Centre for Social Science and Global Health

Reinstate community health workers to reach vulnerable populations

26 January 2017

In their article in PLOS Danny de Vries and Robert Pool discuss the potential of Community or Lay Health Workers to reach vulnerable populations in low-income countries. Interventions to reduce priority health problems are often unable to reach these groups. The effectiveness of health programmes can be improved when the community level is better incorporated.

A community or lay health worker (CHLW) is a member of the community who is able to carry out functions related to health care delivery at community level without a formal certificate or educational degree. CHLWs have the potential to reach local and vulnerable populations but health programmes that include these workers often seem to fail and show high attrition rates.

The authors propose that the roles and interests which support community health work should emerge directly from the way in which health is organized at community level. Acceptance, support, and respect from the community as well as from the formal health system is essential for the motivation and effectiveness of CLHWs.

Evidence to confirm the role of the community level

De Vries and Pool explore evidence in peer-reviewed articles to confirm their proposition: CLHW programmes which are inclusive and sensitive to indigenous community roles, groups and networks are more effective than those built on new roles and groups developed and implemented from the outside.

Their search for evidence however reveals a lack of data to come to an evidence-based conclusion, but instead indicates a larger problem, namely the complete absence of indicators measuring community relationships with the programmes studied. The historicity of the health worker and the community s/he belongs to is absent in most studies reviewed and most studies falsely presume that because CLHWs are installed, this automatically means that community relationships are also taken into account.


The authors conclude that community relationships remain an under-reported resource in the evidence base of academic literature and community agency is chronically undervalued as explanation of programmatic effectiveness. This leads to a fundamental misunderstanding of what a CLHW really is. Instead of a representative of a historical and place-specific community network, the CLHW is conceptualised as a labor unit, an interchangeable commodity.

The increasing awareness of a global shortage of human resources for health and the observed inequity in health systems, however emphasizes the continued need to strengthen linkages to the community and to reinstate community health workers.

About the authors 

Danny de Vries is assistant professor in the Anthropology of Health at the University of Amsterdam. Robert Pool is Professor of Social Science and Global Health and co-director of the Centre for Social Science and Global Health at the University of Amsterdam. Both are researchers at the Amsterdam Institute for Social Science Research.

Publication details

The Influence of Community Health Resources on Effectiveness and Sustainability of Community and Lay Health Worker Programs in Lower-Income Countries: A Systematic Review, Daniel H. de Vries , Robert Pool, PLOS, Published: January 17, 2017, doi.org/10.1371/journal.pone.0170217

Research context

The paper was written in the context of the NWO (Dutch Scientific Research Council) funded project Developing sustainable community health resources in poor settings in Uganda (CoHeRe).

Published by  AISSR