Community health workers – are they part of the health facility or part of the community?


By Elizeus Rutebemberwa



It was very enlightening to read the blog by Sarah Johnson on ‘Beyond the Facility Walls: Community Health Workers Need Support’.

In this thoughtful piece, Sarah Johnson raises a number of pertinent issues including the important contribution of Community Health Workers (CHW) to primary health care/health work outside facility walls. Drawing on examples like the successful use of CHW in HIV/AIDS, she argues that the impact of the work of CHWs is big.

She also brings out a key challenge; the lack of systematic data on the actual impact of the activities the CHWs engage in, making their recognition and how to organise them, fund them and support their work through policy and other means, problematic.

I cannot agree with the author more. Health activities need to go beyond the health facilities. Community Health Workers need to be supported if we are to achieve universal health coverage and the sustainable development goals. But how does the Community Health Worker (CHW) fit in the picture of the entire health care system?

As I reflected on the role of community health workers in the rural areas in Uganda where I have lived and worked – and this is not different from many other sub-Saharan countries – I kept wondering whether CHWs were an extension of the health facilities; functioning as ‘health facilities outside walls’ or they were functioning as ‘linkages of communities to the health facilities’.

The work of community health workers is often an extension of what health workers do at health facilities. They distribute drugs and conduct focussed health education talks. Some do some diagnostic work using Rapid Diagnostic Tests for malaria treatment or support TB or HIV patients in taking their drugs. Admittedly, they mobilize communities for immunization campaigns but this is more of facilitating the work of the vaccinators from the health facilities.

Community health workers are mostly supervised by the health workers and not the local community leaders in whose communities they work. There comes the dilemma: Are the CHWs part of the facility or part of the community?

ellie chart


Rarely are community health workers expected to gather the views of the community on health issues for presentation to the health facilities. There is no formal forum where CHWs can transmit community concerns. When they present complaints to the health care system, it is more on how the health care system does not support them in their work rather than how the health care system does not respond to the health needs of the communities they serve. Correspondingly, any support they receive in terms of gum boots, bicycles, rain coats etc. is to help them do health worker-related jobs.

If Universal Health Coverage is to be attained, community health workers need to work in a system that creates linkages between the communities and the health facilities. They need to transmit the community needs to the health facilities as well as transmit health services from health facilities to communities. This dialogue and constant engagement will enable the health facilities respond to the needs of particular communities rather than implement a blue print of health services that may not respond to the specific needs of the community. CHWs should be seen as bridges linking the communities to the facilities and not as another cadre of ‘doctors’ doing care and treatment at community level. A bridge allows movement to and from each side. What is crucial to note is that this is not an individual affair. Alongside their efforts should be the work of community leaders, the women groups’ leaders, the cultural leaders, the youth leaders and others whose interests determine the success or failure of health interventions.

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CHWs could be the champions of linkages rather than the sole players, create an intersection of purpose alongside other participants. CHWs need to be supported not only by supplies for their treatment and distribution work but also supported by leaders in the community to become true representatives and champions for health improvements on both sides. Other areas that need to be addressed include, 1) comprehensive studies on the impact of their activities, 2) skills upgrade to enable them meet the UHC demands, including collection of data on the key indicators and 3) policies that address their involvement in health service delivery.

The question remains though; Are they part of the health facility or part of the community?


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