Do cash or digital payment modalities affect community health worker performance? - a case study of a remote refugee settlement in Western Uganda.

BACKGROUND: There is inadequate evidence about the influence of digital and cash payment modalities on the performance of Community Health Workers (CHWs) in underserved communities, such as refugee settlements. OBJECTIVE: To compare the performance of CHWs when paid in cash or digitally in Kyaka II refugee settlement, Uganda. METHODS: A comparative cross-sectional mixed methods design was used. Secondary data comprising 247 CHW reports during a six-month period of cash and digital payments were analyzed using Stata v14. Eleven focus group discussions, four in-depth interviews, and ten key informant interviews were conducted among the settlement stakeholders to explore perceptions of the payment methods. Qualitative data were analyzed thematically using Atlas.ti v9. RESULTS: CHWs performed better when paid cash than digital payments (t = 5.28; df = 246; p < 0.001). During the cash payment period, at least secondary education (APR 1.71 CI: 1.14-2.58) and having a side occupation (APR 1.58; CI: 1.13-2.21) were positively associated with performance. For digital payments, being male (APR 0.58; CI: 0.34-0.98), serving longer than 9 years (APR 0.87; CI: 0.82-0.93), and being allocated more than 60 households per month (APR 0.31; CI: 0.19-0.52) were negatively associated with CHW performance. Qualitative data revealed that most stakeholders preferred cash due to inconsistent and delayed digital payments. CONCLUSION: CHWs preferred and performed better with cash payments because digital payments were associated with delays and payment shortfalls that demotivated them. Implementers should invest towards averting digital payment shortfalls in remote settings to enhance CHW motivation and performance.

Main findings: Regarding the influence of payment modalities on Community Health Workers' performance, this study found that community health workers were motivated to perform better when paid with cash compared to digital payments.Added knowledge: Cash payments offer better reliability than digital payments in refugee settlements, which underscores the need to understand further the barriers to digital payments, particularly in hard-to-reach areas.Global health impact for policy and action: Health systems adapting to digital payments should consider a gradual transition through a hybrid approach that includes cash and digital payments while addressing the challenges associated with digital payments, especially in refugee settings and similar resource-constrained contexts.

Collaboration for implementation of decentralisation policy of multi drug-resistant tuberculosis services in Zambia.

BACKGROUND: Multi-drug-resistant tuberculosis (MDR-TB) infections are a public health concern. Since 2017, the Ministry of Health (MoH) in Zambia, in collaboration with its partners, has been implementing decentralised MDR-TB services to address the limited community access to treatment. This study sought to explore the role of collaboration in the implementation of decentralised multi drug-resistant tuberculosis services in Zambia. METHODS: A qualitative case study design was conducted in selected provinces in Zambia using in-depth and key informant interviews as data collection methods. We conducted a total of 112 interviews involving 18 healthcare workers, 17 community health workers, 32 patients and 21 caregivers in healthcare facilities located in 10 selected districts. Additionally, 24 key informant interviews were conducted with healthcare workers managers at facility, district, provincial, and national-levels. Thematic analysis was employed guided by the Integrative Framework for Collaborative Governance. FINDINGS: The principled engagement was shaped by the global health agenda/summit meeting influence on the decentralisation of TB, engagement of stakeholders to initiate decentralisation, a supportive policy environment for the decentralisation process and guidelines and quarterly clinical expert committee meetings. The factors that influenced the shared motivation for the introduction of MDR-TB decentralisation included actors having a common understanding, limited access to health facilities and emergency transport services, a shared understanding of challenges in providing optimal patient monitoring and review and their appreciation of the value of evidence-based decision-making in the implementation of MDR- TB decentralisation. The capacity for joint action strategies included MoH initiating strategic partnerships in enhancing MDR-TB decentralisation, the role of leadership in organising training of healthcare workers and of multidisciplinary teams, inadequate coordination, supervision and monitoring of laboratory services and joint action in health infrastructural rehabilitation. CONCLUSIONS: Principled engagement facilitated the involvement of various stakeholders, the dissemination of relevant policies and guidelines and regular quarterly meetings of clinical expert committees to ensure ongoing support and guidance. A shared motivation among actors was underpinned by a common understanding of the barriers faced while implementing decentralisation efforts. The capacity for joint action was demonstrated through several key strategies, however, challenges such as inadequate coordination, supervision and monitoring of laboratory services, as well as the need for collaborative efforts in health infrastructural rehabilitation were observed. Overall, collaboration has facilitated the creation of a more responsive and comprehensive TB care system, addressing the critical needs of patients and improving health outcomes.

Empowerment of Lay Mental Health Workers and Junior Psychologists Online in a Task-Shared, Rural Setting in Kerala, India.

BACKGROUND: Patients with severe mental health issues who live in isolated rural areas are difficult to reach and treat. Providing effective treatment is difficult because mental health problems are complex and require specialized knowledge from a range of professionals. Task-sharing with lay mental health workers (LMHWs) has potential but requires proper training and supervision to be effective. This article reports on the challenges and facilitators experienced in empowering LMHWs in their role, with the help of a technology supported supervision group. The study sought to understand the functioning of the Empowering Supervisory Group (ESG) in the context of junior psychologists and LMHWs in rural India, and investigate how they experienced it by exploring challenges, lessons and empowerment. METHODS: Qualitative analysis of interviews with the 22 ESG participants and their supervisors. RESULTS: A total of three discrete phases of supervision were identified where supervisors responded to the changing needs of the group. This began with building trust at a baseline level, tackling issues with competence and autonomy and finally experiencing meaning and impact through self-determination. The experience of empowerment even in an online setting was very beneficial given the challenges of working in rural areas. CONCLUSION: Empowerment based supervision of LMHWs and junior psychologists online enables a level of engagement that positions them to engage in community mental health practices with greater independence and confidence.

Implementing a Population-Based Social Determinants of Health Intervention: Early Lessons Learned from Collaboration between Clinical and Community Organizations.

The purpose of this study was to understand the barriers and facilitators among diverse health care and community organization stakeholders implementing a populationbased social determinants of health (SDOH) intervention. The SDOH intervention included three core programs: SDOH screening, a community health worker program, and a digital referral platform. After one year of implementation, we conducted semi-structured qualitative interviews with clinical and community-based organization stakeholders about (1) the three SDOH programs, (2) organizational implementation strategies, (3) interactions with partner organizations, and (4) perceived target population needs. Findings from the first year of implementation highlighted several factors to consider when designing and implementing SDOH programming, including (1) the successful features of the three SDOH programs, (2) the local implementation strategies and challenges across organizations, (3) the impact of broader community needs and resource availability on implementation, and (4) the importance of intentionally fostering relationships and collaboration among partner organizations.

Private pharmacy and community health worker engagement in the provision of TB services.

Engaging private health providers and community healthcare workers (CHWs) in the provision of TB care services can increase TB case notification and limit community transmission. We determined whether private pharmacy and community engagement could affect access to TB diagnostic and treatment services in Uganda.We conducted a cross-sectional study on patients diagnosed with TB through three different pathways; by private pharmacies, CHWs, and public health facilities. We collected data on patient demographics, time between symptom recognition and TB treatment initiation, and the amount of money spent on TB care seeking.We collected data from 325 participants; 65.2% were male, with a mean age of 35 years (SD 11.50). The time in days between the onset of symptoms and initiation of treatment was significantly different: respectively 149 (IQR 65.5-295), 119 (IQR 51-200), and 106.5 (IQR 60-201) days for CHWs, pharmacies, and public facilities (P = 0.04). The longest time was between the first contact with a health provider and the TB diagnosis (51 days, IQR 19-104). Participants diagnosed at public health facilities incurred the highest costs.Although the use of CHWs and pharmacies did not shorten the TB treatment pathway, the costs incurred were lower than those in private health facilities..

From the periphery to inclusion within the health system: promoting community health worker empowerment as a way forward.

BACKGROUND: Community health worker programmes have the potential to contribute critically towards universal health coverage. However, CHWs globally have often continued to operate on the periphery of the health care system, viewed as a non-essential cadre. This results in a workforce that often remains disempowered and under-supported. This paper presents evidence from a study conducted in a rural part of South Africa, to better understand issues of CHW prioritisation, integration, and empowerment. METHODS: We applied an analytical lens based on empowerment theory and conducted a secondary analysis of qualitative data emerging from a sub-study of a cRCT evaluating the effectiveness of supportive supervision for CHWs within a large-scale national CHW programme. The cRCT was conducted between 2017 and 2022, and 39 CHWs were included in the study. RESULTS: We organised our findings across the four domains of structural empowerment; information, resources, support, and opportunity, and mapped these domains against the domains of psychological empowerment. Our findings show how CHWs are still working in the periphery of the healthcare system. Without sufficient prioritisation, high level-support from national and district governments, and sufficient investments in programmatic domains-such as training, equipment, and supportive supervision-it is likely that the CHW cadre will continue to be seen as informal health care workers. CONCLUSIONS: CHW empowerment could be a lever to potentially transform the current health system towards universal coverage; however, this process can only happen with sufficient high-level prioritization and investment.

A Community-based Intervention to Improve Health Outcomes for Vietnamese Americans.

Vietnamese Americans experience significant health disparities compared with other groups, but their health care utilization is suboptimal. Boat People SOS (BPSOS), a nationwide Vietnamese-serving community-based organization, implemented a community health worker and community-clinical linkage electronic referral system to improve health care utilization. Three sites (in Alabama, California, and Virginia) received the intervention; Mississippi was the comparison site. The intervention included bridging between communities and health systems, culturally appropriate health education, informal counseling and social support, advocating for individual and community needs, direct services, and building individual and community capacity through partnerships with service providers. Compared with the comparison site, clients at the intervention sites reported better overall perceived health after the intervention. Past-year medical checkups declined in both groups during the COVID-19 pandemic but declined less in the treatment group. The intervention did not reduce emergency room visits. Findings suggest that this intervention can improve health care utilization and health status among Vietnamese Americans.

Actualizing the Full Potential of Public Health Community Health Workers.

Community health worker career paths that include policy, system change, program and process development, and advocacy will increase job satisfaction and sustainability. Community health workers employed at an organizational level can be liaisons between public health and community organizations to improve relationships and develop system-level culturally and linguistically appropriate services, information, resources, and policies.

Post-intervention perceptions on the antiretroviral therapy community group model in Trans Nzoia County, Kenya.

Introduction: the increasing number of people receiving antiretroviral therapy (ART) in sub-Saharan Africa has stressed already overburdened health systems. A care model utilizing community-based peer-groups (ART Co-ops) facilitated by community health workers (CHW) was implemented (2016-2018) to address these challenges. In 2018, a post-intervention study assessed perceptions of the intervention. Methods: forty participants were engaged in focus group discussions consisting of ART Co-op clients, study staff, and health care providers from Kitale HIV clinic. Data were analyzed thematically for content on the intervention, challenges, and recommendations for improvement. Results: all participants liked the intervention. However, some reported traveling long distances to attend ART Co-op meetings and experiencing stigma with ART Co-ops participation. The ART Co-op inclusion criteria were considered appropriate; however, additional outreach to deliberately include spouses living with HIV, the disabled, the poor, and HIV pregnant women was recommended. Participants liked CHW-directed quarterly group meetings which included ART distribution, adherence review, and illness identification. The inability of the CHW to provide full clinical care, inconvenient meeting venues, poor timekeeping, and non-attendance behaviors were noted as issues. Participants indicated that program continuation, regular CHW training, rotating meetings at group members´ homes, training ART Co-ops leaders to assume CHW tasks, use of pill diaries to check adherence, nutritional support, and economically empowering members through income generation projects would be beneficial. Conclusion: the intervention was viewed positively by both clinic staff and clients. They identified specific challenges and generated actionable key considerations to improve access and acceptability of the community-based model of care.

Shifting roles of community health workers in the prevention and management of noncommunicable disease during the COVID-19 pandemic: a scoping review.

Community Health Workers (CHWs) play a crucial role in the prevention and management of noncommunicable diseases (NCDs). The COVID-19 pandemic triggered the implementation of crisis-driven responses that involved shifts in the roles of CHWs in terms of delivering services for people with NCDs. Strategically aligning these shifts with health systems is crucial to improve NCD service delivery. The aim of this review was to identify and describe COVID-19-triggered shifting roles of CHWs that are promising in terms of NCD service delivery. We searched Ovid Medline, Embase, CINAHL, Web of Science and CABI for Global Health for relevant articles published between 1 January 2020 and 22 February 2022. Studies that were conducted within a COVID-19 context and focused on the shifted roles of CHWs in NCD service delivery were included. We used Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines to report the findings. A total of 25 articles from 14 countries were included in this review. We identified 12 shifted roles of CHWs in NCD service delivery during COVID-19, which can be categorized in three dimensions: 'enhanced' role of CHWs that includes additional tasks such as medication delivery; 'extended' roles such as the delivery of NCD services at household level and in remote communities; and 'enabled' roles through the use of digital health technologies. Health and digital literacy of people with NCDs, access to internet connectivity for people with NCDs, and the social and organizational context where CHWs work influenced the implementation of the shifted roles of CHWs. In conclusion, the roles of CHWs have shifted during the COVID-19 pandemic to include the delivery of additional NCD services at home and community levels, often supported by digital technologies. Given the importance of the shifting roles in the prevention and management of NCDs, adaptation and integration of these shifted roles into the routine activities of CHWs in the post-COVID period is recommended.

Reaching Vulnerable and Underserved Communities in the US Southwest Through a Successful COVID-19 Community-Academic Partnership.

This article describes a community-academic partnership designed and implemented to address disparities in accessing COVID-19 testing in Arizona, from November 2020 through March 2023. An equitable community-academic partnership, the involvement of local leaders, and the engagement of community health workers were critical for the success of the intervention. More than 5000 previously underserved patients were tested and received COVID-19 related services. A profile comparison with a matched group documents the success of the program in reaching the targeted population. (Am J Public Health. 2024;114(S5):S388-S391. https://doi.org/10.2105/AJPH.2024.307684).

Methodology for adapting a co-created early childhood development intervention and implementation strategies for use by frontline workers in India and Guatemala: a systematic application of the FRAME-IS framework.

There is little evidence on optimizing the effectiveness and implementation of evidence-based early childhood development (ECD) interventions when task-shifted to frontline workers. In this Methods Forum paper, we describe our adaptation of the International Guide for Monitoring Child Development (GMCD) for task-shifting to frontline workers in Guatemala and India. In 2021-2022, implementers, trainers, frontline workers, caregivers, and international GMCD experts collaborated to adapt the GMCD for a task shifted implementation by frontline workers. We used an eight-step co-creating process: assembling a multidisciplinary team, training on the existing package, working groups to begin modifications, revision of draft modifications, tailoring of visual materials and language, train-the-trainers activities, pilot frontline worker trainings, final review and feedback. Preliminary effectiveness of adaptations was evaluated through narrative notes and group-based qualitative feedback following pilot trainings with 16 frontline workers in India and 6 in Guatemala. Final adaptations included: refining training techniques to match skill levels and learning styles of frontline workers; tailoring all visual materials to local languages and contexts; design of job aids for providing developmental support messages; modification of referral and triage processes for children in need of enhanced support and speciality referral; and creation of post-training support procedures. Feedback from pilot trainings included: (1) group consensus that training improved ECD skills and knowledge across multiple domains; and (2) feedback on ongoing needed adjustments to pacing, use of video-based vs. role-playing materials, and time allocated to small group work. We use the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) framework to document our adaptations. The co-creating approach we use, as well as systematic documentation of adaptation decisions will be of use to other community-based early childhood interventions and implementation strategies.

Main findings: The International Guide for Monitoring Child Development, an early childhood development support and monitoring tool, was successfully adapted for use by frontline workers in rural India and Guatemala.Added knowledge: Our Methods Forum paper uses a detailed framework to document the collaborative, co-creating process used and the adaptive decisions taken.Global health impact for policy and action: Evidence on how best to adapt and optimize early childhood interventions for frontline workers will be useful or scaling up support for children globally.

Community Health Workers Deliver Mental Health Intervention to Uninsured Latinx in Baltimore: Evaluation and Lessons Learned in a Pilot Program.

BACKGROUND: Implementation of evidence-based interventions to reduce depression among uninsured Latinx patients who are at high risk of depression are rare. OBJECTIVES: Our goal was to evaluate Strong Minds, a language and culturally tailored, evidence-based intervention adapted from cognitive behavioral therapy (CBT) for mild-moderate depression and anxiety, delivered by community health workers (CHWs) in Spanish to uninsured Latinx immigrants. METHODS: As part of the pilot, 35 participants, recruited from a free community primary care clinic, completed Strong Minds. Assessments and poststudy interviews were conducted. Paired t-tests were used to assess change of depressive symptoms at 3 and 6 months. LESSONS LEARNED: CHW delivery of depression care to this population was feasible and among those who completed the program, preliminary evidence of depression outcomes suggests potential benefit. CHWs had specific training and support needs related to mental health care delivery. CONCLUSIONS: Further implementation studies of depression care interventions using CHWs for underserved Latinx is needed.

A Model of Community Health Worker Integration into Schools: Community-based Participatory Research in Action.

BACKGROUND: Schools are rich sites for collaborations between health and educational sectors. OBJECTIVES: To identify lessons learned from formation of a community-academic partnership and application of community-based participatory research (CBPR) to develop a model that integrates community health workers into schools. METHODS: Individuals from an academic medical center, a large public school district, and a community-based research institute applied CBPR principles to reimagine schools as a place for improving the health of children. LESSONS LEARNED: Three lessons emerged. Leveraging each team member's expertise centered the partnership on community strengths, co-learning, and stakeholder engagement. Adherence to CBPR's principles of power sharing and equity helped navigate the challenges of collaboration between large institutions. Early focus on sustainability helped address unexpected issues, build capacity, and boost advocacy. CONCLUSIONS: This partnership demonstrates how CBPR fosters conditions in which equitable partnerships between research institutions and public schools can thrive to promote childhood health.

Advancing social care integration in health systems with community health workers: an implementation evaluation based in Bronx, New York.

BACKGROUND: In recent years, health systems have expanded the focus on health equity to include health-related social needs (HRSNs) screening. Community health workers (CHWs) are positioned to address HRSNs by serving as linkages between health systems, social services, and the community. This study describes a health system's 12-month experience integrating CHWs to navigate HRSNs among primary care patients in Bronx County, NY. METHODS: We organized process and outcome measures using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation framework domains to evaluate a CHW intervention of the Community Health Worker Institute (CHWI). We used descriptive and inferential statistics to assess RE-AIM outcomes and socio-demographic characteristics of patients who self-reported at least 1 HRSN and were referred to and contacted by CHWs between October 2022 and September 2023. RESULTS: There were 4,420 patients who self-reported HRSNs in the standardized screening tool between October 2022 and September 2023. Of these patients, 1,245 were referred to a CHW who completed the first outreach attempt during the study period. An additional 1,559 patients self-reported HRSNs directly to a clinician or CHW without being screened and were referred to and contacted by a CHW. Of the 2,804 total patients referred, 1,939 (69.2%) were successfully contacted and consented to work with a CHW for HRSN navigation. Overall, 78.1% (n = 1,515) of patients reported receiving social services. Adoption of the CHW clinician champion varied by clinical team (median 22.2%; IQR 13.3-39.0%); however, there was no difference in referral rates between those with and without a clinician champion (p = 0.50). Implementation of CHW referrals via an electronic referral order appeared successful (73.2%) and timely (median 11 days; IQR 2-26 days) compared to standard CHWI practices. Median annual cost per household per CHW for the intervention was determined to be $184.02 (IQR $134.72 - $202.12). CONCLUSIONS: We observed a significant proportion of patients reporting successful receipt of social services following engagement with an integrated CHW model. There are additional implementation factors that require further inquiry and research to understand barriers and enabling factors to integrate CHWs within clinical teams.

Use of Community Health Workers Among U.S. Male Latino Population: A Scoping Review.

Community Health Workers (CHWs) are an effective strategy to address the health needs of specified communities. The purpose of this scoping review was to explore the use of CHWs to address the health needs of the Latino male population. This project used specific search terms to identify relevant articles from PubMed, PsycINFO, and Google Scholar. Eligible articles included studies, conducted in the U.S. and in English from 2010 to 2022, that assessed the use of CHWs among a predominantly male (≥ 50%) Latino population. Twenty articles consisting of 13 interventions were identified for review and were further categorized into male-only participant samples (n = 10) and mixed-gender but predominantly-male participant samples (n = 10) for synthesis. Male-only participant samples focused on occupational health and participant's social support and networks. Predominantly-male, mixed-gender participant sample interventions were disease-centered and emphasized the longitudinal support of CHWs as well as social networks. Of the 13 interventions reviewed, almost all (n = 10) utilized existing social networks for engagement and nearly half (n = 6) employed community-based participatory research (CBPR) principles. Findings suggest that recruiting CHWs from within existing social networks and using CBPR are important factors for successful health promotion among male Latinos.

A systematic review of the types, workload, and supervision mechanism of community health workers: lessons learned for Indonesia.

BACKGROUND: Community health workers (CHWs) have demonstrated capability to improve various health indicators, however, many programmes require support in meeting their objectives due to subpar performance and a high rate of CHW attrition. This systematic review investigated the types of CHWs, their workloads, and supervision practices that contribute to their performance in different countries. METHODS: The search was carried out in November 2022 in Medline, Embase, and Neliti for studies published in Indonesian or English between 1986 and 2022 that reported public health services delivered by CHWs who live and serve the community where they live but are not considered health professionals. The findings were synthesised using a thematic analysis to assess key factors influencing the performance of CHWs. RESULTS: Sixty eligible articles were included in this review. CHWs were responsible for more than two diseases (n = 35) and up to fifteen, with more than eighteen activities. Their roles covered the human life cycle, from preparation for pregnancy, care for newborns, health for children, adolescents, and productive age to elderly individuals. They were also involved in improving environmental health, community empowerment, and other social issues hindering access to health services. They carried out promotive, preventive, and curative interventions. The CHW-population ratio varied from eight to tens of thousands of people. Some CHWs did not have a clear supervision system. Challenges that were often faced by CHWs included inappropriate incentives, inadequate facilities, insufficient mentoring, and supervision, many roles, and a broad catchment area. Many studies revealed that CHWs felt overburdened and stressed. They needed help to balance their significant work and domestic tasks. CONCLUSIONS: Effective planning that considered the scope of work of CHWs in proportion to their responsibilities and the provision of necessary facilities were crucial factors in improving the performance of CHWs. Supportive supervision and peer-supervision methods are promising, however, any CHW supervision required a detailed protocol. This systematic review emphasised the opportunity for CHW management system improvement in Indonesia.

"Nos apoyamos mutuamente": Strategies to supporting community health workers addressing the emergency and chronic needs of Latinx families.

Community health workers (CHWs) have established pathways to implementing effective, sustainable, and cost-effective health programs among underserved populations. Despite the significant role of CHWs, there is limited literature describing the needs of CHWs, specifically in times of health emergencies and crises. Thus, we explored the challenges and sources of support among CHWs providing services to Latinx families. Participants were recruited from a Latinx community-based organization in metro Atlanta, working to strengthen family relationships using evidence-based programming. Fifteen semistructured interviews were conducted among CHWs. Interviews were conducted primarily in Spanish, recorded, transcribed, and translated into English for analysis. Following a thematic analysis, data were double-coded, and codes were described and compared for themes. Participants identified as Latinx (n = 15), were between the ages of 29 and 69 years, and had worked as CHWs between 1 month to 4 years. Two themes and seven subthemes were identified in the data. Theme 1 highlighted barriers and strategies employed by CHWs to address clients' preexisting and emerging needs, and Theme 2 focused on responding to client needs during the COVID-19 pandemic, which introduced new challenges and barriers that provoked adaptive organizational strategies to promote worker resilience. Addressing the needs of vulnerable communities in times of crisis to improve the working conditions for CHWs will require a multifaceted approach that prioritizes the removal of structural barriers. Barriers can be mitigated by prioritizing cultural assets, adopting flexible and equitable work policies, and enacting policies at the federal level that promote health justice. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Mapping and analysing community health worker programmes in the Eastern Mediterranean region.

BACKGROUND: Community health worker (CHW) programmes are increasingly being recognized as an important strategy that can help to strengthen comprehensive primary health care (PHC), as the foundation of work towards achieving universal health care (UHC) and meeting the Sustainable Development Goals (SDGs). The WHO Regional Office for the Eastern Mediterranean undertook a situational analysis of CHW programmes in the Region to better understand the current situation and the issues involved. METHODS: A two-step process was employed: a review of available literature on CHWs in the Region was conducted, followed by a survey of CHW programmes in the region, focussing on programmes that were country-led and country-wide. RESULTS: Thirteen countries were found to have community health worker programmes with varying governance and programmatic structures. Broadly, two categories can be distinguished: (a) several countries have well established and mature national CHW programmes that are in most cases supported by external donors but driven and coordinated by national governments; (b) a greater number of countries that have smaller, emerging government or partner led projects and programmes. A few countries have deliberately opted for other models to strengthen primary care and community outreach, for example, through community nursing. CONCLUSION: CHW programmes play an increasingly important role in primary health care in the Eastern Mediterranean Region, providing promotive, preventive, and emergency services. This bodes well for efforts to strengthen and embed comprehensive primary health care as the foundation of national health systems, to improve health emergency preparedness, achieve UHC and meet the SDGs. Nonetheless, all but a few programmes face challenges of weak governance, fragmentation and unreliable support, similar to those in other countries. However, the main finding of the analysis was that the role of CHWs in countries' health service delivery is woefully under-researched in almost all countries in the region, and more research to better understand and support programmes in the context of local health system contexts is urgently needed.