n.V1-7.13 | COMMUNITY HEALTH WORKERS
01| Put a trained local person between the health system and the household. She lives in the village, knows the families, visits homes, advises, refers, and sells or supplies basic preventive and curative products. The theory is that the services already exist and the missing element is a person who closes the distance to them.
02| This is the most testable claim in the whole book part, because the role already exists in several fields under other names — community health worker, lay counsellor, patient navigator, case manager — and some of it has been evaluated against mortality rather than satisfaction.
03| Björkman Nyqvist, Guariso, Svensson and Yanagizawa-Drott randomised a community health promoter programme across 214 rural villages in ten Ugandan districts. In treatment villages, a locally recruited agent was incentivised to conduct home visits, educate households on health behaviour, give advice and referrals, and sell preventive and curative products. Control villages had none. After three years: under-five mortality down roughly 27 percent, infant mortality down 33 percent, neonatal mortality down 28 percent.
04| The design matters as much as the number. No clinics were built. No doctors were added. No new drugs entered the system. Everything the intervention relied on was already there. What was added was a person who lived in the village and walked to households — and roughly a quarter of small children who would have died did not.
05| That is the strongest single result in this book part, and it should be stated without hedging before the hedging starts.
06| Now the hedging, which is substantial. The agents were paid through product sales. How much of the effect depends on that commercial incentive — an agent with a reason to knock on the next door — is not separated by the trial, and it is precisely the feature that most government programmes do not have. A salaried worker and a volunteer are different jobs with different attrition and different daily behaviour, and nothing here tells you whether either produces the same result.
07| The scale evidence is where the optimism runs out. Reviews describe community health worker effectiveness as mixed rather than established, with outcomes depending heavily on implementation context. A synthesis of a decade of published research on India's ASHA programme — the largest such workforce in the world — reports that a majority of studies of the routine programme produced mixed findings and roughly a quarter negative, with few clearly positive, attributed to broader health system constraints.
08| So the same pattern as everywhere else in this book part, in its clearest form. A trial in which the implementer selected, trained, supervised and paid the workers closely produced a mortality effect. A national programme that scaled the job title without the supervision architecture produced mixed to negative findings across a decade of study.
09| The reviews are consistent about what the architecture consists of: initial and ongoing training, structured management and accountability, salaries rather than volunteer status, and continuous monitoring. High attrition is a persistent problem everywhere. What none of them provide is the threshold — the minimum supervision and support below which the role stops working. That is the most decision-relevant unanswered question for anyone building such a system, and the literature names the ingredients without quantifying any of them.
10| The second missing number is caseload. How many households one worker can carry before the effect degrades, and whether it degrades gradually or falls off a cliff, determines whether the model can be afforded at national scale. A role that has been trialled to the point of measuring child mortality has not been characterised on the one dimension that sets its cost. That absence is itself a finding about what the sector chooses to study.
