Community health workers at the dawn of a new era: 1. Introduction: tensions confronting large-scale CHW programmes.

BACKGROUND: Community health worker (CHW) programmes are again receiving more attention in global health, as reflected in important recent WHO guidance. However, there is a risk that current CHW programme efforts may result in disappointing performance if those promoting and delivering them fail to learn from past efforts. This is the first of a series of 11 articles for a supplement entitled "Community Health Workers at the Dawn of a New Era". METHODS: Drawing on lessons from case studies of large well-established CHW programmes, published literature, and the authors' experience, the paper highlights major issues that need to be acknowledged to design and deliver effective CHW programmes at large scale. The paper also serves as an introduction to a set of articles addressing these issues in detail. RESULTS: The article highlights the diversity and complexity of CHW programmes, and offers insights to programme planners, policymakers, donors, and others to inform development of more effective programmes. The article proposes that be understood as actors within community health system(s) and examines five tensions confronting large-scale CHW programmes; the first two tensions concern the role of the CHW, and the remaining three, broader strategic issues: 1) What kind of an actor is the CHW? A lackey or a liberator? Provider of clinical services or health promoter? 2) Lay versus professional? 3) Government programme at scale or nongovernmental organization-led demonstration project? 4) Standardized versus tailored to context? 5) Vertical versus horizontal? CONCLUSION: CHWs can play a vital role in primary healthcare, but multiple conditions need to be met for them to reach their full potential.

A new resource for developing and strengthening large-scale community health worker programs.

Large-scale community health worker programs are now growing in importance around the world in response to the resurgence of interest and growing evidence of the importance of community-based primary health care for improving the health of populations in resource-constrained, high-mortality settings. These programs, because of their scale and operational challenges, merit special consideration by the global health community, national policy-makers, and program implementers. A new online resource is now available to assist in that effort: Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers ( http://www.mchip.net/CHWReferenceGuide ). This CHW Reference Guide is the product of 27 different collaborators who, collectively, have a formidable breadth and depth of experience and knowledge about CHW programming around the world. It provides a thoughtful discussion about the many operational issues that large-scale CHW programs need to address as they undergo the process of development, expansion or strengthening. Detailed case studies of 12 national CHW programs are included in the Appendix-the most current and complete cases studies as a group that are currently available. Future articles in this journal will highlight many of the themes in the CHW Reference Guide and provide an update of recent advances and experiences. These articles will serve, we hope, to (1) increase awareness about the CHW Reference Guide and its usefulness and (2) connect a broader audience to the critical importance of strengthening large-scale CHW programs for the health benefits that they can bring to underserved populations around the world.