Community health workers in South Africa: Where in this maze do we find ourselves?

Background The increasing burden on health services of HIV/AIDS and tuberculosis, as well as the need to meet the Millennium Development Goals for health, has renewed interest in community health worker (CHW) programmes in South Africa. The recent Expanded Public Works Social Sector Plan promotes CHW programmes as a mechanism for addressing the health, social, educational and employment needs of disadvantaged communities. This paper reports key issues emerging from a two day workshop for health policy-makers, project managers and researchers, on the implementation of CHW projects. Results The workshop considered a wide range of issues. Robust evidence for the effectiveness of focused CHW interventions, where this cadre function within a limited scope of practice, is now available but further evidence on the effects of ‘generalist’ CHWs is necessary before wide roll-out can be recommended. Further work is also needed on approaches to evaluating CHW programmes, given their complexity and the need to understand the impacts of context. How best to organize CHW programmes, including community participation and approaches to training, were debated. Several key challenges facing CHW programmes in South Africa were identified, including responsiveness to community needs; financing; training; programme management and CHW supervision. Further research on the cost-effectiveness of CHW interventions and on factors affecting scaling up of programmes is required. Conclusions Although a national CHW policy framework is now in place in South Africa, many questions and challenges related to implementation remain. The renewed interest in CHW programmes provides opportunities to examine these questions and to increase the contribution of CHWs to improving health in South Africa.