Towards universal health coverage: what are the system requirements for effective large-scale community health worker programmes?

Against the background of efforts to strengthen health systems for universal health coverage and health equity, many African countries have been relying on lay members of the community, often referred to as community health workers (CHWs), to deliver primary healthcare services. Growing demand and great variability in definitions, roles, governance and funding of CHWs have prompted the need to revisit CHW programmes and provide guidance on the implementation of successful programmes at scale. Drawing on the synthesised evidence from two extensive literature reviews, this article determines foundational elements of functioning CHW programmes, focusing in particular on the systems requirements of large-scale programmes. It makes recommendations for the effective development of large-scale CHW programmes. The key foundational elements of successful CHW programmes identified are (1) embeddedness, connectivity and integration into the larger system of healthcare service delivery; (2) cadre differentiation and role clarity in order to maintain clear scopes of work and accountability; (3) sound programme design based on local contextual factors and effective people management; and (4) ongoing monitoring, learning and adapting based on accurate and timely local data in order to ensure optimal fit to local context since one size does not fit all. We conclude that CHWs are an investment in health systems strengthening and community resilience with enormous potential for contributing to universal health coverage and the sustainable development goals if well designed and managed. While the evidence base is uneven and mixed, it provides extensive insight and knowledge to strengthen, scale up and sustain CHW programmes throughout Africa.