A sub-national level analysis of the human resource implications of large-scale community health programs in developing countries
1
Public Health Unit, Gauteng Health Department AND University of Pretoria AND University of Witwatersrand, Pretoria, South Africa
2
School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
3
Director: HIV & TB delivery, Gates Foundation, Pretoria, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A1698
ABSTRACT
ABSTRACT:
Introduction/
BACKGROUND:
Large-scale community health worker (CHW) programmes are central to advancing universal health coverage in low and middle income countries (LMICs). While global literature emphasises selective, disease specific CHW programmes, emerging evidence from South Africa demonstrates that long term, comprehensive CHW models can be equally effective in improving population health outcomes. However, less is known about the human resources for health (HRH) policy implications required to sustain and scale such programmes. This study synthesises findings from a decade long CHW programme in an urban South African district to identify key HRH lessons relevant for national policy.
METHODS:
This policy analysis draws on findings from a mixed methods quasi experimental study conducted in the Gauteng health department (Ekurhuleni Health District) between 2010 and 2019, from four published studies.
RESULTS:
The Ekurhuleni experience demonstrates that formally embedding CHW teams in health services through the permanent employment of CHWs are crucial in strengthening community-based services in health districts. Long-term stability of district management teams enabled consistent leadership supporting CHW programme management. CHWs with low formal schooling can be as highly effective as those more educated, supporting the feasibility of recruiting such unemployed youth and adults to expand the workforce in vulnerable communities. Enrolled nurses (ENs) serving as team leaders performed as well as professional nurses, highlighting opportunities to absorb unemployed ENs and mid-level workers into structured supervisory roles. A three tiered supportive supervisory model—clinic based nurse team leaders, sub district coordinators, and facility managers—was critical to programme performance and health system integration. Clarity on CHW scope of work: supported management and retention.
CONCLUSIONS:
Sustaining and scaling comprehensive CHW programmes in LMICs requires dedicated HRH policies that ensure stable management structures, appropriate supervisor cadres, long-term investment, and clarity of CHW scope. South Africa’s experience offers a replicable model for strengthening community-based primary health care.
Introduction/
BACKGROUND:
Large-scale community health worker (CHW) programmes are central to advancing universal health coverage in low and middle income countries (LMICs). While global literature emphasises selective, disease specific CHW programmes, emerging evidence from South Africa demonstrates that long term, comprehensive CHW models can be equally effective in improving population health outcomes. However, less is known about the human resources for health (HRH) policy implications required to sustain and scale such programmes. This study synthesises findings from a decade long CHW programme in an urban South African district to identify key HRH lessons relevant for national policy.
METHODS:
This policy analysis draws on findings from a mixed methods quasi experimental study conducted in the Gauteng health department (Ekurhuleni Health District) between 2010 and 2019, from four published studies.
RESULTS:
The Ekurhuleni experience demonstrates that formally embedding CHW teams in health services through the permanent employment of CHWs are crucial in strengthening community-based services in health districts. Long-term stability of district management teams enabled consistent leadership supporting CHW programme management. CHWs with low formal schooling can be as highly effective as those more educated, supporting the feasibility of recruiting such unemployed youth and adults to expand the workforce in vulnerable communities. Enrolled nurses (ENs) serving as team leaders performed as well as professional nurses, highlighting opportunities to absorb unemployed ENs and mid-level workers into structured supervisory roles. A three tiered supportive supervisory model—clinic based nurse team leaders, sub district coordinators, and facility managers—was critical to programme performance and health system integration. Clarity on CHW scope of work: supported management and retention.
CONCLUSIONS:
Sustaining and scaling comprehensive CHW programmes in LMICs requires dedicated HRH policies that ensure stable management structures, appropriate supervisor cadres, long-term investment, and clarity of CHW scope. South Africa’s experience offers a replicable model for strengthening community-based primary health care.
| eISSN: | 2654-1459 |
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