a need for mixed
improves outputs and outcomes is also required. methods research, including the use of factorial designs that
can test the relative impact of a variety of training doses and conducted on the effectiveness of non-didactic, on-the-job
durations. Outcomes should be assessed on CHW competence training that combines practice demonstration with expert
and effectiveness. observation, feedback and supervision.
Regarding CHW pre-service training curricula, studies should Further research is required to assess the effect of formal
be conducted assessing the impact that different levels certification for pre-service training of CHWs on critical
(specific versus broad) and methods of competency-based outcomes. Such studies should include a qualitative
training have on CHW expertise and performance, as well component that aims to understand potential downsides
as on population- and patient-level outcomes. There is a of formal certification, such as the costs and administrative
need for qualitative research that directly measures the burdens. Studies testing the effectiveness of monovalent
comparative experiences of CHWs receiving specific and versus polyvalent CHWs are also needed.
broad competency-based training. Studies should also be
8.2 Management and supervision

Further research is needed on different combinations of different contexts and activities, and to determine which
supportive supervision strategies for CHWs. Such studies bundles of financial and non-financial incentives optimize
should include identifying optimal monitoring mechanisms to CHW performance and resource use. Research studies on
track the performance of CHWs. Studies should also examine formal contracts for CHWs should include the contribution
the role of population size on CHW performance, and evaluate of formal agreements and contracts to optimal community
the optimal frequency of supervision of CHWs. health working conditions and performance. For CHW career
ladder opportunities, more scoping studies are needed to
Regarding the payment of CHWs, high-quality studies are facilitate a basic understanding in preparation for advanced
required to compare the various incentive models across studies and data mining efforts.
8.3 Integration into and support by health systems

and communities
Scoping reviews of CHW literature describing community to measure the effect of home visits and in-home care by
mobilization efforts, and examining CHW tasks in the context CHWs on access to care and mortality. A cross-cutting aspect
of mobilization, are needed. Conceptual models of CHW is to explore across different research priorities the role of
roles as agents in community mobilization should also be gender factors, stigma, poverty, and consideration of special
developed. Comparative analyses or other study designs that population groups in order to examine the health equity
allow for causal attribution of different strategies for data implications of different policy options.
collection and use, and supply chain management, would
be beneficial to expand and strengthen the current evidence Finally, policy and system research should evaluate strategies
base. Within this context, further research is needed on CHW on scalability, sustainability and cost-effectiveness of the
workflow for community engagement and care, including various components of CHW integration into health systems.
65
8.4 Implications for non-health development outcomes
The research identified was entirely focused on various and social protection through CHW programmes are being met;
health-related outcomes. As some of the recommendations what unintended consequences, if any, selection, education,
highlight, however, policy and investment decisions on health licensing and employment policies might entail from a gender
workers have broader implications on several other targets perspective; and how labour laws around informal work
of the SDGs, including job creation, economic growth, gender and CHW formal associations and unions may enable the
empowerment and education. There are untapped opportunities development of a better policy implementation environment
for future research to expand the evidence base on some of for CHW programme integration.
these aspects, including whether expectations of employment
8.5 Future research and guideline update

Recognizing the potential for additional research to modify and enablers (how, for whom, under what circumstances), and
strengthen the evidence base that informed the development of the broader health system requirements and implications
this guideline, the need and opportunity for a potential update of supporting the implementation of several interventions
will be considered five years after publication. simultaneously. Getting an answer to such policy questions
requires health policy and systems research methodologies
In calling for additional research on the topic, it is important to (254), such as implementation research, systems thinking
recognize that, while more methodologically robust evidence is tools, agent-based modelling, complex adaptive systems,
needed, it is probably unrealistic to envisage that there would heuristics guidance, process monitoring, and rapid synthesis
be large-scale RCTs to address from a pure effectiveness of available research.
perspective all the persisting evidence gaps. Furthermore,
RCT design is relatively unhelpful in providing insights into As most of the evidence retrieved for this guideline
the dynamics of complex programmes. More useful would be originated in low- and middle-income countries, additional
comprehensive, critical programme case studies. research should be considered in advanced economies to
better identify any differences in contextual factors and
It is necessary to avoid too narrow a focus on intervention- effectiveness of approaches that would impact policy
specific CHW effectiveness. There is a need to investigate options and recommendations.
not only what works, but also the contextual factors and
9
Guideline use
9.1 Plans for guideline dissemination
WHO will coordinate a range of activities to support the Advocacy, communications and engagement activities will
dissemination, uptake and implementation of the guideline. target three groups of stakeholders.
Recognizing the important role that other stakeholders • Primary target audience. The primary target audience
play, WHO has convened a CHW hub of the Global Health of this strategy includes (a) national policy-makers
Workforce Network, a collaborative mechanism facilitated (ministry of health, ministry of finance); (b) planners
by the WHO Secretariat through its Health Workforce and managers responsible for health workforce policy,
Department. The CHW hub comprises advocates, funders planning and management at national and district or
and implementers of CHW programmes from developed, provincial levels that include CHWs in the delivery of
emerging and developing countries, and will collaborate health services; and (c) health workforce educators.
with WHO in the roll-out of the guideline. • Secondary target audience. The secondary target
audience of this strategy includes development partners,
WHO has started developing, in consultation with and with funding agencies, global health initiatives, donor
inputs from the CHW hub, a communications, advocacy contractors, nongovernmental organizations and activists
and engagement strategy, whose overarching purpose is to (at global, regional and national levels) who fund, support,
support uptake and implementation of the guideline at country implement, or advocate greater and more efficient
level. The advocacy and engagement strategy is built as a involvement of CHWs in the delivery of health services.
multipronged approach based on a four-phase uptake model: • Influencers. The engagement strategy will also
• Phase 1: Generate awareness and understanding leverage relevant influencers and champions at the
• Phase 2: Foster commitment global, regional and national levels to support advocacy
• Phase 3: Ensure uptake and transformation and engagement of primary and secondary audiences.
• Phase 4: Monitor and evaluate advocacy and uptake.
Overarching principles of the communication and advocacy
To ensure that the most relevant and appropriate entry points strategy include the following.
are identified and guidance on uptake and implementation • Country ownership is key to successful implementation
are effective, the messaging will be tailored to groups of of the guideline; a range of activities will therefore
countries as follows: ensure involvement of ministries of health, ministries of
• countries that already have CHW policies that are finance and other relevant stakeholders and actors at
aligned with the new guideline; various levels of the national health systems.
• countries that already have CHW policies that are not • Partner support should be harmonized at global,
necessarily aligned with the new guideline; regional and country levels to ensure all messages,
• countries that do not have policies regarding CHWs. products and support activities are aligned.
67
• Clearly articulating and communicating the global awareness is important to keep momentum going
benefits of adopting the recommendations and the after the launch, more intense promotion of the guideline
return on investment are essential, as is the focus on and uptake support is needed in the countries where it
building lasting relationships with key stakeholders would have the most impact.
instead of one-off activities and events. • Concrete mapping suggestions should be developed
• Existing event opportunities should be tapped into on how to most effectively implement the guideline
to maximize efficiencies and increase visibility and recommendations at the country level, as per segmentation
awareness at all levels (global, regional, national). While of countries, including action plan templates.
9.2 Plans for guideline adaptation,

implementation and evaluation
In order to maximize the opportunities for the guideline • selection of a few countries in which to prioritize policy
to be implemented, it will need to be adapted and dialogue and capacity-building activities, supported by
contextualized, including through a number of derivative drafting a regional and country implementation map;
products made available in relevant languages to promote • meetings of country stakeholders involved with CHWs to
uptake at country level. present the guideline and design a partner support plan
(agree on roles and responsibilities and contributions);
Beyond the adaptation, simplification and development • a workshop with government stakeholders (ministry of
of user-friendly summaries of messages, a range of health, ministry of finance, development partners) for
accompanying activities will be considered and implemented, awareness raising and country mapping of existing CHW
subject to resource availability. Some of these activities situation and policies, to create a baseline and, poten-
might be directly implemented and supported by WHO, others tially, a roadmap for uptake of the recommendations, and
by or in collaboration with other agencies and partners to support the ministry of health in advocacy with the
involved in the Global Health Workforce Network CHW hub, or ministry of finance;
other institutions. A non-exhaustive and non-binding list of • a self-assessment tool based on the recommendations
activities that will be considered includes: of the guideline that supports countries in developing
• development of a dedicated online portal; baseline information related to CHWs, and that can be
• a one-stop shop suite of derivative products, including used to monitor and evaluate implementation of policies
toolkits, to ensure the guideline is easily comprehensible and programmes aligned with the recommendations.
and is taken up by stakeholders (this will include
Potential toolkit components include:
translation of the guideline into the WHO official
• technical summary of the guideline and the implications
languages), with the assets filtered through different
by audience (for example, what the guideline means for
lenses by audience (such as funders, implementers);
implementers, funders, or other stakeholders);
• a launch event with substantive global visibility (potential
• policy briefs on specific subtopics (such as management
candidates: 40th Alma Ata anniversary events, WHO
and supervision, training and education, contracting,
regional committees);
remuneration and career advancement);
• a series of webinars;
• key messages, narrative;
• regional workshops bringing together regional and
• infographic or video derivative products;
country champions and stakeholders involved with
• return on investment – the business case for
CHWs to assess which countries would most benefit
implementing the guideline;
from the guideline and are in a position to take up
• practical guidance on how to map the implementation
some of the recommendations;
of the guideline, according to baseline conditions of
countries in relation to the CHW policy environment;
• repository of partners and how they can help.
Evaluating the effectiveness of the guideline uptake and evidence generation through existing mechanisms, such as the
implementation will be focused on tracking over time policy National Health Workforce Accounts or piggy-backing on other
process indicators, such as a self-reported assessment existing surveys or meetings that could provide an opportunity
on the adoption of the guideline policy recommendations to gather relevant evidence and information.
in national policies and mechanisms. Over time, tracking
of CHW-specific indicators through relevant health After a few years of implementation, and subject to resource
workforce data collection mechanisms, such as the regular availability, commissioning dedicated country case studies
implementation and reporting of National Health Workforce on the experience in specific countries in implementation
Accounts (255), will enable establishing baseline data of the guideline will enable more light to be shed on
and tracking progress regarding CHW education capacity, concrete experiences, including enablers and hindering
availability, distribution, and other attributes. factors, in uptake of the guideline recommendations. This
will inform both subsequent efforts at supporting guideline
All efforts will be made to avoid the need for dedicated surveys implementation and eventual updates and revisions of the
and ad hoc data collection processes, with priority given to guideline document itself.
69
10
General implementation
considerations
In addition to the detailed recommendations specifically their international partners should consider the following
developed to address the policy questions examined in the key principles and cross-cutting aspects for the design and
preceding sections, planners, policy-makers, managers and successful implementation of CHW policies.
10.1 Key principles

• Countries should use a combination of CHW policies • In the design and organization of health care, CHWs
selected based on the objectives, context and should be contributing to the provision of integrated,
architecture of each health system. This guideline people-centred health services.
is not a blueprint that can be uncritically adopted; • When considering and setting policies that affect CHWs,
it should rather be seen as a critical overview of their voices and perspective should be represented in
evidence and a menu of interrelated policy options the policy dialogue.
and recommendations, which need nevertheless to be • Health services do not naturally gravitate towards
adapted and contextualized to the reality of a specific equitable outcomes. CHWs, by working at the front line
health system. of service provision in underserved communities, have
• CHW programmes and policies will need to be monitored the potential to contribute to a reduction in inequality
and evaluated over time, and adapted and amended in access to health services and health outcomes; but
through a dynamic process informed by context- in order for this potential to be fully realized, equity
specific evidence. In order to promote learning and considerations should be embedded at the outset
innovation it is important that policy-makers and in programme design, as well as in monitoring and
managers have a willingness to transparently share evaluation of implementation and effectiveness.
data on the characteristics of CHWs and their • In identifying the optimal features of a CHW programme,
performance, and information on programme consideration should be given not only to the traditional
implementation and effectiveness. performance measures focused on health service outputs,
• CHWs should not be regarded as a way to save costs or outcomes and impact, but also to the labour rights of
as substitutes for health care professionals, but as an CHWs themselves, including safe and decent working
element of integrated primary health care teams. The conditions, and freedom from all kinds of discrimination,
role of CHWs should be defined and supported with the coercion and violence. Some of these aspects are of
overarching objective of constantly improving equity, particular concern and relevance in conflict-affected
quality of care and patient safety. settings and chronic complex emergencies.
10.2 Operational aspects of CHW programme
design and implementation
The starting point for an effective design of CHW initiatives be envisaged that the role of CHWs might need to
and programmes is a sound situation analysis of population evolve over time in parallel with changes in the
needs and health system requirements. Planners should adopt epidemiological profile of the population and health
a whole-of-system approach, taking into consideration health system requirements. The education, certification and
system capacities and population needs and framing the role career ladder elements of CHW programmes should
of CHWs vis-à-vis other health workers, in order to integrate consider these factors and future scenarios, with a
appropriately CHW programmes into the general health system. view to ensuring employability of these health workers
in a long-term perspective, or an exit strategy that
10.2.1 Programme design considers CHWs as citizens and workers with rights,
• When designing a CHW programme, consideration and treats them with dignity.
should be given to its social, cultural, political and
financial feasibility. 10.2.3 Health system support
• The objectives of a CHW programme and the roles of • The recommendations in this guideline are rooted in
CHWs should be defined within a holistic approach that an overarching logic of formalization of CHW roles and
considers optimal service delivery modalities in a country or their integration into the health system. In order for
jurisdiction, and the corresponding workforce implications. such formalization to be effective, it is necessary to
Within those, the roles and objectives of CHWs should be have clarity on which level of the system (for example,
considered vis-à-vis those of other occupational groups. national or local) and programmatic area (for example,
• Accordingly, this guideline reiterates and reinforces the human resources for health or community health or
principle underscored by the WHO Global Strategy on others) represents the institutional “anchor” in the
Human Resources for Health: Workforce 2030, namely health system for the CHW programme.
that countries should plan for their health workforce as a • Related to the requirement for overarching health system
whole, rather than segmenting planning and corresponding support, it is necessary to have an understanding of the
programming and financing efforts by single occupational underlying health system capacity to effectively support the
groups, which carries a risk of fragmentation, inefficiency CHW programme. The recommendations in the preceding
and policy inconsistency. sections implicitly assume that the health system would
have the capacity to effectively carry out a range of
10.2.2 Policy coherence supporting functions, including to train and supervise,
• CHW initiatives and programmes should therefore be provide competency-based certification, effectively manage,
aligned to and be part of broader national health and protect from malpractice risks, remunerate in a timely
health workforce policies. As relevant, they should and adequately manner, create the appropriate channels
also be linked with national education, labour and for linkages and referrals, and procure commodities and
community development sectoral or subsectoral essential supplies. However, the actual capacity of the
policies and frameworks. health system to perform these functions might vary
• The policies recommended within this guideline should considerably across different contexts and may fall short.
not be considered in isolation from one another. There • Where the CHW programme depends on the health system
is a need for internal coherence and consistency adequately performing some of its enabling functions as
among different policies, as they represent related described above, the CHW programme might represent an
and interlocking elements that complement and can occasion to put the spotlight on needs and opportunities
reinforce one another. for support and strengthening of the system.
• The role of CHWs should be considered in a long-term
perspective. Beyond addressing the immediate and
pressing needs of health systems, it should
71
10.2.4 Financing implications have put in place and funded, mostly out of domestic
• Little evidence was found on resource requirements resources, large-scale CHW initiatives (20), and that
in the context of the evidence reviews. However, the the deployment of CHWs has been identified as a
policy options recommended in this guideline have, in cost-effective approach (19).
the aggregate, considerable cost implications, and these • The key determinant of success in securing adequate levels
require long-term dedicated financing: attempting to set of investment is the political will to prioritize approaches
up and run a large-scale CHW initiative on a shoestring and strategies that are most likely to lead to improved
budget is likely to yield disappointing outcomes. population health outcomes.
• The financial feasibility of implementing the policy • some low-income countries where the domestic resource
In
recommendations contained in this guideline envelope is unlikely to allow self-reliance in the short term,
(especially the ones on education and remuneration) aligning external support to domestic policy needs and
might be questioned by some stakeholders. However, health system mechanisms may contribute to the impact
it is important to note that even low-income countries and long-term sustainability of CHW programmes.
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Annex 1
Search terms to identify CHWs and other

relevant community-based health workers
“Community Health Workers”[Mesh] OR “Community Health OR “lady Health worker”[tw] OR “lady Health workers”[tw]
Nursing”[Mesh] OR “health auxiliary”[tw] OR “frontline OR “barefoot doctor”[tw] OR “Community Practitioners”[tw]
health workers”[tw] OR “frontline health worker”[tw] OR OR “Community Practitioner”[tw] OR “community-based
“midwife”[tw] OR “Midwifery”[tiab] OR “midwives”[tw] practitioners”[tw] OR “community-based practitioner”[tw] OR
OR “Birth Attendant”[tw] OR “Midwives”[tw] OR “outreach “promotoras de salud”[tw] OR “agentes de saúde”[tw] OR “rural
worker”[tw] OR “outreach workers”[tw] OR “lay health health auxiliaries”[tw] OR “traditional birth attendants”[tw]
worker”[tw] OR “lay health workers”[tw] OR “promotora”[tw] OR OR “traditional birth attendant”[tw] OR “Activista”[tw] OR
“promotoras”[tw] OR “village health worker” OR “village health “Agente comunitario de salud”[tw] OR “Agente comunitário
workers”[tw] OR “volunteer health worker”[tw] OR “volunteer de saúde”[tw] OR “Anganwadi”[tw] OR “Animatrice”[tw] OR
health workers”[tw] OR “voluntary health workers”[tw] “Barangay health worker”[tw] OR “Barangay health workers”[tw]
OR “voluntary health worker”[tw] OR “community health OR “Basic health worker”[tw] OR “Basic health workers”[tw]
agent”[tw] OR “community health agents”[tw] OR “health OR “Brigadista”[tw] OR “Colaborador voluntario”[tw] OR
promoter”[tw] OR “health promoters”[tw] OR “community “Community drug distributor”[tw] OR “Community drug
health worker”[tw] OR “community health workers”[tw] OR distributors”[tw] OR “Community health agent”[tw] OR
“community health aide”[tw] OR “community health aides”[tw] “Community health agents”[tw] OR “Community health
OR “community health nursing”[tw] OR “community health promoter”[tw] OR “Community health promoters”[tw] OR
nurses”[tw] OR “community health nurse”[tw] OR “community “Community health representative”[tw] OR “Community health
health officers”[tw] OR “community health officer”[tw] OR representatives”[tw] OR “Community health volunteer”[tw] OR
“community health volunteer”[tw] OR “community health “Community health volunteers”[tw] OR “Community resource
volunteers”[tw] OR “community health distributors”[tw] OR person”[tw] OR “Female multipurpose health worker”[tw]
“community health distributor”[tw] OR “community health OR “Female multipurpose health worker”[tw] OR “Health
surveyors”[tw] OR “community health surveyor”[tw] OR promoter”[tw] OR “Health promoters”[tw] OR “Kader”[tw] OR
“community health assistants”[tw] OR “community health “Monitora”[tw] OR “Mother coordinator”[tw] OR “Outreach
assistant”[tw] OR “community health promoters”[tw] OR educator”[tw] OR “Outreach educators”[tw] OR “Promotora”[tw]
“community health promoters”[tw] OR “community IMCI”[tw] OR “Shastho shebika”[tw] OR “Shastho karmis”[tw] OR
OR “community volunteer”[tw] OR “community volunteers”[tw] “Sevika”[tw] OR “Village health helper”[tw] OR “Village drug-kit
OR “health extension workers”[tw] OR “health extension manager”[tw] OR “Accompagnateur”[tw] OR “Accredited
worker”[tw] OR “village health volunteer”[tw] OR “village health Social Health Activist”[tw] OR “Animator”[tw] OR “ASHA”[tw]
volunteers”[tw] OR “close-to-community provider”[tw] OR OR “Auxiliary Nurse”[tw] OR “Auxiliary Nurse-midwife”[tw]
“close-to-community providers”[tw] OR “community-based OR “Bridge-to-Health Team”[tw] OR “Behvarz”[tw] OR “Care
practitioner”[tw] OR “community-based practitioners”[tw] Group”[tw] OR “Care Groups”[tw] OR “Care Group Volunteer”[tw]
OR “Care Group Volunteers”[tw] OR “Community Case Community Health Volunteer”[tw] OR “Female Community Health
Management Worker”[tw] OR “Community Case Management Volunteers”[tw] OR “Health Agent”[tw] OR “Health Agents”[tw]
Workers”[tw] OR “Community Health Agent”[tw] OR “Community OR “Health Assistant”[tw] OR “Health Assistants”[tw] OR “Health
Health Agents”[tw] OR “Community Health Care Provider”[tw] Extension Worker”[tw] OR “Health Extension Workers”[tw] OR
OR “Community Health Care Providers”[tw] OR “Community “Health Surveillance Assistant”[tw] OR “Health Surveillance
HealthCare Provider”[tw] OR “Community HealthCare Assistants”[tw] OR “Kader”[tw] OR “Lead Mother”[tw] OR
Providers”[tw] OR “Community Health Extension Worker”[tw] “Malaria Agent”[tw] OR “Malaria Agents”[tw] OR “Maternal
OR “Community Health Extension Workers”[tw] OR “Community and Child Health Worker”[tw] OR “Maternal and Child Health
Health Officer”[tw] OR “Community Health Officers”[tw] OR Workers”[tw] OR “Mobile Clinic Team”[tw] OR “Mobile Clinic
“Community Surveillance Volunteer”[tw] OR “Community Teams”[tw] OR “Nutrition Agent”[tw] OR “Nutrition Agents”[tw]
Surveillance Volunteers”[tw] OR “Family Health Worker”[tw] OR OR “Nutrition Counselor”[tw] OR “Nutrition Counselors”[tw] OR
“Family Health Workers”[tw] OR “Family Planning Agent”[tw] “Peer Educator”[tw] OR “Peer Educators”[tw] OR “Shasthya
OR “Family Planning Agents”[tw] OR “Family Welfare Shebika”[tw] OR “Socorrista”[tw]
Assistant”[tw] OR “Family Welfare Assistants”[tw] OR “Female
91
Annex 2
Service delivery areas on which there is published

evidence of CHW effectiveness
Setting
Health issue
High-income countries Low- and middle-income countries
Multiple primary Most CHW programmes focused on underserved populations CHW programmes can promote equity of health care access and
health care in high-income countries (such as ethnic or racial minorities, utilization by reducing inequities relating to place of residence, gender,
interventions the economically marginalized, rural populations or immigrant education and socioeconomic position, and supporting more equitable
groups) (1–7). CHW interventions, such as through peer uptake of referrals (12). There is low-quality evidence from Brazil (13).
support telephone calls (8) or home visits (9), can be effective Deploying lay refugees or internally displaced persons as CHWs to
for a wide range of health issues, including increasing provide basic health services to women, children and families in camps
knowledge about parenting (9), disease prevention (moderate can increase service coverage, knowledge about disease symptoms and
strength of evidence) (1), influenza prevention (9), promotion prevention, uptake of treatment and protective behaviours, and access
of home safety (9), increasing parenting self-efficacy (9), to reproductive health information (some evidence, weak quality) (14).
patient enrolment in research (10), uptake of early intervention There was no clear evidence for equitable quality of services provided by
services (10), increasing access to primary health care for CHWs, and there was limited information regarding the role of CHWs in
screening (2), improving workplace safety (low strength of generating community empowerment to respond to social determinants
evidence) (1) and disease prevention (mixed evidence) (1), of health (12). There is some evidence (moderate quality) that CHWs are
and reducing urgent care visits (9). CHWs can reduce obesity effective in providing health education (15) and psychosocial support
among postpartum teens (9), improve nutritional eating habits (15). There is an absence of evidence on the potential of CHWs to support
(10), and increase physical activity (11). community-based palliative care (16).
Reproductive, maternal, neonatal and child health

Neonatal and CHW interventions can be effective in increasing infant- CHWs providing community-based care for infants and children
child health stimulating home environment scores (9), reducing in resource-limited settings can reduce neonatal, infant and child
psychiatric diagnoses among children (9), improving child mortality and morbidity (for example, from malaria, pneumonia and
development (10), and improving child well-being (mixed diarrhoea) (17–27). While there is high-quality evidence that home-
evidence) (1). based neonatal care reduces neonatal and perinatal mortality in South
Asian settings with high neonatal mortality rates and poor access
to health facility-based care (22, 23), other reviews reported mixed
results, with some individual empirical studies included in reviews not
showing improvements in CHW intervention areas (18). Evidence of the
impact of CHW interventions on neonatal outcomes is promising but of
moderate quality (21) and on CHW capacity to provide skilled birth care
is of low quality (21). Antenatal and neonatal practice indicators also
significantly improved (23). Compared to physicians, trained CHWs may
screen for possible bacterial infection in young infants with relatively
high sensitivity but somewhat lower specificity (28). There is some
evidence of moderate quality that CHWs are effective in the promotion
of essential newborn care (15), including skin-to-skin care for newborns
(15). CHWs can perform effective case management of child pneumonia
(29), although pneumonia management performance is mixed when
pneumonia management is integrated with malaria diagnosis and
treatment (30).
(continued)
Service delivery areas on which there is published evidence of CHW effectiveness (continued)
Setting
Health issue
Reproductive, maternal, neonatal and child health
Neonatal and The use of CHWs, compared to usual health care services, may
child health increase the number of parents who seek help for their sick child (27).
(continued) Women’s groups (facilitated by CHWs) practising participatory learning
and action, compared with usual care, have a positive impact on
reducing neonatal mortality in low-resource settings (but no evidence
of impact on reducing stillbirths) (31). Trained traditional birth
attendants compared to untrained traditional birth attendants showed
significant increases in safe delivery practices and appropriate
referral knowledge and practice (32) and are associated with small but
significant decreases in perinatal mortality and neonatal mortality due
to birth asphyxia and pneumonia (32). However, another review (33)
concludes that there is insufficient evidence to establish the potential
of training of traditional birth attendants to improve perinatal and
neonatal mortality. CHWs in Brazil have demonstrated effectiveness in
increasing the frequency of child weighings (13).
Maternal health Peer support can be effective for reducing depressive Almost all of the intervention studies involving CHWs showed a
symptoms in mothers with postnatal depression (8) and significant impact on reducing maternal mortality and on improving
can positively impact women’s perinatal mental health (34). perinatal and postpartum service utilization indicators (26). Community-
One study on addressing stress and mental health among based intervention packages, which almost always involved CHWs, may
pregnant women on Medicaid found that adding a CHW to have a possible effect on reducing maternal mortality, although the
a nurse home visit programme increased the number of pooled result just crossed the line of no effect (24). Women’s groups
at-risk women reached (6). (facilitated by CHWs) practising participatory learning and action,
compared with usual care, have a positive impact on reducing maternal
mortality in low-resource settings (31). In settings characterized by high
mortality and weak health systems, trained traditional birth attendants
can contribute to reducing mortality through participation in key
evidence-based interventions (32). There is some evidence of moderate
quality that CHWs are effective in providing psychosocial support
(15). CHWs were effective in delivering psychosocial and educational
interventions to reduce maternal depression (35). Non-specialist
providers (a classification that includes CHWs) may be effective in
reducing perinatal depression (36).
Immunization CHW programmes increased the number of children whose There is evidence, but low quality or inconsistent, that CHWs can
vaccinations were up to date (moderate quality) (37). increase immunization coverage through promoting vaccination
(27, 32, 37, 38) and providing vaccination themselves (37). There is
low-quality evidence that health professionals are confident that
CHWs can deliver vaccines or other medicines using compact prefilled
autodisposal devices (39).
Contraception CHW interventions have been found to reduce unplanned CHWs were able to deliver injectable contraception safely and
repeat births among adolescents (9, 40) but there was effectively, with high quality and with high levels of patient
no significant association detected in terms of repeated satisfaction (41, 42), and initiate their use (which involves screening
pregnancies (40). women and counselling them on side-effects), with no difference in
the quality of counselling on side-effects between CHWs and clinic-
based providers (42). Most (93%) studies indicated that CHW family
planning programmes increased the use of modern contraception
and most (83%) reported an improvement in knowledge and attitudes
concerning contraceptives (43). CHWs can provide counselling on
contraceptives, provide contraceptives, and refer to health facilities
for more specialized care (43).
Breastfeeding CHW interventions can be effective for increasing The use of lay health workers, compared to usual health care services,
breastfeeding continuation (8, 44), attempts and duration probably increases breastfeeding (27), and there is some evidence
(9), initiation, duration, and exclusivity (45). of moderate quality that CHWs are effective in exclusive breastfeeding
promotion (15). CHWs in Brazil have demonstrated effectiveness in
increasing the prevalence of breastfeeding (13) and delaying the
introduction of bottle-feeding (13).
(continued)
93
Setting
Health issue
Noncommunicable diseases
Diabetes There is weak evidence that CHW interventions improve CHW capacity in addressing diabetes in low- and middle-income
knowledge of medication label reading among diabetics (1); countries was not reported in the systematic review literature.
improve self-management (46) (low strength of evidence)
(1); decrease glycaemia (46) (mixed evidence) (5) (modest
reduction) (47). There is no evidence that telephone
interventions provided by lay and peer support workers
improve mental health or quality of life among diabetics (46).
For children with type 1 diabetes, CHWs improved glycaemic
control and decreased hospitalizations (48).
Cancer CHW interventions – peer support phone calls (8), home Only one non-systematic review (50) discussed the potential of CHWs
visits (9) – can be effective in increasing cancer screening to address cancer in low- and middle-income countries, and did not
rates (2, 8–10, 49); knowledge about prostate cancer (but provide evidence of CHW capacity.
not screening) (9); cancer screening (moderate evidence) (1);
planned use of cancer screening tests (mixed evidence) (1);
breast self-examination (mixed evidence) (1).
Mental health CHW interventions can reduce depression (9) and stigma CHW-led interventions can reduce the burden of mental, neurological
toward depression treatment (one study) (6), improve and substance use disorders, including depression and post-traumatic
depression knowledge and efficacy to seek treatment (6), stress disorder among adults (evidence from three studies) (52), and can
and produce beneficial changes in health status measures in also improve child mental health outcomes (evidence from four studies)
many, but not all, studies (51). CHW interventions in children (52). Non-specialist providers, usually CHWs, are more effective than
with chronic conditions may lead to modest improvements usual care or delayed treatment (wait-listed) groups in the provision of
in parental psychosocial outcomes (48) and parental quality mental health treatments, generally for depression or post-traumatic
of life (48). stress (53). Non-specialist health workers, which in this review (36)
included both professionals (for example, doctors, nurses and social
workers) and CHWs (22 of the 38 studies), compared with usual health
care services, have some promising benefits in improving outcomes for
general and perinatal depression, post-traumatic stress disorder and
alcohol use disorders, and outcome for patients with dementia and their
caretakers (evidence mostly of low or very low quality) (36).
Asthma Peer support telephone calls can be effective for increasing CHW capacity in addressing asthma in low- and middle-income
the number of asthma-free days (9) as well as the use countries was not reported in the systematic review literature.
of bedding encasements for asthma patients (moderate
strength of evidence) (1). While some CHW interventions for
children with asthma decreased rapid breathing episodes,
activity limitation, and asthma exacerbations, and increased
the number of symptom-free days, results were inconsistent
and risk of bias was often unclear (48). Lay and peer
interventions for adolescents with asthma could lead to
small improvements in asthma-related quality of life (weak
evidence) but there was insufficient evidence on asthma
control, exacerbations and medication adherence (54).
Noncommunicable diseases
Other Peer support telephone calls can be effective for diet change CHW capacity in addressing other noncommunicable diseases in
noncommunicable in post-myocardial infarction patients (8). CHW interventions low- and middle-income countries was not reported in the systematic
diseases may improve chronic disease management among children – review literature.
(chronic diseases, including modest improvements in reduced urgent care use
hypertension) (48), decreased symptoms (48), and fewer missed work and
school days (48) – and in adults (2), including improvements
in blood pressure among adults with hypertension (10, 55), in
self-management behaviours, including appointment keeping
and adherence to antihypertensive medications (55), and in
health care utilization (for example, fewer emergency visits
and an increased proportion of patients having a nurse or
physician) (55).
(continued)
Setting
Health issue
Infectious diseases
HIV Task shifting to CHWs may enhance emotional support and Task shifting from higher-level providers and clinic-based care to CHWs
increase retention in care, and better link people with HIV to was generally acceptable to individuals living with HIV (56, 57). This may
care (one qualitative study) (56–58). enhance dignity and quality of life (59) and increase retention in care
(56, 59), without decreasing the quality of care (60) or patient outcomes
(such as virologic failure and mortality) (59, 61, 62). Task shifting and
community-based outreach involving CHWs effectively links people
living with HIV to care (58).
Malaria CHW capacity in addressing malaria in high-income countries There is some evidence of moderate quality that CHWs are effective in
was not reported in the systematic review literature. malaria prevention (15, 26). CHWs can perform rapid diagnostic tests
with high sensitivity and specificity, and display high levels of adherence
to treatment guidelines (29, 30, 63–65). There was insufficient research
to enable an effect on morbidity or mortality to be estimated (63).
Tuberculosis CHW interventions have helped decrease the incidence of TB (26).
CHWs probably increase the number of people with TB who are cured,
though they do not appear to affect the number of people who complete
preventive therapy (27). Community initiatives were highly effective in
stigma reduction, treatment support, referral of persons with suspected
TB and reducing defaulting (66–68). Psychosocial support, referral of
persons with TB symptoms and household contact tracing in the context
of multidrug-resistant TB have been effective in Peru (69).
Other infections Home visits from CHWs can be effective in increasing CHW interventions have contributed to the control of neglected
hepatitis B testing (9) and increasing hepatitis B virus testing tropical diseases (70). They can support the control of Buruli ulcer in
uptake (moderate quality evidence) (7). sub-Saharan Africa (71).
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99
Annex 3
Existing WHO guidelines that identify specific

roles and services rendered by CHWs
Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection (WHO HIV, 2016);
and Optimizing health workers’ roles for maternal and newborn health (WHO RHR, 2012)
The guidelines for task sharing and delegation provide countries with the guidance on how to most efficiently and rationally
use a more diverse skills mix for the delivery of essential HIV/AIDS and maternal and newborn health services.
http://www.who.int/hiv/pub/arv/arv-2016/en/ and http://www.optimizemnh.org/
Engage-TB approach: integrating community-based tuberculosis activities into the work of nongovernmental and
other civil society organizations (WHO TB, 2012)
The document guides the integration of TB activities into the work of CHWs and community volunteers working on other
health and development themes through close collaboration between the public sector and nongovernmental organizations
and with standardized indicators for the national monitoring and evaluation systems.
http://apps.who.int/iris/bitstream/10665/75997/1/9789241504508_eng.pdf
The community health worker: working guide, guidelines for training, guidelines for adaptation (WHO, 1987)
These guidelines date back to 1987 and provide a comprehensive overview of the possible breadth of responsibilities
of community health workers in primary health care in developing countries. The document however d oes not
reflect contemporary evidence, and it is not clear what evidence was used to inform the service delivery and training
recommendations. It is therefore a document of mostly historical relevance. http://apps.who.int/iris/handle/10665/38101
Additional guidelines that refer to scope of work of CHWs from the perspective of their roles in selected programme and service
delivery areas
Guidelines for training community health workers in nutrition

http://apps.who.int/iris/handle/10665/37922
WHO/WFP/SCN and UNICEF joint statement on community-based management of severe acute malnutrition
http://www.unicef.org/publications/index_39468.html
Malaria: a manual for community health workers

Training of community health workers and community volunteers
Caring for newborns and children in the community (joint WHO/UNICEF)

http://apps.who.int/iris/bitstream/10665/204273/2/9789241549295_FacilitatorNotes_eng.pdf?ua=1
Caring for the newborn at home (joint WHO/UNICEF)

http://www.who.int/maternal_child_adolescent/documents/caring-for-the-newborn-at-home/en/
Caring for the child’s health: growth and development (joint WHO/UNICEF)
http://www.who.int/maternal_child_adolescent/documents/care_child_development/en/
Caring for the sick child in the community (joint WHO/UNICEF)

http://www.who.int/maternal_child_adolescent/documents/caring-for-the-sick-child/en/
WHO/UNICEF joint statement on iCCM

http://www.unicef.org/health/files/iCCM_Joint_Statement_2012(1).pdf
Revised WHO classification and treatment of childhood pneumonia at health facilities

http://www.who.int/maternal_child_adolescent/documents/child-pneumonia-treatment/en/
Community case management during an influenza outbreak: a training package for community health workers
http://www.who.int/influenza/resources/documents/community_case_management_flipbook/en/
Caring for newborns and children in the community: planning handbook for programme managers and planners
Community health workers: what do we know about them?

http://www.who.int/hrh/documents/community_health_workers.pdf
WHO/ GHWA/UNICEF/IFRC/UNHCR joint statement: scaling up the community-based health workforce for emergencies
http://www.unicef.org/media/files/Scaling-up_community-based_health.pdf
Age-friendly primary health care centres toolkit

http://apps.who.int/iris/bitstream/10665/43860/1/9789241596480_eng.pdf?ua=1
Baby-friendly hospital initiative

Clinical guidelines for withdrawal management and treatment of drug dependence in closed settings
http://www.wpro.who.int/publications/docs/ClinicalGuidelines_forweb.pdf?ua=1
Comprehensive cervical cancer control: a guide to essential practice

101
HIV prevention, diagnosis, treatment and care for key populations
http://apps.who.int/iris/bitstream/10665/128048/1/9789241507431_eng.pdf?ua=1&ua=1
The use of antiretroviral drugs for treating and preventing HIV infection
Guidelines on the treatment of skin and oral HIV-associated conditions in children and adults
HIV and adolescents: guidance for HIV testing and counselling and care for adolescents living with HIV
Home visits for the newborn child: a strategy to improve survival (joint WHO/UNICEF)
http://apps.who.int/iris/bitstream/10665/70002/1/WHO_FCH_CAH_09.02_eng.pdf?ua=1&ua=1
Infant and young child feeding

Guideline: managing possible serious bacterial infection in young infants when referral is not feasible
Operations manual for delivery of HIV prevention, care and treatment at primary health centres in high-prevalence,
resource-constrained settings
http://www.who.int/hiv/pub/imai/om.pdf?ua=1
Optimizing health worker roles to improve access to key maternal and newborn health interventions through
task shifting
Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines
Treatment of tuberculosis guidelines: fourth edition

Guideline: updates on the management of severe acute malnutrition in infants and children
Guidelines for the management of conditions specifically related to stress

WHO recommendations on health promotion interventions for maternal and newborn health, 2015
http://apps.who.int//iris/bitstream/10665/172427/1/9789241508742_report_eng.pdf?ua=1
Annex 4
List of members of Steering Group, Guideline

Development Group and External Review Group
Table A4.1: Steering Group members

Name and affiliation Gender
WHO headquarters
COMETTO, Giorgio (RTO) – WHO Health Workforce M
NEGUSSIE, Eyerusalem Kebede / FORD, Nathan – WHO HIV F, M
ABOUBAKER, Samira – WHO Maternal, newborn, child and adolescent health F
SYED, Lana – WHO Global TB Programme F
OLADAPO, Olufemi Taiwo – WHO Reproductive health research M
BARKLEY, Shannon – WHO Service delivery and safety F
MORAN, Thomas – WHO Polio, emergencies and country collaboration M
PORIGNON, Denis Georges – WHO Health governance and financing M
ARAUJO DE CARVALHO, Islene – WHO Ageing and life course F
DUA, Tarun – WHO Mental health and substance abuse F
WHO regional offices
NYONI, Jennifer – WHO Regional Office for Africa F
ASSAI ARDAKANI, Mohammad – WHO Regional Office for the Eastern Mediterranean M
GEDIK, Fethiye Gulin – WHO Regional Office for the Eastern Mediterranean F
SENANAYAKE, Gunasena Sunil – WHO Regional Office for South-East Asia M
GARCIA GUTIERREZ, Jose Francisco – WHO Regional Office for the Americas M
PARK, Kunhee / HAZARIKA, Indrajit – WHO Regional Office for the Western Pacific M, M
PERFILIEVA, Galina – WHO Regional Office for Europe F
Other United Nations agencies
PFAFFMANN, Jerome – (UNICEF) Health unit, child health M
103
Table A4.2: Guideline Development Group members
Constituency/role Last name First name Gender Region Country Institution
Methodologist
Akl Elie M Eastern Mediterranean Lebanon American University of Beirut
and co-chair
Academia Universidade Peruana
Huicho Luis M Americas Peru
Cayetano Pereira
Dambisya Yoswa M Africa South Africa Limpopo University
National Health Development

Guangpeng Zhang M Western Pacific China
Research Centre
Co-chair McPake Barbara F Western Pacific Australia University of Melbourne
Bhutta Zulfiqar M Eastern Mediterranean Pakistan Aga Khan University
Instituto Hygiene e Medicina Tropical,

Dussault Gilles M Europe Portugal
Lisbon, Portugal
Co-chair Lehmann Uta F Africa South Africa University of Western Cape
Policy-makers
Ngwenya Shirley F Africa South Africa University of the Witwatersrand
from government
Deputy Director PHC,
Chala Tesfaye M Africa Ethiopia
Ministry of Health
Deputy Director HRD,
Abdalla Amel F Eastern Mediterranean Sudan
Ministry of Health
United States
Kauffman Arthur M Americas University of New Mexico
of America
Wales Welsh Government, Health
White Jean F Europe
(United Kingdom) and Social Services Group
Gbanya Miatta F Africa Liberia Ministry of Health
Mugeni Catherine F Africa Rwanda Ministry of Health
Universidade Federal de Bahia /

Medina Guadalupe F Americas Brazil
Ministry of Health
Nargis Makhduma F South-East Asia Bangladesh Ministry of Health
Republic
Jelamschi Nicolae M Europe Ministry of Health
of Moldova
Latianara Arieta F Western Pacific Fiji Ministry of Health

Professional
associations,
Mungherera Margaret F Africa Uganda World Medical Association
labour unions,
civil society
Catton Howard M Europe United Kingdom International Council of Nurses
Walker Polly F Europe United Kingdom World Vision
Shresta Ram M South-East Asia Nepal Tufts

Vermuyten/ Sandra/
F, M Europe Belgium Public Services International
Aye Babatunde
Community
Nakibuuka Maxensia F Africa Uganda Ministry of Health
health worker
Community Leonard
Mbiu M Africa Kenya Ministry of Health
health worker Sharia
Observer (funder) United States of United States Agency for
Qureshi Nazo F Americas
America International Development
Table A4.3: External Review Group members
Full names Institution Country WHO region Gender
Abimbola Olaniran Liverpool School of Tropical Medicine United Kingdom Europe M
University of California, San Francisco, Global Health Sciences United States

Ari Johnson Americas M
Muso of America
Bhanu Pratap International Federation of Red Cross and Red Crescent Societies Switzerland Europe M
Camila Giugliani Federal University of Rio Grande do Sul, Porto Alegre, Brazil Brazil Americas F
United States
Jennifer Breads Jhpiego Americas F
of America
Karin Källander Malaria Consortium United Kingdom Europe F
Madeleine Ballard Community Health Impact Coalition Germany Europe F
Magali Romedenne UNICEF Senegal Africa F
Memorial University of Newfoundland Health Sciences Centre,

Maisam Najafizada Canada Americas M
Newfoundland and Labrador
Maryse Kok Royal Tropical Institute Netherlands Europe F
ICF/Maternal and Child Survival Program,

Ochiawunma Ibe Nigeria Africa / Americas F
United States of America
Peter Ngatia Amref Health Africa Kenya Africa M
United States
Rajesh Panjabi Last Mile Health Americas M
of America
Ruth Ngechu Living Goods Kenya Africa F
Samson Kironde University Research Co., LLC Uganda Africa M
Sara Javanparast Flinders University Australia Western Pacific F
United States
Eric Sarriot Save the Children Americas M
of America
Stephen Hodgins University of Alberta Canada Americas M
Sunita Singh London School of Hygiene and Tropical Medicine India South-East Asia F
105
Table A4.4: GDG conflict of interest management
Name Designation Interests Decision
American University of Beirut
Elie Akl No interests declared No further action required
Beirut, Lebanon
Babatunde Health and Social Sector
No interests declared No further action required
Aiyelabola Public Services International, France
Aga Khan University
Zulfiqar Bhutta No interests declared No further action required
Karachi, Pakistan
Director, Nursing and Health Policy Consultant

Howard Catton No interests declared No further action required
International Council of Nurses, Geneva, Switzerland
East, Central and Southern Africa Health Community

Yoswa Dambisya No interests declared No further action required
Arusha, United Republic of Tanzania
International Public Health and Biostatistics Unit

Gilles Dussault No interests declared No further action required
Instituto de Higiene e Medicina Tropical, Lisbon, Portugal
Miatta Zenabu Manager, Health Sector Pool Fund

Gbanya Ministry of Health, Liberia
Amel Abdalla Deputy Director HRD

Gesmalla Federal Ministry of Health, Khartoum, Sudan
Universidad Peruana Cayetano Pereira

Louis Huicho Av. Honorio Delgado 430, Urb. Ingeniería, S.M.P., Lima, No interests declared No further action required
Peru
Zhang China National Health Development Research Centre,

Guangpeng Beijing, China
Coordination, Implementation and Monitoring Unit of

Nicolae Health System Projects
Jelamschi Ministry of Health of the Republic of Moldova
Chisinau, Moldova
Employment and consulting on

Public Health the topic of CHWs as part of job
Arieta Latianara No further action required
Fiji Ministry of Health, Suva, Fiji responsibilities with Government of
Republic of Fiji
Director, School of Public Health Research support: development of

Uta Lehmann University of the Western Cape, Cape Town, regional technical paper on CHWs No further action required
South Africa for WHO Regional Office for Africa
University of New Mexico

Arthur Kaufman No interests declared No further action required
Albuquerque, United States of America
Isabela Cardoso Financial support, to the research

Instituto de Saude Coletiva, Brazil No further action required
de Matos Pinto unit, Ministry of Health
Ministry of Health and Sanitation
Leonard Mbiu No interests declared No further action required
Kitui County, Kenya
(continued)
Table A4.4: GDG conflict of interest management (continued)
Professor McPake’s declared
interests were not deemed to
Funded research support on CHWs
require any further action.
and HRH policy and research
The subsequent selection
activities in the context of numerous
of a consortium including
grants and initiatives.
Director, Nossal Institute for Global Health researchers from the same
Subsequently, a consortium
Barbara McPake School of Population and Global Health, University of institution for the development
including academics from the same
Melbourne, Australia of the systematic reviews led to
institution (University of Melbourne)
a decision to request Professor
was selected through a competitive
McPake not to entertain direct
selection process to conduct the
communications on the CHW
systematic reviews.
guideline with the systematic
review team.
Researcher, Public Health Department Received financial support for
Maria Guadalupe
Institute of Collective Health, Federal University of Bahia, research on community health No further action required
Medina
Salvador, Brazil workers in Brazil
Director, Community Health Unit

Catherine IHDPC/Maternal Child and Community Health Division,
Mugeni Rwanda Biomedical Centre
Ministry of Health, Rwanda
Employed in care provision, policy

Maxensia Community Health Worker
dialogue, research and advocacy No further action required
Nakibuuka Kampala, Uganda
on CHWs
Former Chief Coordinator, Community Based

Makhduma Health Care
Nargis House 4, Road 14, Sector 7
Uttara, Dhaka 1230, Bangladesh
University of the Witwatersrand

Shirley Ngwenya Richard Ward, 1 Jan Smuts Ave No interests declaredrequired No further action required
Braamfontein, Johannesburg 2000, South Africa
Senior Quality Improvement Advisor

Ram Shrestha University Research Co, LLC No interests declared No further action required
Bethesda MD, United States of America
Federal Ministry of Health

Chala Tesfaye No interests declared No further action required
Addis Ababa, Ethiopia
Sandra Public Services International

Vermuyten Rome, Italy
Community Health Worker Programming Advisor

Polly Walker World Vision International, Middlesex, No interests declared No further action required
United Kingdom
Health and Social Services Group
Jean White No interests declared No further action required
Welsh Government, Wales, United Kingdom
107
Table A4.5: ERG conflict of interest management
Liverpool School of Tropical Medicine Consulting and research support on No further

Abimbola Olaniran
Liverpool, United Kingdom CHW-focused policy and academic activities action required
Employment and research financial support:
research on, support implementation of, and
Muso No further
Ari Johnson provision of paid technical assistance related
University of California, San Francisco action required
to community health worker programme
implementation
International Federation of Red Cross and Red
No further
Bhanu Pratap Crescent Societies No interests declared
action required
Geneva, Switzerland
Federal University of Rio Grande do Sul No further
Camila Giugliani No interests declared
Porto Alegre, Brazil action required
Jhpiego
No further
Jennifer Breads 1615 Thames Street Paid consultancy on CHW training
action required
Baltimore, United States of America
Malaria Consortium No further
Karin Källander No interests declared
London, United Kingdom action required
Community Health Impact Coalition No further
Madeleine Ballard No interests declared
Berlin, Germany action required
UNICEF Regional Office for West and Central Africa No further
Magali Romedenne No interests declared
Yoff Dakar, Senegal action required
Memorial University of Newfoundland Health Sciences No further
Maisam Najafizada No interests declared
Centre, Newfoundland and Labrador action required
KIT Royal Tropical Institute No further
Maryse Kok No interests declared
Netherlands action required
Serves as paid Senior Community Health
Advisor on a USAID-funded MNCH project
working for an organization that receives
ICF/Maternal and Child Survival Program
contracts and grants for work in strengthening No further
Ochiawunma Ibe USAID Grantee
community health systems within primary action required
Washington, DC, United States of America
health care (paid; current position)
Served as Technical Advisor with USAID
(2006–2017)
Amref Health Africa Headquarters No further
Peter Ngatia No relevant interests declared
Nairobi, Kenya action required
Last Mile Health No further
Rajesh Panjabi No interests declared
Boston, United States of America action required
Living Goods No further
Ruth Ngechu No interests declared
Nairobi, Kenya action required
No further
Samson Kironde University Research Co., LLC, Uganda No interests declared
action required
Flinders University, Health Sciences Building
No further
Sara Javanparast Sturt Rd, Bedford Park No interests declared
action required
Adelaide, Australia
Department of Global Health
No further
Eric Sarriot Save the Children No interests declared
action required
United States of America
No further
Stephen Hodgins University of Alberta Edmonton, Canada No interests declared
action required
London School of Hygiene and Tropical Medicine Paid consultancy on issue relevant to guideline No further
Sunita Singh
London and Delhi topic action required
Annex 5
Selected findings of stakeholder

perception survey
Stakeholder perceptions of health systems anchors: 1 = not important; 5 = important; 9 = critical. The
support for CHW programmes: a survey study. acceptability scale had the following anchors: 1 = definitely
not acceptable; 5 = uncertain whether acceptable or not;
CHWs are an important component of the health workforce 9 = definitely acceptable. The feasibility scale had the
in many countries. This semi-quantitative cross-sectional following anchors: 1 = definitely not feasible; 5 = uncertain
study was conducted to assess the acceptability and whether feasible or not; 9 = definitely feasible.
feasibility of the policy options under consideration in the
guideline by stakeholders. Applying this scale to the retrieved data, most of the outcome
measures of the CHW policy options were deemed to be
A self-administered online survey was disseminated in close to the “critical” end of the spectrum of the Likert
English and French languages to stakeholders through three scale rating, though the highest-ranking outcomes were as
major channels: WHO human resources for health contact follows: improved quality of CHW health services, increased
list, the Health Information For All (HIFA) online platform, and health services coverage, and increased access to care for
participants at the 2017 Institutionalizing Community Health patients. Most of the policy options under consideration
Conference held in South Africa in 2017. Eligible participants in the guideline were also deemed to be acceptable and
included stakeholders who were involved directly or indirectly feasible for implementation by stakeholders (Table A5.1).
in the implementation of CHW programmes in countries. Very few interventions were rated as uncertain in terms of
acceptability or feasibility, for instance the selection of CHWs
A total of 96 submissions were obtained. Responses were for pre-service education on the basis of age and a minimum
graded using a 9-point Likert scale to rate the outcome secondary level of education. No outcome measure was rated
measures and the level of acceptability and feasibility of the as “not important”, nor were any interventions deemed to be
interventions. The outcomes value scale had the following “definitely unacceptable” or “definitely unfeasible”.
109
Table A5.1: Acceptability and feasibility of CHW interventions
Acceptability Feasibility
Average Likert scale ranking for CHW interventions (1 = lowest; 9 = highest)
(N = 95) (N = 92)
1) Compared to other methods or no assessment at all, how acceptable is the use of this questionnaire to rate the 6.3 6.2
acceptability by stakeholders of implementing CHW policy interventions?
2) Using essential and desirable attributes to select CHWs for pre-service training 7.3 7.2
a) Adopting only CHWs who have completed a minimum of secondary education (relative to lower levels of literacy) 5.2 5.5
b) Selecting older candidates on the basis of age (relative to random age selection) 4.5 5.2
c) Selecting members of the target community (relative to selecting non-members) 6.9 7.0
3) Training of CHWs for a short period (could range from a number of days to one month relative to training for a longer period
6.4 7.0
of 6 months to 3 years)
6.8 7.0
4) Having standardized educational curricula
a) Curricula should address biological/medical (determinants, basic notions of human physiology, pharmacology, and 5.6 5.8
diagnosis and treatment)
b) Curricula addressing household-level preventative behaviours in relation to priority health conditions 7.9 7.8
c) Curricula addressing education about social determinants of health 7.6 7.6
d) Curricula addressing counselling and motivation skills (including communication skills) 8.0 7.8
e) Curricula addressing scope of practice (attitude, when to refer patients, range of tasks, power relationships with the 7.9 7.8
client, personal safety)
f) Curricula addressing CHW integration within the wider system (access to resources) 7.7 7.5
5) Issuing a formal certification for CHWs who have undergone competency-based pre-service training 7.6 7.6
6) Strategic supervision support for CHWs 8.2 7.8
a) Coaching of CHWs 8.0 7.5
b) Use of task checklists 7.9 7.8
c) Observation of CHWs at facility 7.1 7.2
d) Observation of CHWs at community and facility 7.8 7.6
e) CHWs supervising CHWs 6.1 6.3
f) Higher cadre health workers supervising CHWs 7.7 7.5
g) Trained supervisor 7.9 7.8
h) Assessing CHWs by service delivery supervision only 5.2 6.3
i) Assessing CHWs by service delivery supervision and community feedback 7.6 7.4
7) Rewarding CHWs for their work 7.9 7.6
a) Monetary incentives 7.2 6.7

b) Non-monetary incentives 7.2 7.1
c) Benchmarking full-time CHW salary to the government minimum wage of the locality 6.7 6.2
8) CHWs having a career ladder opportunity/framework within the health and education systems 7.3 6.4
9) CHWs having a formal contract within the health system 7.0 6.7
10) CHWs collecting and submitting data on their routine activities 8.0 7.7
11) Community engagement strategies to support practising CHWs (including village committees and community health action 7.9 7.6
planning activities)
12) Proactive community mobilization by CHWs (identifying priority health and social problems, mobilizing local resources, 8.0 7.5
engaging communities in participation of health service organization and delivery)
13) Providing strategies to ensure adequate availability of commodities and consumable supplies in the context of practising 7.9 7.4
CHW programmes
a) Ensuring inclusion of relevant commodities in the national pharmaceutical supply plan or equivalent national supply 7.9 7.3
chain plan
b) Simplified stock management tools and visual job aids for CHWs that accommodate low literacy with minimum data 8.0 7.6
points to facilitate recording of data and resupply
c) Use of mobile phone applications (mHealth) for reporting stock and other data 7.4 7.0
d) Coordination, supervision and standardization of resupply procedures, checklists and incentives 7.8 7.3
e) Products specifically designed for use by CHWs (presentation, strength, form and packaging) 7.3 7.0
f) Use of social media to manage redistribution 6.0 6.0
Beyond the average rating values, it is important to note that for several of the interventions under consideration the values showed a wide
distribution of responses, indicating substantial variance in the perceived acceptability and feasibility among respondents (Figures A5.1 and A5.2).
Figure A5.1: Acceptability and feasibility of social media use in redistribution of commodities
and supplies
Acceptability of social media use in managing distribution of commodities

40
35
Number of responses
30
25
20
15
10
0
1 2 3 4 5 6 7 8 9
Likert rating
Feasibility of social media use in managing distribution of commodities

40
35
Number of responses
30
25
20
15
10
0
1 2 3 4 5 6 7 8 9
Likert rating
111
Figure A5.2: Acceptability and feasibility of selecting older candidates
Acceptability of selecting older candidates
40
35
Number of responses
30
25
20
15
10
0
1 2 3 4 5 6 7 8 9
Likert rating
Feasibility of selecting older candidates

40
35
Number of responses
30
25
20
15
10
0
1 2 3 4 5 6 7 8 9
Likert rating
National health policies, strategies, and plans are more likely to be implemented effectively if their negotiation and
development is inclusive of all stakeholders and reflective of their perceptions and value preferences.
This stakeholder perception survey adds a complementary perspective to the decision-making framework utilized by
the Guideline Development Group in formulating the recommendations of the guideline. In addition to synthesis of the
scientific evidence through the systematic reviews, the results of the survey add confidence to the applicability of most
recommendations in practice settings.
Health Workforce Department
ISBN 978-92-4-155036-9
World Health Organization
20 Avenue Appia
CH 1211 Geneva 27 Switzerland
www.who.int/hrh

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WHO guideline

on health policy and

© World Health Organization 2018

++ 4. Objectives and scope of the guideline 21

++ 5. How this guideline was developed 26

++ 8. Research priorities and guideline update 64

++ 10. General implementation considerations 70

++ Annex 5. Selected findings of stakeholder perception survey 109

Dr Tedros Adhanom Ghebreyesus

4.2 Types of health workers covered by this guideline

Maternal & newborn health

Public health & Noncommunicable

5.1 Steering Group, Guideline Development Group and

5.2 Sources of evidence for guideline

Table 1: Overarching search strategy for the 15 PICO questions

Table 2: Inclusion and exclusion criteria

Studies published in 1990 or later Studies published before 1990

6.2 Systematic reviews on the 15 PICO questions

Figure 3: PRISMA diagram of studies assessed by the systematic reviews

Citations from Citations from

Not eligible n=5373

Published pre-1990 : n = 532

Studies included: n=137

Eligible Eligible Eligible included from

Certainty of the evidence – very low. Strength of the recommendation – strong.

7.1.1 Background to the recommendation 7.1.2 Rationale for recommendation

Recommendation 2: Duration of pre-service training

Certainty of the evidence – low. Strength of the recommendation – conditional.

Table 3: Duration of training for CHWs with a polyvalent role

Source: Adapted from Bhutta et al. (13).

Certainty of the evidence – moderate. Strength of the recommendation – conditional.

Table 4: Variations in contents of pre-service training curriculum for CHWs

Clinical, diagnostic and Disease prevention, Counselling, motivation Community Management

Clinical, diagnostic and Disease prevention, Counselling, motivation Community Management

Recommendation 4: Modalities of pre-service training

Certainty of the evidence – very low. Strength of the recommendation – conditional.

Recommendation 5: Competency-based certification

Certainty of the evidence – very low. Strength of the recommendation – conditional.

Recommendation 6: Supportive supervision

Certainty of the evidence – very low. Strength of the recommendation – conditional.

Certainty of the evidence – very low. Strength of the recommendation – strong.

Certainty of the evidence – very low. Strength of the recommendation – conditional.

Recommendation 8: Contracting agreements

Certainty of the evidence – very low. Strength of the recommendation – strong.

Recommendation 10: Target population size

Certainty of the evidence – very low. Strength of the recommendation – conditional.

Certainty of the evidence – very low. Strength of the recommendation – conditional.

that the service meets the needs of recipients;

Recommendation 12: Types of CHWs

Certainty of the evidence – very low. Strength of the recommendation – conditional.

Recommendation 13: Community engagement

Certainty of the evidence – moderate. Strength of the recommendation – strong.

Table 5: Categories of community engagement strategies

Recommendation 14. Mobilization of community resources

Certainty of the evidence – very low. Strength of the recommendation – conditional.

7.14.3 Summary of evidence 7.14.4 Interpretation of the evidence and

7.14.5 Implementation considerations Successful implementation of community mobilization

Recommendation 15. Availability of supplies

Certainty of the evidence – low. Strength of the recommendation – conditional.

5.1 Steering Group, Guideline Development Group and

7.14.3 Summary of evidence 7.14.4 Interpretation of the evidence and

8.3 Integration into and support by health systems

9.2 Plans for guideline adaptation,