Community health workers are central to primary health care delivery in many low- and middle-income countries, yet questions remain about how community health worker (CHW) programs should be designed, financed, and institutionalized to achieve sustainable scale. Commissioned by the Gates Foundation, the START team conducted a synthesis of peer-reviewed and grey literature to examine how CHW programs have evolved across diverse national contexts, and what that evolution implies for health systems strengthening.
The team reviewed evidence on CHW scope of practice, workforce models, supervision, remuneration, financing, effectiveness, and cost-effectiveness, mapping both the geographic distribution and structure of economic evaluations. From an initial pool of twelve countries, five were selected for in-depth comparative analysis including Kenya, Burkina Faso, Malawi, Tanzania, and Mozambique, to maximize variation in governance pathways, workforce formalization, and financing alignment.
The analysis identified recurring cross-country patterns, including the importance of sequencing institutionalization before scope expansion, aligning CHW financing with domestic budget systems, and measuring system-level contributions such as coverage, referral integration, and continuity of care. While cost-effectiveness evidence is strong in priority disease areas such as HIV, TB, malaria, and RMNCH, affordability and long-term fiscal sustainability analyses remain limited.
The project concluded with strategic recommendations for countries and funders seeking to institutionalize CHWs as part of routine primary health care systems rather than parallel, donor-driven programs.
