Count CHWs.

Making the case for Community Health Worker Master Lists

To make community health workers count, we must count CHWs.

CHWs have been a cornerstone of primary health delivery across the globe for more than a century.

They deliver a range of promotive, preventative, diagnostic, and treatment services in areas as diverse as malaria treatment, to HIV management, to the surveillance of and response to disease threats, such as Ebola and COVID-19.

The World Health Organization (WHO) recognizes CHWs as being integral to primary health care and important contributors to health for all. CHWs are also well-placed to address the current 43 million health worker shortage.

But unfortunately, many nations don’t know how many CHWs they have, how to contact the ones they do, or even where those workers are located.

This lack of data hampers the ability of governments to engage in strategic health planning and workforce coordination. It also means CHWs often miss out on the crucial support and resources they need to do their job effectively.

CHWs work, but to provide robust, high-quality care to patients, they must be salaried, skilled, supervised, and supplied. And they must be a recognised and valued part of a strong health system.

So, the first step in making professional CHWs (proCHWs) the norm is to #CountCHWs.

The Extent of the Problem.

Since we published the first #CountCHWs guidance, data has improved markedly. But there is still work to do. The 2024 estimate of 4.7 million CHWs was reported by 100 countries, and whilst 71% of reported data is from 2019-2023, it still means we are lacking accurate and up to date figures from almost 30% of countries.

Information deficits include official CHW counts, records of CHWs’ active and accreditation status and competencies, location of service, and availability of essential supplies.

This lack of information has frustrated efforts to procure and distribute the correct amount of personal protective equipment (PPE) for CHWs, and hampered efforts by governments to leverage these essential health workers during the COVID-19 pandemic.

The often limited availability of CHW information stunts the ability to provide robust, accessible care. It also impedes health system planning, health workforce management, and evidence-based decision-making.

The Solution: A National Georeferenced CHW Master List.

A National Georeferenced CHW Master List (CHWML) is a single source of truth.

It contains the data elements required to uniquely identify, effectively describe, enumerate, locate, and contact all CHWs in a country.

The CHWML is critical for strategic planning, training, deployment, payment, supply, supervision, and monitoring and evaluation of CHWs in the context of broader human resources for health and primary health care systems.

Establishing and reinforcing the use of a CHWML can serve many needs, like:

building more resilient and sustainable health systems at the community level
informing more accurate financial planning and resource allocation
planning for surge capacity needs at the last mile during emergencies
guiding general program design and service delivery
measuring PPE quantification and delivery
advising resourcing for campaign-based health interventions such as vaccinations
facilitating community-based mobilization

But, establishing a CHW master registry is only the first step. The registry also has to be georeferenced – meaning the locations of the CHWs across the country would be carefully mapped out. By providing insight into the number, spatial distribution, socio-demographics, and training of CHWs across different parts of the country, a CHWML hosted in an appropriate registry is fundamental to maximizing the impact, efficiency, and equity of health service delivery. And for achieving health for all.

See Table 1 for a more detailed explanation of use cases for a CHWML.

The CHWML Implementation Support Guide

To assist governments and their technical and financial partners with a roadmap for generating, sharing, and maintaining a national, up-to-date, and georeferenced list of CHWs, several organizations leading the #CountCHWs campaign (Clinton Health Access Initiative, Community Health Impact Coalition, Health GeoLab, Living Goods, The Global Fund, and UNICEF) have developed an Implementation Support Guide for governments committed to establishing a CHW registry.

The guide includes an overview of the characteristics of a functional and institutionalized CHW, followed by a seven-step process of establishing, sharing, and maintaining a CHWML in a registry.

A Community Health Worker checking the pressure of a woman while seated on the ground

Nyaya Health

Characteristics of a Functional and Institutionalized CHWML

Inclusive: Depending on how health systems have been segmented and the role of implementing non-governmental organization (NGO) partners, there may be multiple CHW lists that need to be reconciled.
Routinely updated: Ad hoc CHW censuses should be avoided in favor of routine updating after the initial master list is established within a registry. The list needs to be updated routinely. Data must also be regularly checked to ensure it is complete, accurate, and validated.
Stored in a registry: The usefulness of CHW censuses can be maximized if the data collected is managed in a registry that is used to maintain and update lists of CHWs over time. Typically, the CHWML may sit within the broader Health Worker Registry as one health worker group. However, some CHWs may not be allowed in the HWR due to country policy (e.g., non-government supported or unpaid CHWs not yet recognized as a formal part of the national health workforce). In such cases, the CHWML may sit in a separate registry from the HWR, but link to it to facilitate operations. View figures 1 and 2 of the guide here
Interoperable: The CHWML should be hosted in a registry that uses standards to allow the access, exchange, integration, and use of data between information systems. May include the ability to integrate with human resource, health management information, community health, logistics management, and point-of-service (POS) information systems.
Secure: The CHWML and registry should align with national data protection standards and international best practices to protect CHW privacy and confidential information. There should be robust standard operating procedures (SOPs), with caution taken to protect sensitive information such as names and location.
Governed: A clear institutional owner and governing structure for the CHWML and registry is required. Owners of the CHWML and registry may differ, but should have a clear understanding of each party’s roles and responsibilities.
Routinely used: Registries, including their interface with other systems and datasets, must be used in accordance with SOPs to strengthen management and coordination of CHWs and avoid data silos. The potential for the CHWML and registry to improve programme function and health outcomes is only realized when they are leveraged for planning and decision making.
Sustainable: The CHWML and the registry should be sustained through dedicated funding to support the people, processes and technologies required to ensure their continuous maintenance and regular updating.

7 Steps to Creating a CHWML.

1. Current State Assessment

Understand the current people, processes, and technology involved in tracking and maintaining data on CHWs. Identify improvement opportunities.

2. Governance structure

Define leadership, institutional home, roles, and responsibilities over the CHW master list and registry.

3. Target State Definition

Partner with stakeholders to identify functional and technical requirements, as well as associated SOPs for a CHW master list and registry.

4. Master List Generation

Merge existing list (as relevant) into a master list to be shared across entities and conduct additional data collection as relevant to fill gaps.

5. Establishing a CHW Registry

Undertake technical setup of a registry to host CHW master list and its associated hierarchies and geospatial data train stakeholders.

6. Sharing the CHW Master List

Develop a data sharing policy, identify data sharing mechanisms, and support a culture of data use.

7. Maintaining the CHW Master List and registry

Document SOPs for updating the CHW master list and maintaining the registry. Secure resources for sustainability.

CHWML maturity continuum

Establishing a functional and institutionalized CHWML is an iterative process. The figure below illustrates how the progress of a CHWML can be measured qualitatively against four high-level domains (Use, Master List, Registry, and Supporting Environment). The continuum suggests what actions may be taken to increase CHWML effectiveness and robustness.

View figure 3

How the CHWMLs are being used

To illustrate the real-world outcomes from implementing a CHWML, we’ve included an overview of experiences in Sierra Leone and Uganda

View box 1 and box 2

A Community Health Worker measuring the arm of a baby being held by its mother

MUSO

To Achieve Health for all, We Must #CountCHWs.

CHWs are vital to achieving health for all. But to do their essential work – CHWs must be treated like the professionals they are.

When CHWs are salaried, skilled, supervised, and supplied, everyone benefits. However, this is only possible when countries know how many CHWs they have, how to contact them, and where their CHWs are located.

In short, to make CHWs count, we have to count CHWs.

Watch the official launch of #CountCHWs, where a panel of key campaign partners, government officials, and a CHW discuss their views and experiences with a CHWML and the Implementation support guide.