How community health workers reach families

The nearest hospital is two hours away by motorbike — if the road isn't flooded. The health centre is 12 kilometres away and often has long queues. A baby has a fever. The mother is worried but doesn't have money for transport, and she's not sure if the fever is serious.

Then someone knocks on the door. It's the community health worker — a woman from the same village, trained to check for danger signs, test for malaria, give basic treatment and refer serious cases. She knows the family. She speaks their language. She comes back the next day to check.

For millions of African families, this person is the health system.

Who are community health workers, how do they reach families, and why are they so important for Africa's health?

What is a community health worker?

A community health worker (CHW) is a member of the community who is trained to provide basic health services, education and referrals, usually close to people's homes. They have many names:

• Relais communautaires (in Benin and other francophone countries)
• Health Extension Workers (Ethiopia)
• Community Health Volunteers (Kenya)
• Village Health Teams (Uganda)
• Health Surveillance Assistants (Malawi)

Some are paid professionals; many are volunteers or receive small stipends. Their training ranges from a few weeks to a year.

What they do

CHWs' work varies by country, but often includes:

• Home visits to pregnant women, newborns and young children.
• Testing and treating malaria (with rapid tests).
• Treating diarrhoea (with oral rehydration salts and zinc) and pneumonia in children, in programmes that allow it.
• Screening for malnutrition (with arm measurement tapes).
• Promoting vaccination and following up missed doses.
• Family planning information and supplies.
• Health education: handwashing, bed nets, nutrition, hygiene.
• Referring serious cases to health centres.
• Collecting health data for the health system.
• Supporting responses to epidemics (Ebola, cholera, COVID-19).

Ethiopia's Health Extension Program trained and deployed tens of thousands of health extension workers — mostly women — to health posts across the country. (Ethiopian Federal Ministry of Health) It's one of the largest and most studied CHW programmes in Africa.

Why CHWs matter: the evidence

Community health workers help solve a big problem: there aren't enough doctors and nurses, especially in rural areas. WHO estimates that the African Region carries a large share of the global burden of disease but has only a small share of the global health workforce.

Research shows CHWs can:

• Increase use of maternal and child health services.
• Improve treatment of childhood illnesses like malaria, pneumonia and diarrhoea.
• Increase vaccination coverage.
• Improve early detection of malnutrition.
• Support TB and HIV treatment adherence.

WHO published guidelines in 2018 on how to design and support CHW programmes, recommending proper training, supervision, pay and integration into the health system.

Joke break: A CHW in a village once said her job has three parts: "One part medicine, one part teacher, and one part detective — because every child who says 'I took my medicine' needs a little investigation."

Ethiopia: the famous example

In 2003, Ethiopia launched the Health Extension Program. It trained women — often with at least a secondary education — as health extension workers and posted two in each rural health post. They focused on prevention: hygiene, sanitation, family planning, vaccination, maternal health and disease control.

Ethiopia made major progress in child survival in the years that followed, and studies credit the Health Extension Program as one important contributor alongside other investments. Many countries have studied Ethiopia's approach.

Beyond Africa: lessons from elsewhere

Brazil's Family Health Strategy uses community health agents to visit households regularly. Bangladesh's BRAC trained thousands of community health volunteers. Nepal's female community health volunteers helped reduce child deaths. These global examples show that community health work is effective when well organised and supported.

"Health for all" — the famous goal of the Alma-Ata Declaration (1978), which placed primary health care and community participation at the heart of global health.

A day with a community health worker (illustrative)

Let's follow an illustrative CHW we'll call Mme. Chabi (illustrative) in a rural area of northern Benin.

6:30 a.m. She checks her supplies: malaria tests, medicines, ORS sachets, zinc tablets, a MUAC tape (for malnutrition), her register and phone. 7:30 a.m. First home visit: a pregnant woman. Mme. Chabi reminds her about antenatal appointments and checks for danger signs. 9:00 a.m. A child with fever. She does a rapid malaria test — positive. She gives treatment according to protocol and explains how to give the medicine. She'll return in two days. 11:00 a.m. A baby with fast breathing. It could be serious pneumonia. She refers the family to the health centre and calls ahead. 1:00 p.m. A group session under a tree about handwashing and bed nets. 3:00 p.m. She records visits in her register and sends a report by phone. 5:00 p.m. She passes by the health centre to restock and meet her supervisor.

This day includes prevention, treatment, referral, education and data. That's why CHWs are called the "bridge" between communities and the health system.

The challenges CHWs face

• Low or no pay. Many CHWs are volunteers or receive small, irregular stipends. This leads to high turnover.
• Heavy workloads. Large areas, many families, long distances.
• Stock-outs. Without medicines and tests, CHWs can't do their job — and lose community trust.
• Limited supervision and training.
• Transport. Walking long distances in heat or rain.
• Data burden. Paper registers and reports can take lots of time.
• Safety. Travelling alone, especially at night.

WHO guidelines recommend that CHWs receive fair pay, training, supervision and supplies — not just good intentions.

Technology helping CHWs

Mobile phones are changing community health work:

• Digital registers and decision-support apps help CHWs follow protocols step by step.
• SMS reminders support vaccination and antenatal visits.
• Phones allow CHWs to call health centres about referrals.
• Data is sent faster, helping detect outbreaks.

Open-source tools like the Community Health Toolkit (used by organisations such as Medic in several African countries) support CHWs with apps designed for low connectivity. See How to design useful technology for low connectivity.

Why trust is their superpower

CHWs are trusted because they're neighbours. They speak local languages, understand customs and are available. This trust makes them powerful health communicators — especially during rumours and epidemics. Read What makes health information easy to trust?.

During the Ebola outbreak in West Africa, community workers and leaders were essential in tracing contacts, explaining safe burials and encouraging people to seek care.

How communities can support CHWs

• Welcome them and follow their advice.
• Report sick family members early.
• Help them reach remote households (guide them, lend a bicycle).
• Support fair pay and recognition through local councils.
• Encourage young people, especially young women, to train as CHWs.

How governments and partners can support CHWs

• Pay CHWs fairly and regularly.
• Train and supervise them well.
• Keep medicines and tests in stock.
• Provide transport and phones.
• Integrate CHWs into the formal health system.
• Listen to CHWs' feedback — they know what works on the ground.

For more on how communities and governments can work together, read What happens when a neighbourhood solves its own problem.

Why CHWs are good value

Health economists often point out that community health programmes are among the best-value investments in health. Preventing a child's malaria from becoming severe, catching malnutrition early or convincing a mother to give birth in a health facility can avoid expensive hospital care — and save lives.

Studies of integrated community case management (iCCM), where CHWs treat malaria, pneumonia and diarrhoea in children, have shown that trained CHWs can deliver correct treatment close to home when they have supplies and supervision. The key word is "when": without medicines, tests and support, even the most dedicated CHW can do little.

That's why many health experts argue CHWs should be treated as a core part of the health workforce — not as unpaid volunteers filling gaps.

Myths about community health workers

Myth: "CHWs are not real health workers." Reality: They're trained for specific tasks and follow clear protocols. They're a real and essential part of the health system.

Myth: "People prefer doctors." Reality: People often prefer someone nearby, affordable and familiar — especially for common problems. CHWs refer serious cases to doctors.

Myth: "Volunteers are free, so they're cheap." Reality: Unpaid volunteers often leave, taking their training with them. Fair pay keeps skilled CHWs working.

Joke break: A CHW was asked if she had a car for her rounds. She said, "Yes — it's called my legs. Good suspension, no fuel costs, but the air conditioning is terrible."

Health begins at home

Hospitals and specialists are important. But much of good health happens at home: clean water, good nutrition, early treatment, vaccination, safe pregnancies. Community health workers bring the health system to that doorstep.

If Africa is to achieve universal health coverage, community health workers won't be a side project. They'll be the foundation.

Keep reading: A simple guide to asking better questions at a clinic, What a healthy city needs beyond hospitals, and our Health & Well-being section.

Questions

What does a community health worker do?

CHWs visit homes to provide basic health care, health education, testing and treatment for common illnesses (in some programmes), and referrals to health centres.

Are community health workers paid?

It varies. Some are paid professionals; many are volunteers with small stipends. WHO recommends fair pay.

What is Ethiopia's Health Extension Program?

A national programme launched in 2003 that trained and deployed health extension workers to rural health posts to focus on prevention and basic care.