In partnership with the Global Health Workforce Alliance at WHO, NEPAD, and AMREF, and
with funding from the Bill and Melinda Gates Foundation, the Earth Institute convened key
stakeholders -- including governments, NGOs, donors, and representatives from the private
sector -- to address the constraints to scaling-up human resources for health (HRH) in sub-
Saharan Africa. The meeting intended to accelerate the development of initiatives to address the
HRH crisis by creating a forum for candid discussion and evidence-based decision-making on
community health worker (CHW) models. The two-day meeting focused on lessons learned from
CHW models, putting forth a set of recommendations for scaling up and implementing national
CHW programs.

For the first time, the world has the financial resources and technical know-how to prevent and
treat the vast majority of common health conditions that kill millions of people every year. At the
same time, the central challenge of getting sufficient and appropriate health services to all
communities remains particularly acute in the resource-constrained countries of sub-Saharan
Africa. The critical bottleneck to the reach of the health systems is a massive health worker gap
-- estimated by the WHO to be 820,000 doctors, nurses, and midwives across sub-Saharan Africa
-- that is especially pronounced in rural areas. As it would take years and billions of dollars to fill
that gap with traditional clinical officers and nurses, CHWs are a practical and affordable
alternative strategy for providing healthcare across sub-Saharan Africa. CHWs can provide direct
services, including the prevention and promotion of care, and, to a lesser extent, basic curative
care.

Drawing on the expertise of decades of community health work in Africa, the Nairobi meeting
gathered an unprecedented group of over 130 government officials, policy makers, donors,
academics, and practitioners to discuss CHW models and the human and financial capital
necessary to scale up CHW programs to enable countries to achieve the Millennium
Development Goals (MDGs). In a series of presentations, panel discussions, and small working
groups, ministers of health and ministry representatives from Kenya, Rwanda, Senegal, Sudan,
Tanzania, and Uganda discussed their national CHW programs, with participants also examining
the different roles for the various partners in implementing and scaling up these programs. In
addition, conference participants cooperated on putting together a set of guidelines for CHW
programs.

The discussions revealed a striking degree of agreement on CHW programs, and participants
reached consensus on key aspects of CHW programs, making the following recommendations
for guidelines to be used in district and national settings:
• CHWs should be paid and trained individuals committed to and recognized by the
community they serve; they should coordinate health services with the existing health
system of professionals and volunteers.
• CHWs’ training should focus on meeting their communities’ health promotion/prevention
needs as well as high impact curative interventions such as vaccinations, maternal and
child health, malaria treatment, and DOT adherence.
• CHWs should be trained by a multi-faceted team of health specialists on both practical
and theoretical aspects of health care delivery. The extent and duration of training would
circumscribe the specific skill set that a CHW could use in the community setting. For
those interventions beyond the scope of CHW training, individuals would be referred to
other health centers.
• Supervision and selection of CHWs should be undertaken by professional health workers
and community members through theoretical and practical evaluative tools in a
transparent manner.
• CHW programs should be linked to public health systems and the national health
structure but can be operationalized through various providers (such as governments,
NGOs, and FBOs) through a multi-layered management structure.

The critical mass of participants with CHW experience in sub-Saharan Africa has begun to
facilitate new networks and partnerships among implementers, decision makers, and donors. Key
international organizations and NGOs have made CHWs an important priority, and governments
have also displayed a high level of commitment to implement national-level CHW programs. To
this end, governments have called for $10 million in funding for each country’s detailed CHW
strategy. Donors must meet these demands to fund national CHW strategies, which will make a
significant contribution to addressing the HRH crisis. With strong support from all of the key
players, we must seize this opportunity to implement nationally scaled, technically proven and
designed national programs that will address the HRH crisis and provide adequate health care to
millions of people in sub-Saharan Africa.