“Community Health Workers at the Dawn of a New Era:” a Reflection for the Future

By: Caroline Eason and Hannah Marcus

“Community health workers are the antidote to the ignorance of the expert.” – Daniel Palazuelos

On November 5, 2022, members of CHW Central attended the American Public Health Association’s Community-based Primary Health Care, or CBPHC, workshop in Boston, Massachusetts, United States. The workshop, “Community Health Workers at the Dawn of a New Era,” featured a keynote address from Daniel Palazuelos, the director of Community Health Systems at Partners in Health followed by a panel discussion with industry experts: Denise Smith, executive director of the National Association of Community Health Workers; Matt Price, former coordinator of the Gates Exemplars Project on CHWs; and Rebecca Furth, technical manager of CHW Central. The workshop, which also offered four student-led presentations and included discussion of an 11-part supplement titled Community Health Workers at the Dawn of a New Era, focused on several key messages.

Takeaway #1: Global CHW Remuneration and Funding

One of the largest discussion points of the workshop, and a topic that frequently arises in community health work, was CHW remuneration. During the panel discussion, Smith highlighted that even in the United States, a country that spends more on healthcare than any other nation in the world, CHWs are underpaid or not paid at all. In other parts of the world, such as Africa, about 86 percent of CHWs act as volunteers and receive little to no compensation.¹

Often, fair and equitable payment is presented as an incentive for CHWs. However, as Palazuelos noted, “payment is an enabler, not a motivator.” In no other profession are individuals expected to work without a fair wage, so why should community health work be any different? Health expenditures should reflect the lifesaving role that CHWs have in communities around the world. CHWs must be compensated fairly.

This topic is validated in Community Health Workers at the Dawn of a New Era, which describes inadequate funding as the most common challenge among CHW programs. For example, a joint report from the Financing Alliance for Health and the United States Agency for International Development found a $2 billion funding gap for an annual CHW program in Sub-Saharan Africa. (Realistically, this number is now likely closer to $4 billion.) Many CHW programs rely too heavily on donor support, and are often funded for one disease or health outcome. Potential future steps are building political will for larger domestic investment, cross-subsidizing CHW programs with other initiatives, and finding opportunities for a sustainable funding stream.2

Takeaway #2: The Importance of CHW-led Conversations

Workshop panelists discussed the lack of national definition for CHWs in the U.S. Incredibly, the Advance CHW survey conducted by NACHW in partnership with Johnson and Johnson found that participants with more than 190 job titles in the U.S. identified themselves as CHWs.³ Further, Smith pointed out that, despite the desire of CHWs to integrate with local, county, and state health departments, they are not recognized by federal law. Consequently, CHW-led organizations don’t have the power to make demands from the government.

In the future, governments at all levels must include CHWs and CHW-led organizations in the process of designing, implementing, and evaluating community programs and services. Additionally, identifying current and future CHW leaders and giving them a platform to share their experiences, challenges, and opinions will amplify the CHW movement.² 

Takeaway #3: Breadth of Roles and Tasks

Finally, the workshop included discussion on the range of tasks and roles of CHWs around the globe. During the panel discussion, panelists highlighted that CHW research often focuses on the ability of CHWs to identify, treat, or manage different health conditions. Almost always, researchers conclude that, yes, this task is an important part of a CHW’s role, and one they can absolutely deliver. (This is evident when reviewing our resource database.) 

In part 5 of the Community Health Workers at the Dawn of a New Era supplement, authors explain how CHWs initially began performing tasks related to maternal and child health. However, CHWs have increasingly provided services for non-communicable and chronic diseases, mental health, and more. Additionally, CHWs serve within multiple domains, such as health promotion, surveillance, and clinical treatment, offering health education, care coordination, patient advocacy, and helping communities navigate the healthcare system.⁴ 

When planning future CHW programs or revising existing ones, there are many considerations to make. The New Era authors emphasize the need for program planners to understand the current and potential stressors that CHWs may face while performing their tasks, such as existing infrastructure. Additionally, planners should consider if a task or role is feasible with the current health system. Many other factors, such as cultural appropriateness and safety, should also be considered.⁴ Broadly speaking, a more holistic CHW research agenda should be defined for the coming years, and include more attention to the systems contexts which surround, facilitate, and constrain CHW performance. This would not only address critical literature gaps, but also define clearer mechanisms for ensuring CHWs can be successful in health service provision.

Through the various presentations, discussions and literature review, the 2022 APHA conference made clear that CHW programs need to be prioritized by governments and health service providers. Conferences and workshops such as these provide a platform for rich discussion and engagement on how to catalyze the shifts needed to make CHW integration into healthcare systems worldwide a reality. Such events should be encouraged by the public health community, embraced by relevant stakeholders, and convened regularly in a spirit of health leadership, but with the condition that the CHWs themselves are ALWAYS represented, and in fact leaders, at the discussion table. 

Community health workers themselves must be recognized as essential members of the healthcare workforce. They should be rewarded with fair compensation that acknowledges their contribution, and given a voice in planning and executing the programs that will address evolving community health needs. Most importantly, they should be included in (or encouraged to lead) conversations about their profession and its future. 

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¹Community Health Impact Coalition. 2021. New Research From the Coalition: Common CHW Payment Models Do Not Reflect WHO Recommendations For Pay.

²Masis, L., Gichaga, A., Zerayacob, T., Lu, C., & Perry, H. B. (2021). Community health workers at the dawn of a new era: 4. Programme financing. Health Research Policy and Systems, 19(3), 1-17.

³National Association of Community Health Workers. 2021. Data for Action – NACHW National CHW Survey Summit Series.

⁴Glenton, C., Javadi, D., & Perry, H. B. (2021). Community health workers at the dawn of a new era: 5. Roles and tasks. Health Research Policy and Systems, 19(3), 1-16.