Research for stronger health systems during and after crisis

Using community health workers in fragile and conflict-affected settings

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Lead: Dr Joanna Raven

African men and women in blue t-shirts sitting around a table, all drawing
Community health workers' workshop in Sierra Leone

Purpose of the research

Community health workers (CHW) play an important role in healthcare delivery. They provide key links to the community and may significantly outnumber formal health workers.  The aim of this research is to identify how the CHW cadre might be better supported to play an effective and long-term role in the broader health system in fragile contexts.


Countries and policy context

The main study is being carried out in Sierra Leone, with smaller case studies in Liberia and the Democratic Republic of Congo (DRC).  In Sierra Leone and Liberia, the recent Ebola outbreak emphasised the importance of CHWs’ understanding of their communities in the management of the outbreak, as well as in re-establishing trust with the health system. In DRC, CHWs play an important role in providing health services to communities, and are often the only health care workers who stay in insecure areas. 

In Sierra Leone, a revised national community health policy and programme was launched in February 2017, with plans for 12,000 CHW to be trained nationwide.  It was acknowledged that this policy did not have a strong evidence base and therefore more research was advocated, making this research timely. The research team is strategically positioned to feed into the new CHW policy which will undergo a mid-term review process which we anticipate will occur at the end of 2018.

In Liberia, since the Ebola outbreak there have been ongoing changes to community health activities, specifically through the launch of the community health animator (CHA) programme. Our rapid appraisal of the current situation and evidence on CHA in Liberia, will provide a more holistic understanding of the CHA policy and its implementation in Liberia.

In DRC, the community relais, or CHW programme, has been running for several years. Research shows the need to generate evidence and action about the management and support of CHW at both the regional and district levels.


A well with broken walls and a plastic bucket in a semi-rural setting

Expected areas of influence

In Sierra Leone, the main area of influence is expected to be in the revision of the national community health policy and programme. ReBUILD will present evidence to the mid-term review in late 2018.  The main interface of the project, and therefore possibility of influence, will be the Ministry of Health, but there will also be interactions with organisations that fund or work with CHWs such as UNICEF, Voluntary Service Overseas and the World Bank. We would aim to influence organisations that fund CHW programmes including WHO, UNICEFUSAID and DFID

In Liberia, the main influence is expected to be inputs into the CHA programme. Again, the main interface will be the Ministry of Health.

In the DRC the study will be conducted in Ituri region and our influence is expected to into the implementation of the CHW programme at the regional and district levels. The main interface will be the regional and district management health teams. 



CHW are active in educating people about the
dangers of dirty water, and treating those affected by it.


At the international level, the project stakeholders are:



Sierra Leone: Ethical approval at all levels was received, training for data collection has been completed and data collection and data analysis is underway. 

Liberia and DRC: Ethical approval has been received and data collection has started.


Resource lists

This study builds on ReBUILD’s earlier work looking at formal health workers in fragile and post-conflict settings.

A policy brief has been produced on 'Gender and Community Health Worker programmes in fragile and conflict-affected settings. Findings from Sierra Leone, the Democratic Republic of the Congo and Liberia'. Brief published by ReBUILD and RinGs.

The photovoice elements of this project have been brought together in two booklets:


What a photovoice project with Community Health Workers in Sierra Leone teaches us about health systems





How gender influences the service provided by Community Health Workers in Sierra Leone.