Addressing health workforce shortage, maldistribution and performance challenges is essential for progress towards all health-related goals, including universal health coverage.
Further, as evidenced by the recommendations of the United Nations High-Level Commission on Health Employment and Economic Growth, there is increasing recognition of the potential of the health sector to create qualified employment opportunities, in particular for women, contributing to the job creation and economic development agenda. The education and deployment of interprofessional primary care teams of health workers should reflect a diverse and sustainable skills mix; in some contexts this may entail harnessing the potential of community health workers (CHWs) as part of broader efforts to strengthen primary health care and the health workforce more generally.
There is growing recognition that CHWs and other types of community-based health workers are effective in the delivery of a range of preventive, promotive and curative health services, and that they can contribute to reducing inequities in access to care.
The support for CHWs and their integration into health systems and communities are uneven across and within countries; good-practice examples are not necessarily replicated and policy options for which there is greater evidence of effectiveness are not uniformly adopted. There is a need for evidence-based guidance on optimal health policy and system support to optimize the performance and impact of these health workers.

# Target audience
The primary target audience for this guideline is policy-makers, planners and managers responsible for health workforce policy and planning at national and local levels.
Secondary target audiences include development partners, funding agencies, global health initiatives, donor contractors, researchers, CHW organizations, CHWs themselves, civil society organizations and community stakeholders.

# Objectives and scope
The overall goal of this guideline is to assist national governments and national and international partners to improve the design, implementation, performance and evaluation of CHW programmes, contributing to the progressive realization of universal health coverage.
This guideline is primarily focused on CHWs (as defined by the International Labour Organization through its International Standard Classification of Occupations), but its relevance and applicability include also other types of community-based health workers. The recommendations of this guideline are of relevance to health systems of countries at all levels of socioeconomic development.
The guideline follows a health system approach and specifically it identifies the policy and system enablers required to optimize design and performance of CHW initiatives. It does not appraise the body of evidence on which health services or interventions CHWs can deliver to quality standards, which are covered by other World Health Organization (WHO) guidelines.
The development of this guideline followed the standard WHO approach: a critical appraisal of the evidence through the development of systematic reviews of the relevant literature and the assessment of the quality of the evidence through standardized methodologies, including the assessment of the certainty of the evidence. A Guideline Development Group, comprising a geographically and gender-balanced representation across different constituencies (including policy-makers, end-users of guidelines, experts, health professional associations, CHWs and labour union representatives) led the formulation of recommendations, with the support of a Steering Group, and benefiting from peer review by a competitively-selected External Review Group. One systematic review of published literature reviews, 15 systematic reviews (one for each policy question) of relevant primary studies, and a stakeholder perception survey were conducted for the specific purpose of identifying relevant evidence contributing to this guideline.

# Executive summary
The systematic review of published literature reviews identified 122 eligible reviews (75 systematic reviews, of which 34 were meta-analyses, and 47 non-systematic reviews). The systematic reviews for the studies for the 15 questions considered by the guideline screened almost 88 000 records, resulting eventually in the identification of 137 studies eligible for inclusion and analysis in the reviews.
The stakeholder perception survey obtained inputs from 96 respondents (largely policy-makers, planners, managers and researchers involved in the design, implementation, monitoring and evaluation of CHW programmes) on the acceptability and feasibility of the interventions under consideration in the guideline.
WHO suggests using the following criteria for selecting CHWs for pre-service training:
- minimum educational level that is appropriate to the task(s) under consideration;
- membership of and acceptance by the target community;
- gender equity appropriate to the context (considering affirmative action to preferentially select women to empower them and, where culturally relevant, to ensure acceptability of services by the population or target group);
- personal attributes, capacities, values, and life and professional experiences of the candidates (e.g. cognitive abilities, integrity, motivation, interpersonal skills, demonstrated commitment to community service, and a public service ethos).

# Certainty of the evidence -very low. Strength of the recommendation -conditional.

# Recommendation 1B
WHO suggests not using the following criterion for selecting CHWs for pre-service training:
- age (except in relation to requirements of national education and labour policies).

# Certainty of the evidence -very low. Strength of the recommendation -conditional.

# Recommendation 1C
WHO recommends not using the following criterion for selecting CHWs for pre-service training:
- marital status.
Certainty of the evidence -very low. Strength of the recommendation -strong.

# Duration of pre-service training
WHO suggests using the following criteria for determining the length of pre-service training for CHWs:
- scope of work, and anticipated responsibilities and role;
- competencies required to ensure high-quality service delivery;
- pre-existing knowledge and skills (whether acquired through prior training or relevant experience);
- social, economic and geographical circumstances of trainees;
- institutional capacity to provide the training;
- expected conditions of practice.
Certainty of the evidence -low. Strength of the recommendation -conditional.

# Competencies in curriculum for pre-service training
WHO suggests including the following competency domains for the curriculum for pre-service training of CHWs, if their expected role includes such functions.
- promotive and preventive services, identification of family health and social needs and risk;
- integration within the wider health care system in relation to the range of tasks to be performed in accordance with CHW role, including referral, collaborative relation with other health workers in primary care teams, patient tracing, community disease surveillance, monitoring, and data collection, analysis and use;
- social and environmental determinants of health;
- providing psychosocial support;
- interpersonal skills related to confidentiality, communication, community engagement and mobilization;
- personal safety.
- diagnostic, treatment and care in alignment with expected role(s) and applicable regulations on scope of practice.
Certainty of the evidence -moderate. Strength of the recommendation -conditional.

# Modalities of pre-service training
WHO suggests using the following modalities for delivering pre-service training to CHWs:
- balance of theory-focused knowledge and practicefocused skills, with priority emphasis on supervised practical experience;
- balance of face-to-face and e-learning, with priority emphasis on face-to-face learning, supplemented by e-learning on aspects on which it is relevant;
- prioritization of training in or near the community wherever possible;
- delivery of training and provision of learning materials in language that can optimize the trainees' acquisition of expertise and skills;
- ensuring a positive training environment;
- consideration of interprofessional training approaches where relevant and feasible.
Certainty of the evidence -very low. Strength of the recommendation -conditional.

# Competency-based certification
WHO suggests using competency-based formal certification for CHWs who have successfully completed pre-service training. 1 Certainty of the evidence -very low. Strength of the recommendation -conditional.

# Supportive supervision
WHO suggests using the following supportive supervision strategies in the context of CHW programmes:
- appropriate supervisor-supervisee ratio allowing meaningful and regular support;
- ensuring supervisors receive adequate training;
- coaching and mentoring of CHWs;
- use of observation of service delivery, performance data and community feedback;

# Target population size Recommendation 10
WHO suggests using the following criteria in determining a target population size in the context of CHW programmes.
Criteria to be adopted in most settings:
- expected workload based on epidemiology and anticipated demand for services;
- frequency of contact required;
- nature and time requirements of the services provided;
- expected weekly time commitment of CHWs (factoring in time away from service provision for training, administrative duties, and other requirements);
- local geography (including proximity of households, distance to clinic and population density).
Criteria that might be of relevance in some settings:
- weather and climate;
- transport availability and cost;
- health worker safety;
- mobility of population;
- available human and financial resources.
Certainty of the evidence -very low. Strength of the recommendation -conditional.

# Data collection and use Recommendation 11
WHO suggests that practising CHWs document the services they are providing and that they collect, collate and use health data on routine activities, including through relevant mobile health solutions.
Enablers for success include minimizing the reporting burden and harmonizing data requirements; ensuring data confidentiality and security; equipping CHWs with the required competencies through training; and
providing them with feedback on performance based on data collected.
Certainty of the evidence -very low. Strength of the recommendation -conditional.

# Types of CHWs Recommendation 12
WHO suggests adopting service delivery models comprising CHWs with general tasks as part of integrated primary health care teams. CHWs with more selective and specific tasks can play a complementary role when required on the basis of population health needs, cultural context and workforce configuration.
Certainty of the evidence -very low. Strength of the recommendation -conditional.

# Community engagement Recommendation 13
WHO recommends the adoption of the following community engagement strategies in the context of practising CHW programmes:
- pre-programme consultation with community leaders;
- community participation in CHW selection;
- monitoring of CHWs;
- selection and priority setting of CHW activities;
- support to community-based structures;
- involvement of community representatives in decision-making, problem solving, planning and budgeting processes.
Certainty of the evidence -moderate. Strength of the recommendation -strong.

# Mobilization of community resources Recommendation 14
WHO suggests that CHWs contribute to mobilizing wider community resources for health by:
- identifying priority health and social problems and developing and implementing corresponding action plans with the communities;
- mobilizing and helping coordinate relevant local resources representing different stakeholders, sectors and civil society organizations to address priority health problems;
- facilitating community participation in transparent evaluation and dissemination of routine community data and outcomes of interventions;
- strengthening linkages between the community and health facilities.
Certainty of the evidence -very low. Strength of the recommendation -conditional.

# Availability of supplies
WHO suggests using the following strategies for ensuring adequate availability of commodities and consumable supplies, quality assurance, and appropriate storage, stocking and waste management in the context of CHW programmes:
- integration in the overall health supply chain;
- adequate reporting, supervision, compensation, work environment management, appropriate training and feedback, and team quality improvement meetings;
- availability of mHealth to support different supply chain functions.
Certainty of the evidence -low. Strength of the recommendation -conditional.

# Research priorities
Evidence was identified to provide policy recommendations for most areas under consideration in the guideline. However, in several instances important gaps in both scope and certainty of evidence emerged from the systematic reviews, providing an opportunity to outline priorities for a future research agenda on CHWs.
The research activities undertaken in support of this guideline found a near-absolute absence of evidence in some areas (for example, on certification or contracting and career ladders for CHWs, appropriate typology, and population target size).
Across most policy areas considered there is some evidence -often substantial -that broad strategies (for example, competency-based education, supportive supervision, and payment) are effective. However, this evidence may not be sufficiently granular to recommend specific interventions, such as which education approaches, which supervision strategies, or which bundles of financial and non-financial incentives are most effective or more effective than others. Other cross-cutting considerations include the absence of economic evaluations of the various interventions under consideration, and the importance of tracking policy effectiveness over time through longer-term longitudinal studies.
As most of the evidence retrieved for this guideline originated in low-and middle-income countries, additional research should be considered in advanced economies to better identify any differences in contextual factors and effectiveness of approaches that would impact the applicability and generalizability of policy options and recommendations in this guideline.

# Implementation considerations
The starting point for an effective design of CHW initiatives and programmes is a sound situation analysis of population needs and health system requirements. Planners should adopt a whole-of-system approach, taking into consideration health system capacities and population needs, and framing the role of CHWs vis-a-vis other health workers, in order to integrate CHW programmes into the health system in an appropriate manner.
CHW initiatives and programmes should therefore be aligned to and be part of broader national health and health workforce policies. As relevant, they should also be linked with national education, labour and community development sectoral or subsectoral policies and frameworks.
Countries should use a combination of CHW policies selected based on the objectives, context and architecture of each health system. This guideline is not a blueprint that can be immediately adopted. It should be read as an analytical overview of available evidence that informs a menu of interrelated policy options and recommendations. The options and recommendations subsequently need to be adapted and contextualized to the reality of a specific health system.
Further, the recommendations should not be considered in isolation from one another. There is a need for internal coherence and consistency among different policies, as they represent related and interlocking elements that complement and can reinforce one another.  (13)(14)(15)(16)(17). There is also substantial evidence that delivering essential health services through CHWs may represent a cost-effective approach in a diversity of contexts (18)(19)(20). Empowering CHWs also offers a critical opening for change towards achieving greater gender equity within communities.
The support for CHWs and their integration into the health system and in the communities they serve are uneven across and within countries; good-practice examples are not necessarily replicated and policy options for which there is greater evidence of effectiveness are not uniformly adopted.
Although they should be considered as an integral part of primary health care strategies and of the health system, CHW

# Target audience
The primary target audience for this guideline is policy-makers, planners and managers responsible for health workforce policy and planning at national and local levels. Throughout this document, policy and actions at "country" or "national" level should be understood as relevant in each country in accordance with subnational and national responsibilities.

# Objectives and scope of the guideline
The overall goal of this guideline is to assist national governments and national and international partners to improve the design, implementation, performance and evaluation of CHW programmes, contributing to the progressive realization of universal health coverage.
The specific objectives of this guideline are to:
- provide gender-sensitive recommendations in the areas of CHW selection, education, continuing training, linkage with other health workers, management, supervision, performance enhancement, incentives, remuneration, governance, health system integration and community embeddedness;
- identify relevant contextual elements and implementation and evaluation considerations at the policy and system levels;
- suggest tools to support the uptake of the recommendations at the country level in the context of the planning and implementation of CHW programmes;
- identify priority evidence gaps to be addressed through further research.

# Goal and objectives 4.2 Types of health workers covered by this guideline
Unclear nomenclature and classification complicate the policy discourse on CHWs: the term "community health workers" is often used in a non-specific way, referring to a diverse typology of lay and educated, formal and informal, paid and unpaid health workers.

# Lead statement
Community health workers provide health education and referrals for a wide range of services, and provide support and assistance to communities, families and individuals with preventive health measures and gaining access to appropriate curative health and social services. They create a bridge between providers of health, social and community services and communities that may have difficulty in accessing these services.

# Task statement
Tasks include: (a) providing education to communities and families on a range of health issues including family planning, control and treatment of infectious diseases, poisoning prevention, HIV risk factors and measures to prevent transmission, risk factors associated with substance abuse, domestic violence, breastfeeding and other topics; (b) assisting families to develop the necessary skills and resources to improve their health status, family functioning and self-sufficiency;
(c) conducting outreach efforts to pregnant women, including those who are not involved in prenatal, health or other community services, and other high risk populations living to help them with access to prenatal and other health care services; (d) ensuring parents understand the need for children to receive immunizations and regular health care;
(e) working with parents in their homes to improve parent-child interaction and to promote their understanding of normal child development; (f) providing advice and education on sanitation and hygiene to limit the spread of infectious diseases;
(g) storing and distributing medical supplies for the prevention and cure of endemic diseases such as malaria and tuberculosis and instructing members of the community in the use of these products; (h) assisting families in gaining access to medical and other health services (24).

# Box 1. ILO definition of community health workers (ISCO 3253)
The generic definition and the blurred boundaries among these health workers, the existence of overlapping terminology in the literature (such as "lay health workers", "front-line health workers", "close-to-community providers"), as well as widely differing policies relating to their scope of practice, education, and relation with health systems, have contributed to undermining efforts to strengthen service delivery systems at community level (13).
Classification according to the ISCO occupational groups and official job titles in a jurisdiction do not always cohere: in some contexts, the term "community health worker" or a similar term is used to refer to health workers that, according to the ILO (Figure 1). This has ramifications for the generalizability of the evidence found and its applicability to contexts different from those to which the primary evidence refers. These aspects are discussed in more detail under the interpretation and implementation considerations of each recommendation.
Each review was structured according to the standard population, intervention, control, outcome (PICO) approach.
The setting for the questions was identified as underserved communities, noting the particularly important role that CHWs can play in these contexts -while recognizing also that underserved communities may exist in countries at all levels of socioeconomic development. Many recommendations however refer to actions and policies at the health system level, making them of broader relevance and applicable to an entire country or jurisdiction.  2 and Annex 2). Current (and future) disease-specific WHO guidelines remain the primary source of normative guidance on which specific preventive, promotive, diagnostic, curative and care services CHWs are effective in providing (Annex 3).

# Geographical areas covered
In addition to the delivery of interventions at the individual and family levels, there is long-standing recognition of the potential for CHWs to play a social and political role at the community level, related to the action on social determinants of health for the transformation of living conditions and community organization. This dimension includes participatory identification with the community of health problems and a reorientation of the concept and the model of health care (26,27). The Health Workforce Department at WHO headquarters led the development of this guideline in conformity with the process and requirements outlined in the WHO handbook for guideline development (28). The GDG held a two-day meeting in October 2016 in Geneva, Switzerland, to define the scope of the guideline through the identification of the population, intervention, control, outcome (PICO) questions that would guide the retrieval of evidence, and provide guidance to inform the methodology of the systematic reviews of the literature.

# Categories of interventions covered

# Steering Group, Guideline Development Group and External Review Group
A public hearing was held in advance of the first GDG meeting on the scope of the guideline, as a result of which over 60 contributions were made. The GDG considered the inputs from the public hearing in its deliberations, and broadened the scope of the guideline from the initial list of 10 PICO questions to a final total of 15. The second meeting

# How this guideline was developed 5
-f the GDG took place over three days in December 2017 in Addis Ababa, Ethiopia, to review the evidence summaries and formulate the guideline recommendations.
In developing the evidence to decision tables, the GDG considered the evidence and other elements under consideration, including the magnitude of effects, balance of benefits and harms, costs and cost-effectiveness, implications for health equity, acceptability and feasibility.
In relation to the direction and strength of recommendations, the GDG always attempted to make decisions through discussion leading to a consensus. In most cases it was possible to achieve a unanimous decision through discussion, and no explicit voting was required for the majority of recommendations under consideration. For most recommendations a low or very low certainty of the evidence translated into conditional recommendations. For a few recommendations, the GDG made a strong recommendation despite the low or very low certainty of the evidence, taking into account other factors, including health workers' rights and equity and gender considerations. In the cases where strong recommendations were proposed despite a low or very low certainty of the evidence, the GDG took an explicit vote, the outcome of which is reported in the sections referring to the specific recommendations. In the cases when voting took place, a majority was defined as 80% or above of the voting members in attendance at the GDG meeting.
Following the second meeting of the GDG, the SG prepared a draft of the guideline document, which was reviewed subsequently by the GDG and ERG, revising and improving the draft through an iterative process, before formal submission to the WHO Guidelines Review Committee, which approved the guideline document on 20 June 2018.

# Sources of evidence for guideline
- An overview of the relevant literature was developed through a systematic review of published literature reviews Three main sources of evidence were specifically commissioned in support of the development of this guideline and were considered as the main information basis:

# PICO category Approach Population
Studies that focus on CHWs as defined through specific inclusion criteria were included in the project. This overarching search was applied to all PICOs that were part of this project.
PICO-specific search strings were developed to capture the different interventions included in each of the 15 systematic reviews. Each of these specific search strategies was combined with the overarching search to form the final search strategy for each systematic review topic.
No further search terms were utilized to limit the output to specific comparison conditions. All studies were included irrespective of the comparisons reported.
No further search terms were utilized to limit the output to specific outcomes. Instead, all publications were retrieved irrespective of the outcomes reported.

# Study design
Any study design was included in the 15 systematic reviews. Responses were graded using a 9-point Likert scale (with 9 being the highest level of importance, acceptability or feasibility, and 1 the lowest).

# Systematic review of reviews
An international team based in Johns Hopkins University was selected through a competitive procurement process to conduct the systematic review of reviews. In the aggregate, a total of 137 studies were included in the 15 PICO reviews, out of a total of 87 933 abstracts meeting the initial screening criteria (Figure 3). Some reviews found several dozen articles to be eligible for inclusion, while others did not result in the inclusion of any study. Despite a deliberate attempt to do so, most of the identified studies did not provide sufficient information on the characteristics of CHWs to allow a stratification of the findings and the resulting recommendations  - minimum educational level that is appropriate to the task(s) under consideration;
- membership of and acceptance by the target community;
- gender equity appropriate to the context (considering affirmative action to preferentially select women to empower them and, where culturally relevant, to ensure acceptability of services by the population or target group); - personal attributes, capacities, values, and life and professional experiences of the candidates (e.g. cognitive abilities, integrity, motivation, interpersonal skills, demonstrated commitment to community service, and a public service ethos).
Certainty of the evidence -very low. Strength of the recommendation -conditional.

# Recommendation 1B
WHO suggests not using the following criterion for selecting CHWs for pre-service training:
- age (except in relation to requirements of national education and labour policies).
Certainty of the evidence -very low. Strength of the recommendation -conditional.

# Recommendation 1C
WHO recommends not using the following criterion for selecting CHWs for pre-service training:
- marital status.
Certainty of the evidence -very low. Strength of the recommendation -strong.

# Background to the recommendation
Effective CHW recruitment and selection for pre-service training may improve CHW performance and the quality of services delivered. Selection criteria may vary depending on which sociodemographic characteristics are most relevant to the community or to the intervention being delivered.
For large-scale CHW programmes, criteria considered typically include age, gender, literacy level, educational attainment, marital status and geographical location (31).
The active involvement of the community being served in the recruitment of CHWs is typically assumed to ensure that the CHW is trusted and accepted into the community.

# Rationale for recommendation
The GDG considered the benefits and harms of having selection criteria for enrolment of candidates in pre-service education to become CHWs. The GDG consensus view was that selection of the most appropriate people as CHWs is crucial to the success of a community health intervention.
The choice of criteria to be adopted, however, depends on the evidence of effectiveness, as well as broader policy considerations related to values and preferences, which may vary considerably across different contexts.
Furthermore, the GDG noted that this recommendation touches on a human rights dimension, the fundamental right of equality of opportunity and treatment in employment or occupation (32). The certainty of the evidence was found to be very low (see below). Because of this, the GDG made a conditional recommendation in favour of adopting as selection criteria personal attributes, membership of and acceptance by the community, and appropriate minimum education levels, while recognizing that good practices outside the minimum education levels recommended in this document exist.
No evidence was found on the adoption of age as a selection criterion. Recognizing the risk for misuse resulting in potentially discriminatory policies, the GDG decided on a conditional recommendation against this criterion. As no evidence was found supporting the use of marital status as a selection criterion, but recognizing that it is applied in some settings, the GDG made unanimously a strong recommendation not to use marital status as a selection criterion in order to avoid the risk of discriminatory practices.
Using marital status as a criterion would encroach on human rights relating to access to education and employment opportunities, with the risk of unfair and unnecessary discrimination. The GDG was also concerned that selection based on marital status might perpetuate and exacerbate existing gender disempowerment dynamics.

# Summary of evidence
The systematic review (Annex 6.  (38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50). Ten of them referred to CHW programmes in sub-Saharan Africa, with three studies from South-East Asia and two from the Region of the Americas. All studies referred to experience from low-and lower middle-income countries, except one from the United States of America.
The review identified some evidence that higher levels of education may improve productivity and health knowledge, two essential elements for the provision of efficient and effective services. This may be related to higher levels of literacy enabling quicker and more accurate completion of certain tasks. The findings from quantitative studies were supported by additional insights from qualitative studies that highlighted that more highly educated CHWs were viewed more positively than less educated CHWs when performing potentially difficult tasks. One practice that has been perceived in qualitative studies as probably leading to more positive results is involvement of community members in the CHW selection process. Results seem to indicate that communities may play an important role in determining the success of CHWs. Overall, the certainty of the evidence was rated as very low.
The systematic review of reviews found that CHWs are accepted by communities when community members trust and respect them and feel a sense of ownership over the programme, which can be achieved by giving communities a role in CHW selection and definition of CHW activities (51).
The community's acceptance of CHWs and their sense that the CHW programme is locally appropriate and "owned" is probably associated with increased CHW retention, motivation, performance, accountability and support.
The stakeholder perception survey identified a high acceptability and feasibility of selecting CHWs on the basis of their personal attributes (for example, cognitive abilities and prior relevant experience) and membership of the target communities, but variable and uncertain feasibility and acceptability of selection based on level of education and, especially, age. Where a CHW from outside the community must be selected (for example, because no one from the community wants to perform the task or meets the minimum requirements to serve in that role), ensuring that the community members still have a voice may improve the chances that the CHW will be integrated and that they can more meaningfully help the health organization tailor services to local needs. In addition, community participation in CHW recruitment and selection enables a dialogue between community members and health organizations, helping them understand local issues. The selection process should take into account the values of the inherent community structures. Potential for bias and discrimination should be avoided. In some contexts, preferential selection of female CHWs for the delivery of reproductive, maternal, newborn and child health services may be necessary to ensure acceptability by communities.
Community and end-users may need to take into consideration as selection criteria core values and attributes of the candidates.
The selection criteria should take into consideration acceptability and feasibility, as well as suitability in the local context and in relation to the needs of the end-users of services.

# Background to the recommendation
The effectiveness of CHWs may be affected by the pre-service training they receive (52). Inadequate training may leave CHWs ill equipped to manage health issues and can adversely affect their motivation and commitment (53).
Currently the length of CHW training is not standardized, with its duration ranging from a few hours to several years (54,55). Longer training periods are typically assumed to allow greater exposure to training content designed to enhance knowledge, skills and competence; more comprehensive training, however, may be cost prohibitive, impractical and in some cases unnecessary (56).

# Rationale for recommendation
The GDG approached this question from the perspective of exploring whether an ideal or desirable duration for

# Summary of evidence
The systematic review (Annex 6.  The systematic review of reviews found that CHW training resulted in improvements in CHW knowledge or skills, but that training duration had no consistent effect on the effectiveness of the intervention (16,66). The optimal amount and type of training required by CHWs must be understood in relation to the health system context, the CHWs' pre-existing skills and experience, the status of CHWs, and the roles that they are expected to play (17).
The stakeholder perception survey identified a generic longer duration of training to be acceptable and feasible (without mentioning a specific cut-off point to define longer training).

# Interpretation of the evidence and other considerations by the GDG
The scope and roles of CHWs are varied, hence it is not

# Implementation considerations
The As these vary substantially based on the role that CHWs play, it is expected that CHWs with a polyvalent role and working on a full-time or regular basis (that is, those delivering more complex interventions or a wide range of primary health care services) would require longer training than those providing a single focused service on a more occasional basis. Table 3 provides selected examples of pre-service education that is considered by national policy-makers to be of appropriate duration (typically several months) in relation to the learning objectives of CHWs with a polyvalent role. CHWs with a more limited set of responsibilities have a shorter pre-service education (for example, 23 days for accredited social health activists in India) (67).
- promotive and preventive services, identification of family health and social needs and risk;
- integration within the wider health care system in relation to the range of tasks to be performed in accordance with CHW role, including referral, collaborative relation with other health workers in primary care teams, patient tracing, community disease surveillance, monitoring, and data collection, analysis and use; - social and environmental determinants of health; - providing psychosocial support; - interpersonal skills related to confidentiality, communication, community engagement and mobilization; - personal safety. Additional:
- diagnostic, treatment and care in alignment with expected role(s) and applicable regulations on scope of practice.
Certainty of the evidence -moderate. Strength of the recommendation -conditional.

# Background to the recommendation
Ensuring CHWs have the necessary skills to fulfil their role within the community is essential to making sure they have a positive effect on population health outcomes. However, currently there are no standards as to how CHWs should be trained or how the adequacy of their skills should be assessed (54). Consequently, there is wide variation in the content of training programmes and the assessment of CHWs (52).

# Rationale for recommendation
The GDG recognized that the heterogeneity of roles played by CHWs requires and benefits from considerable flexibility in determining the contents of curricula for pre-service education. The logic underpinning the recommendation was that while roles -and thus competencies requiredmay vary, the general principle, supported by some limited evidence, is that the addition of specific competencies and skills to the curriculum improves the capacity and performance of CHWs to perform the corresponding task(s).
The recommendation was framed as a conditional one, recognizing both the importance of adapting it to national and local context and the moderate certainty and very limited scope of the underpinning evidence.

# Summary of evidence
The systematic review (Annex 6.       also in the education of CHWs, including the potential for broadening the focus of health education to enable health workers to be change agents in the communities they serve (78); the opportunities opened by interprofessional education approaches (79); and the link between locating education institutions and training in underserved areas and the retention of health workers in these settings (80).

# Rationale for recommendation
The GDG intended to provide guidance to inform decisions on appropriate delivery modalities for pre-service education.
The findings of the systematic review were limited in scope, and did not directly compare alternative modalities for the delivery of pre-service education. Therefore, the GDG considered as a basis for the recommendation also the broader evidence emerging from the review of reviews and indirect evidence on health worker education, recognizing the limitations and caveats of applying it to CHWs as well.

# Summary of evidence
The systematic review (Annex 6.4) addressing the question - face-to-face classroom-based didactic teaching;
- interactive teaching elements such as practice demonstration and role play;
- experiential teaching elements such as on-the-job training, expert feedback and supervision.

# Rationale for recommendation
The GDG noted that the very limited evidence points to a positive, though largely untested, potential of formal credentialing of CHWs. While credentialing may in theory negatively impact equity (by limiting the number of CHWs authorized to practise to those awarded a formal licence, thereby restricting access to services), in many contexts it can be a pathway to greater competency of CHWs (and hence improved patient safety through better quality of care). Further, it can enhance credibility, recognition and employability of CHWs. On this basis, the GDG supported a conditional recommendation in favour of formal certification.

# Summary of evidence
The systematic review (Annex 6. A national view on certification was also included in a study from the Islamic Republic of Iran, where certification is the norm and is required to achieve employment as a CHW (75).
In a fourth study, from Ethiopia, certification was one among many topics discussed with interviewees who represented a scoped community mobilization project (98).
The evidence included in these studies points to potential, but untested, benefits from certification processes related to the motivation, morale and self-esteem of CHWs, as well as their retention, professional development and advancement. The  - coaching and mentoring of CHWs;
- use of observation of service delivery, performance data and community feedback;
- prioritization of improving the quality of supervision.
Certainty of the evidence -very low. Strength of the recommendation -conditional.

# Background to the recommendation
The importance of adequate supervision of CHWs is well recognized. International evidence suggests that regular and systematic supervision, with clearly defined objectives, can improve the performance of CHWs involved in primary health care (100-102). Supportive supervision that targets and measures knowledge and skills, motivation, and adherence to correct practices provides incentives that positively impact performance (103). There is also emerging evidence suggesting that employing mobile phones, including for better supervision, can improve health care delivery in resourcelimited settings (104).
A typical challenge however is a lack of resources to provide a supportive supervision and environment to optimize the capacity of CHWs (21,105,106). It is essential to streamline the supervision process by identifying effective strategies and including them in the implementation of interventions.

# Rationale for recommendation
The evidence retrieved and analysed for the purpose of this guideline reiterated the importance of supportive supervision and identified a number of supervision strategies in the context of different programmes and initiatives. However, the studies typically did not compare specific supervision strategies against others in terms of effectiveness, costs, acceptability, feasibility or other outcomes. The GDG therefore provided indications on core approaches (reflected in the recommendations) and additional strategies (mentioned under the implementation considerations) based on their expertise, and taking into account the models that emerged from the review of the evidence. In light of the very low certainty of the evidence and the need to adapt supervisory strategies to the requirements of different contexts, this recommendation was a conditional one.

# Summary of evidence
The systematic review (Annex 6.6) on the question -"In The systematic review team rated the overall certainty of the evidence as very low.
The systematic review of reviews found several studies confirming the critical importance of supportive supervision to enhance CHW quality, motivation and performance (13,51,(121)(122)(123)(124)(125). However, it similarly found very limited evidence on which supervisory approaches work best. Supervision that focuses on supportive approaches, quality assurance and problem solving may be most effective at improving CHW performance (as opposed to more bureaucratic and punitive approaches) (17,105,126).
Improving supervision quality has a greater impact than increasing frequency of supervision alone (105).
The stakeholder perception survey identified most supportive supervision strategies (including coaching, observation at community and facility, community feedback, and supervision by trained health workers) to be acceptable and feasible, but lower levels of acceptability and especially of feasibility were identified for direct supervision of service delivery and supervision conducted by other CHWs.

# Implementation considerations
In addition to the supportive supervision approaches mentioned in the recommendation, additional options, to be considered as relevant to the local context, might include:
- use of supervision tools such as task checklists as part of a coaching process, while ensuring they also allow qualitative monitoring and interpersonal engagement;
- peer support and supervision by senior, experienced CHWs;
- expert support and supervision conducted by a multidisciplinary team, incorporating as relevant mechanisms for community feedback. Certainty of the evidence -very low. Strength of the recommendation -strong.

# Recommendation 7B
WHO suggests not paying CHWs exclusively or predominantly according to performance-based incentives.
Certainty of the evidence -very low. Strength of the recommendation -conditional.

# Background to the recommendation
The use of incentives for CHWs has been proposed as a means of improving health outcomes, and varying combinations of monetary and non-monetary incentives have been explored in different settings with varying degrees of success (127).
The provision of incentives has a direct impact on the effectiveness and sustainability of a health programme. It is normally assumed that it improves service delivery through enhanced employee motivation and reduced attrition (127).

# Rationale for recommendation
The GDG approached this question from the perspective of exploring whether practising CHWs should be offered a financial package for their work and, if so, of which type.
Despite the overall assessment of very low certainty of the evidence, the majority of reviewed studies were supportive of providing CHWs with a financial package. The GDG considered in its decision-making process also broader criteria, including best practice in relation to labour rights and legislation. This is crucial to align health policy to the broader international agenda on decent work, which entails opportunities for work that is productive and delivers a fair income; security in the workplace and social protection for families; better prospects for personal development and social integration; freedom for people to express their concerns, organize and participate in the decisions that affect their lives; and equality of opportunity and treatment for all women and men (129). The GDG was particularly concerned that models that rely on voluntary CHW work are inconsistent with the international agenda on decent work, and particularly with Sustainable Development Goal (SDG) 8, promoting decent work and economic growth. As most CHWs globally are female, the GDG was also concerned that continued reliance on voluntary work could perpetuate gender disparities in access to employment and income opportunities, and be inconsistent also with SDG 5 -"Achieve gender equality and empower all women and girls" (130).
On this basis, the GDG voted by an overwhelming majority (18 to 1) in favour of a strong recommendation to provide a financial package to practising CHWs, despite the recognition of the very low certainty of the evidence.
The GDG did not recommend a specific form of remuneration (see sections below), but since evidence regarding a specific form of financial package (performance-based incentives) identified some evidence of potential harm, it also made a conditional recommendation against adopting financial packages based exclusively or predominantly on this particular form of incentive.

# Summary of evidence
The systematic review (Annex 6.  Delineating more specifically this distinction should remain the prerogative of authorities within specific jurisdictions.
The GDG noted that, irrespective of direct provision of a financial package for their work, all CHWs and volunteers should be compensated to cover expenses incurred in delivering services according to their roles.
The GDG noted the importance of non-monetary incentives, but noted also that they should not be seen as a substitute for the provision of a financial package, and, conversely, that the provision of a financial package should not be seen as a substitute for non-financial incentives, such as a conducive and respectful work environment, and opportunities for professional development and career advancement.
As most of the concerns emerging from the literature regarding payment of CHWs referred in reality to one particular form of payment (performance-based incentives), the GDG opted for isolating this particular form of payment from the overall recommendation and having a dedicated recommendation focused on it.

# Implementation considerations
The provision of a financial package to CHWs could take different forms (salary, stipend, honorarium, monetary incentives), in accordance with the employment status and applicable laws and regulations in the jurisdiction.
Countries should consider the financial package to remunerate CHWs as a part of the overall health system planning, and adequate resources should be made available to implement this recommendation through the mobilization and prioritization of the required resources.
In addition to the financial package, the provision of non-monetary incentives should also be considered to improve the performance of CHW programmes.
While the GDG cautioned on the adoption of performancebased incentives as the only or predominant mechanism of payment for CHWs, its continued application in contexts where it is well established and found to be effective could be accompanied by dedicated efforts to mitigate the known and potential shortcomings of these mechanisms.

# Recommendation 8: Contracting agreements Recommendation 8 WHO recommends providing paid CHWs with a written agreement specifying role and responsibilities, working conditions, remuneration and workers' rights.
Certainty of the evidence -very low. Strength of the recommendation -strong.

# Background to the recommendation
Because CHWs work at the interface of community and formal health care systems, their role and identity within the health care structure has historically lacked clarity (21). The importance and impact of CHWs with regard to health care delivery are generally well recognized and acknowledged within the sector. However, contracts and agreements have the potential to explicitly and formally determine the responsibilities that CHWs should fulfil, as well as the rights and benefits they are entitled to, and they could represent a tool to more formally integrate CHWs into the health care system. Formal contracts in this context are defined as written agreements specifying CHW working conditions and rights, job responsibilities, duration of employment and remuneration terms.
It is assumed that contracts can serve as an incentive and contribute to job stability and security, and enhance occupational protection and safety. Furthermore, formal contracts set the groundwork for professional development, as they typically require or encourage employers to support professional development opportunities and supervise workers (147). The advantage for the health system is provision of a basis for CHW accountability.

# Rationale for recommendation
The GDG noted the limited evidence supporting the effectiveness of formal contracts in improving the performance of CHW programmes. While the evidence was of very low quality, the GDG considered that some form of written agreement is essential in upholding workers' rights  The systematic review of reviews found no evidence of direct relevance to the policy option under consideration in this question.
The stakeholder perception survey found that formal contracting of CHWs by the health system was both acceptable and feasible.

# Interpretation of the evidence and other considerations by the GDG
The GDG interpreted the limited evidence supporting the effectiveness of contractual arrangements to formalize the role of practising paid CHWs in the broader context of the significance and implications of formal agreements for labour relations and workers' rights. The GDG also concluded that formal contracts for paid CHWs could be instrumental in improving motivation and retention.
The GDG also noted the importance of consistency of the guideline, externally with broader labour rights frameworks, and internally among different recommendations; in particular, the formalization of rights, responsibilities and working conditions covered by this recommendation reinforces and is complementary to the recommendations on certification (recommendation 5), remuneration (recommendation 7)
and career advancement (recommendation 9).

# Implementation considerations
This recommendation only applies to paid practising CHWs.
Formal contracts or any type of binding agreements should not be adopted in the case of volunteer CHWs.
The contractual arrangements, which may apply to both public sector and private employers, should reflect applicable regulatory and legislative frameworks in the jurisdiction.
In particular, the precise terminology may need adaptation, considering that the term "contract" entails specific obligations in some contexts that could inadvertently hinder or deter the institutionalization of CHWs. Ultimately the application of the recommendation will be beneficial as long as a binding written agreement specifies roles, responsibilities, rights and working conditions, including remuneration, of CHWs.

# Background to the recommendation
Providing health workers with a career ladder (that is, opportunities for progressive advancement to higher-level positions in a health system, or upgrading skills and expanding roles) is universally seen as a good practice to reinforce both motivation and retention. This policy issue is particularly relevant for CHWs (151), as retention of these workers is problematic due to a variety of factors (152, 153).
The policy question revolves around whether providing career opportunities for CHWs to retrain or upskill can enable them to more effectively meet community health needs and can positively influence job satisfaction and retention.

# Rationale for recommendation
The GDG, despite the minimal evidence directly addressing this question, provided a recommendation based primarily on its members' expertise and on broader good practice in human resources and health workforce management.
The GDG was of the view that the benefits of offering CHWs a career ladder after some years of satisfactory service can potentially include improved motivation and job satisfaction, contributing to increased retention and reduced attrition.
The GDG concluded that these benefits outweigh potential shortcomings linked to depleting the pool of practising CHWs, and, on the contrary, that career ladder schemes and frameworks can contribute in a positive way to upward social mobility aligned to the Decent Work Agenda.
On this basis, while considering the minimal supporting evidence, the GDG adopted a conditional recommendation in favour of providing CHWs with a career ladder framework.

# Summary of evidence
The systematic review (Annex 6.9) addressing the question - The results demonstrated that providing career progression as an incentive for recruitment of CHWs increased the recruitment of higher-calibre and more ambitious CHWs, who had a statistically significant better performance in terms of clinic utilization, home visits, household behaviours and child health outcomes. There was no difference in retention at 18 months between the two groups.
The systematic review of reviews found that opportunities for career advancement are one of several important non-financial incentives that can improve CHW motivation, although this was most often a conclusion of the authors of the reviews rather than a statement based on evidence of effectiveness (17,51,121,123,144,145).
The stakeholder perception survey found that offering CHWs a career ladder opportunity is acceptable, but its feasibility might be variable across different contexts.

# Interpretation of the evidence and other considerations by the GDG
The GDG interpreted the lack of evidence on this aspect as a reflection of the limited availability of career ladder opportunities for CHWs in most settings, resulting, correspondingly, in the absence of formal evaluation of such (non-existing) schemes. The broader evidence from the systematic review of reviews, and the high level of acceptability according to the stakeholder perception survey, should be interpreted as a strong interest by policy-makers and CHWs to better align CHW policies with best practices in human resources management, including through the provision of career advancement opportunities. The different educational attainment levels, qualifications, certification status and roles of CHWs imply, however, varying levels of feasibility of adoption of this policy option.

# Implementation considerations
The availability and definition of career ladder opportunities should be embedded in CHW programme design from the outset. The prerequisites for eligibility for further education and career development may need to be linked with selection criteria for entry into pre-service education (see recommendation 1), duration and content of pre-service education (recommendations 2 and 3) and formal competency-based certification (recommendation 5).
If compatible with the pre-existing education level, offering

# Rationale for recommendation
The GDG recognized the importance of determining an appropriate target population size to maintain a realistic workload and optimize CHW performance. Given the wide variance in CHW roles, the GDG felt the recommendation should focus on the factors that should be taken into account at the national level in setting the optimal target population size. The certainty of the evidence was very low, hence the conditional recommendation.

# Recommendation 10: Target population size
Recommendation 10 WHO suggests using the following criteria in determining a target population size in the context of CHW programmes. Criteria to be adopted in most settings:
- expected workload based on epidemiology and anticipated demand for services;
- frequency of contact required;
- nature and time requirements of the services provided;
- expected weekly time commitment of CHWs (factoring in time away from service provision for training, administrative duties, and other requirements); - local geography (including proximity of households, distance to clinic and population density). Criteria that might be of relevance in some settings:
- weather and climate;
- transport availability and cost;
- health worker safety;
- mobility of population;
- available human and financial resources.
Certainty of the evidence -very low. Strength of the recommendation -conditional.

# Summary of evidence
The systematic review (Annex 6.10) on the question -"In

# Interpretation of the evidence and other considerations by the GDG
The variability of the evidence points to widely differing practices in determining the target population size and workload of CHWs, resulting in some programmes already stretching CHW capacities to their limits, while in other settings an additional workload can be accommodated without compromising quality and, conversely, improving cost-effectiveness. This variability in baseline situations, as well as in roles, responsibilities and levels of effort of CHWs, prevents setting global benchmarks on workload or appropriate population targets. Rather, the evidence points to the need to identify realistic and context-specific benchmarks.
In doing so, some criteria will be universally relevant (such as expected caseload based on local epidemiology, frequency of contacts required, level of time commitment by CHWs)
(163), while others will be particularly relevant only or mostly in certain contexts (such as factors relating to geographical accessibility of the catchment area, availability of transport, distance to clinic, and population density).

# Implementation considerations
Planning for catchment areas for CHWs, including the optimal size and geographical distribution of their target population, should occur as part of an approach considering the health workforce as a whole, and in alignment with overarching national health strategies (1). Adaptations to routine staffing standards and structures may become necessary in the situations or context of acute onset or protracted emergencies, as these may influence both population demand and need for services, as well as the capacity of other health workers to provide them.

# Background to the recommendation
While the collection of data by CHWs can serve a variety of purposes -for example, surveillance or researcha key objective of routine data collection is service delivery improvement. Data collection and use is an integral part of continuous quality improvement approaches that have proven effective in improving outcomes across a range of settings (164-167). Within practice improvement, data generated through CHW practice are collected for several purposes, including:
- for monitoring service delivery to enable adjustments and identify programme requirements (for example, stockouts, epidemiological trends, human resource needs) so that the service meets the needs of recipients;
- for engaging communities in finding local solutions to identified problems;
- for supervising and supporting CHWs to build their knowledge, competencies and skills for the benefit of service recipients.
For the latter purpose, the inherent assumption is that enhanced expertise and skills will translate into improved service delivery, thereby improving the outcomes of community health interventions. Data collection by CHWs is a potentially meaningful yet still underresearched pathway towards improving community health services (14). This potential should be balanced with data ownership, access and individual patient confidentiality issues.

# Rationale for recommendation
The GDG noted that most published evidence supports a role for CHWs in data collection and use, and this finding is consistent with the broader literature on health information systems and quality improvement. As the evidence base is characterized by a low level of certainty and considering that the most appropriate strategies may vary by context, the GDG adopted a conditional recommendation in favour of the policy option under consideration. Recognizing the potential pitfalls of overburdening CHWs with data collection tasks, the GDG focused on identifying enablers for successful CHW contributions to data collection, collation and use.

# Summary of evidence
The systematic review (Annex 6.11) on the question -"In  Little information was provided on how data collection processes were integrated into supervision, coaching and comparable activities aiming to support CHWs in their work.
Interviews with international experts and stakeholders concluded that retention and attrition of CHWs could potentially improve if they more meaningfully engaged with the data they collect. The researchers suggest that this could involve CHWs collecting and analysing data and applying it to their work environment, CHW supervisors providing more support for the data collected by CHWs to be actively used in professional development, and letting the data collection feed into tools for use by the community (170).
The systematic review team rated the overall certainty of the evidence as very low.
The systematic review of reviews identified one review suggesting that there were cost savings of 24% when CHWs collected data using personal digital assistants compared to when they used traditional manual methods of data collection and transmission (104).
The stakeholder perception survey found involvement of CHWs in data collection and use to be both acceptable and feasible.

# Interpretation of the evidence and other considerations by the GDG
Taken together, the findings of these studies point to potential community health service benefits -across a broad range of outputs and outcomes -associated with data collection by CHWs.
The GDG was aware of potential drawbacks not highlighted by the literature, including distracting CHWs from their service delivery, illness prevention and health promotion tasks; generating data collection fatigue if collected data are not utilized and understood; risks to confidentiality and data security; and the risk of moral hazard and misreporting or overreporting when data production and provision are linked to performance-based incentives and other income-generating activities.
Overall, the GDG concluded that there may be more benefits

# Background to the recommendation
The effective delivery of primary health care services can benefit from multidisciplinary and interdisciplinary teamwork, making it necessary for health care professionals to work in well functioning teams and according to an optimal distribution of roles and tasks in relation to skills (1,180).
CHWs are often trained unimodally to specialize in the care of a single patient condition, such as diabetes or HIV (181,182). There are examples where CHWs have been integrated, using various approaches and with varying levels of success, in primary care teams to deliver a broader range of services, though often with a predominant focus on reproductive, maternal, newborn, child and adolescent health services (183-186).

# Rationale for recommendation
This policy question stood out for the lack of eligible evidence in both the specific systematic review addressing this question and in the systematic review of reviews. The GDG had therefore to rely exclusively on indirect evidence emerging from other reviews and the broader literature, and the expertise and capacity within the GDG.
The GDG noted the availability of evidence demonstrating the effectiveness of both models -one in which polyvalent CHWs perform a relatively broad range of functions, and another
where CHWs have been trained to deliver a single service or a set of preventive, promotive, treatment or care services related to a single disease or cluster of diseases.
Adopting an integrated and person-centred approach to primary health care (187), however, requires a health workforce configuration whereby health workers operating as first point of contact of the health system possess a relatively broad set of skills to enable them to better respond to population needs and demands for services, or refer them to the appropriate level of care when they are unable to do so directly. On this basis, the GDG recommended that, in settings where the health workers operating at the front line of service delivery are CHWs, they should possess a polyvalent profile, enabling them to deliver a range of priority primary health care services. Recognizing that some settings may present particular epidemiology situations, cultural contexts or health system requirements, the addition of more specialized CHWs, with clear division of roles vis-a-vis polyvalent CHWs, should be considered when aligned with public policy objectives and instrumental to the attainment of population health goals.
The lack of underlying evidence on types of CHWs and the need for adapting related measures to country contexts led the GDG to the adoption of a conditional recommendation.

# Summary of evidence
Neither the specific systematic review (Annex 6.12)
addressing this question -"In the context of community health worker (CHW) programmes, should practising CHWs work in a multi cadre team versus in a single cadre CHW system?" (188) -nor the systematic review of reviews, found any studies eligible for inclusion of direct relevance to this question.

# Interpretation of the evidence and other considerations by the GDG
The GDG noted that the lack of evidence on this policy question can be understood in the context of studies typically focusing on analysing the experience of a CHW programme or initiative (be this national in scope or a small pilot), but rarely comparing different initiatives as alternative models against one another. Evidence of effectiveness exists on both monovalent CHWs and polyvalent CHWs delivering a broader range of primary health care services. The GDG was also aware that overburdening CHWs with an unrealistic set of expectations might lead to deteriorating quality of services and attrition due to burnout.
With the objective of supporting an integrated service delivery model responsive to population expectations, the GDG was of the view that the default option for policy-makers in settings
where CHWs are expected to play a significant role in service provision is to adopt a model of polyvalent CHWs, who can understand community needs and provide services according to a holistic perspective and a well defined set of roles and tasks. Conversely, a model based exclusively on specialized CHWs might carry risks of fragmentation of care, resulting in gaps in service provision and inefficiency.
CHWs specialized in the delivery of a single task or narrower set of functions should be considered as an addition to a primary health care team comprising polyvalent CHWs in settings where the epidemiology and local service delivery and workforce configuration make such a policy choice appropriate.
CHWs operating on a volunteer basis or those drawn from patient groups to provide services to people affected by the same condition may more commonly serve as CHWs focusing on a single or few service area(s).

# Implementation considerations
The definition of the role and typology of CHWs should be part of a broader public policy perspective considering the health system and health workforce planning as a whole. The entry point for exploring policy options around which typologies of CHWs may be more appropriate in a given context should be a population and health workforce needs assessment. The process to define the need and opportunity for CHWs as part of the primary health care team should also take into account acceptability by communities that will be served, as well as by other professional and associate professional health workers.
The definition of the roles and typology of CHWs is an essential planning function, which should in turn inform other elements covered by recommendations in this guideline, including population target size, selection criteria, education and accreditation requirements.

# Recommendation 13: Community engagement Recommendation 13 WHO recommends the adoption of the following community engagement strategies in the context of practising CHW programmes:
- pre-programme consultation with community leaders;
- community participation in CHW selection;
- monitoring of CHWs;
- selection and priority setting of CHW activities;
- support to community-based structures;
- involvement of community representatives in decision-making, problem solving, planning and budgeting processes.
Certainty of the evidence -moderate. Strength of the recommendation -strong.

# Background to the recommendation
Community engagement is increasingly recognized and supported by policy-makers as a valued component of health programmes. The term "community" may refer to the general population living in a defined geographical area (whether rural or urban), or to a specific population subgroup requiring targeted support (for example, people with a certain health condition or breastfeeding mothers). Community engagement interventions have been deemed effective in achieving a range of health-related goals, with a positive impact on health behaviours, health literacy, self-efficacy and perceived social support for vulnerable populations (189)(190)(191).
However, the lack of a standard and agreed-upon definition

# CHW project evaluation and oversight
Involving community members in decision-making, quality improvement and evaluation, e.g. participatory evaluation meetings Establishment of a village health committee for project and CHW oversight broadly (189,192,193). This in turn creates substantial challenges for comparing community engagement and its effectiveness across different health outcomes and contexts; particular forms and mechanisms of community engagement may be more or less effective depending on the focal outcome to be achieved, the population, and the sociostructural context. In addition, there are known risks that the voice of a community, however defined, is captured by some interest groups or individuals pursuing personal interests.

# Rationale for recommendation
The GDG considered the benefits and harms of having community engagement activities as part of CHW programmes. Based on evidence available and its own expertise, the GDG consensus view was that community engagement is a key community health intervention that should be part of CHW practicum and activities.
The certainty of the evidence was found to be moderate by the systematic review team, but the potential impact, including on reduction in inequalities, was considered very important. Moreover, the GDG could not identify any meaningful risk or drawback of community engagement activities. Therefore, the GDG adopted unanimously a strong recommendation in favour of adopting community engagement in CHW programmes.

# Summary of evidence
The systematic review (Annex 6.13) on the question -"In the context of practising community health worker (CHW) programmes, are community engagement strategies effective in improving CHW programme performance and utilisation?" (194) -identified 43 eligible studies (12 quantitative, 25 qualitative and six with mixed methods) from all six WHO regions, but with a predominance of studies from the African and South-East Asia Regions, and only one study each from the Region of the Americas and the European Region.
A variety of community engagement strategies were employed across studies, with many studies using more than one strategy. Table 5 presents a categorization of strategies identified in the literature.
Evidence shows that community engagement strategies may be effective in improving CHW performance and utilization.
Most quantitative, qualitative and mixed methods studies indicated that a range of community engagement strategies have beneficial impacts on CHW performance outputs, including CHW motivation, commitment, satisfaction and retention (39,134,(195)(196)(197)(198)(199)(200)(201)(202)(203)(204)(205)(206). Community engagement strategies were also found to have beneficial impacts on CHW performance outcomes, including community trust of CHWs and community awareness, support and sense of ownership of CHW programmes. Three RCTs indicated that community engagement strategies are effective in increasing CHW programme impact at the population level, all in the domain of maternal and child health outcomes among rural communities in low-and middle-income countries (70,71,207).
Some community engagement strategies employed were implemented before programme development and roll-out, including pre-programme consultation with community leaders (43,(208)(209)(210)(211)(212) and meetings to sensitize the community about an impending intervention, led by community leaders or members (213)(214)(215). Other strategies were implemented throughout the programme in engagement of community members in implementation (216)(217)(218)(219)(220)(221) or represented an ongoing evaluation and oversight of the CHW programme (222)(223)(224)(225).
Across all studies, the single most prevalent community engagement strategy described was community participation in nomination or selection of CHWs (see also recommendation 1), which emerged across multiple studies as a factor in improving CHW performance and utilization (46,133,(226)(227)(228)(229)(230).
The community engagement strategies also emerged as reflecting different levels of power afforded to community members, though it was difficult to assess this dimension from the descriptions provided in the majority of studies.
Limited evidence suggests that addressing existing social and gender hierarchies, and taking into account health care system limitations, may support the effectiveness of community engagement strategies in CHW programmes. -though some studies report both. Cautionary evidence emerged with respect to the potential for this mechanism of community engagement to create tension with and within local authorities and other stakeholders.
Finally, the systematic review identified evidence suggesting that community engagement strategies support increased health equity, with improved child and maternal health outcomes among vulnerable populations in low-income settings, and beneficial effects of community engagement strategies in CHW programmes specifically designed for vulnerable populations (for example, ethnic minorities, immigrants, poor and rural communities) that experience health disparities.
The systematic review of reviews showed that community embeddedness is an important enabler of CHW retention, motivation, performance, accountability and support, and ultimately of the acceptability and uptake of the health-related work of CHWs. It identified four reviews documenting specific approaches to foster community embeddedness (17,51,87,124):
- community members being involved in CHW selection and selecting a locally admired and trusted person;
- community having a clear understanding of and reasonable expectations for their CHW;
- community monitoring of CHWs;
- community ownership of the CHW programme;
- community involvement in selection of activities and priority setting of CHW work;
- health system back-up of the CHWs with supervision, supplies and support, which in turn helps to maintain community trust in CHWs.
The systematic review of reviews also identified one review suggesting that CHW embeddedness can lead to CHWs being caught in tensions between the community and the health system (231).
The stakeholder perception survey found that community engagement strategies had both high acceptability and feasibility.

# Interpretation of the evidence and other considerations by the GDG
The GDG was of the view that community engagement is a priority in CHW programmes. However, the GDG considered that the diversity of community engagement strategies means that programme planners and policy-makers should pay specific attention to the variety of options available. Policy-makers and planners should select the ones that are most relevant in relation to the scope and nature of the CHW programme under consideration. Different community engagement strategies that had supporting evidence bases were discussed by the GDG and included in the final recommendation.

# Implementation considerations
The systematic review found a broad range in the type, intensity and scale of community engagement strategies, suggesting these interventions are feasible to implement.
However, it also identified qualitative studies pointing to possible challenges that warrant specific mitigation strategies.
- Attempts to implement community engagement strategies may be subverted by local stakeholders during the CHW nomination and selection process, thereby reinforcing inequitable power relations and alienating local communities. Proactively seeking large participation, inclusive of all components of the community, with specific activities targeting disadvantaged groups, should therefore be considered.
- In the case of highly stigmatized diseases (such as HIV), community engagement interventions may pose perceived threats of inadvertent status disclosure in local communities (for example, calling attention to HIV in the household). Community engagements strategies need to be adapted to ensure non-discrimination of the target group as a result of the activity. In order to avoid discrimination, mainstreaming key community engagement strategies as part of regular CHW work might be required in some situations.
- Community engagement strategies may increase CHW programme utilization and perceived benefits beyond what available health system infrastructures can support. Investments in CHW programmes that comprise community engagement strategies need to be planned as part of a comprehensive and participative health system strengthening approach at community level.
These challenges underscore the importance of adapting policies on community engagement in CHW programmes as a particular form of health intervention; and, secondly, the importance of assessing possible variability in the effectiveness of community engagement in CHW programmes as a function of the focal health conditions, populations and contexts of these programmes.

# Recommendation 14. Mobilization of community resources
Recommendation 14 WHO suggests that CHWs contribute to mobilizing wider community resources for health by:
- identifying priority health and social problems and developing and implementing corresponding action plans with the communities;
- mobilizing and helping coordinate relevant local resources representing different stakeholders, sectors and civil society organizations to address priority health problems; - facilitating community participation in transparent evaluation and dissemination of routine community data and outcomes of interventions;
- strengthening linkages between the community and health facilities.
Certainty of the evidence -very low. Strength of the recommendation -conditional.

# Background to the recommendation
CHWs are most frequently members of the communities they serve, and therefore have deep knowledge and experience of their community cultures and languages (232). Given their in-depth knowledge of local systems, CHWs are in a unique position to act as agents of change by mobilizing communities and additional resources for action to address health issues. Previous authors have conceptualized the CHW role as that of "change agents, empowering individuals, their community, and themselves" (233).
Community mobilization is a process of raising a community's awareness of an issue and involvement in identifying and activating resources and leadership to address it. Community mobilization has long been recognized as a critical strategy for improving health outcomes, and there exists a rich body of literature evidencing successful mobilization on a range of health issues (234)(235)(236)(237). CHWs are uniquely suited to engage communities and lead community mobilization efforts by identifying and recruiting additional resources for health, working with communities to identify health priorities, and mobilizing key stakeholders. However, previous reviews of literature examining the tasks that CHWs perform provide little evidence of CHWs being conceptualized as community mobilizers (17).

# Rationale for recommendation
The GDG noted that the evidence found on this question suggests, but does not provide conclusive evidence of, a positive potential for a role for CHWs in mobilizing community resources for health. No known or theoretical risks arising from such activities were identified through the review of the evidence and the GDG discussions. As the evidence was extremely limited in volume and scope, and characterized by a very low level of certainty on the effects, the GDG adopted a conditional recommendation in favour of the policy option under consideration.

# Summary of evidence
The systematic review (Annex 6.14) on the question -"In the context of community health worker (CHW) programmes, should practising CHWs mobilize wider community resources for health versus not?" (238) -identified as eligible for inclusion two studies (one quantitative, one qualitative), conducted in India and the United States.
One study (239) reported on the quantity of mobilization activities delivered among CHWs who received a health leadership training intervention, finding that CHWs who participated in the training self-reported that they engaged in a "change agent role" at a significantly higher level across multiple mobilization activities than non-trained CHWs in a national sample. For example, trained CHWs were more likely than non-trained CHWs to report that:
- CHWs engaged community members to identify people who influence change;
- community-engaged interventions had an impact on local health and social parameters;
- CHWs and the community engaged in sustainability efforts.
However, trained CHWs were no more likely that non-trained CHWs to report that they engaged the community in initial problem identification efforts.
The other study (240) used ethnographic data to compare a CHW programme at two points in time: first, when it was initially implemented by a nongovernmental organization through CHWs who had a role in community mobilization;
and second, after intervention management was transitioned to government, and the role of CHWs was reframed as peer educators. The loss of the community mobilization role led to diminished credibility with the community and loss of motivation by CHWs.
The systematic review team rated the overall certainty of the evidence as very low.
The systematic review of reviews found no reviews of direct relevance to this policy question.
The stakeholder perception survey found CHW activities in mobilization of community resources to be both acceptable and feasible.

# Interpretation of the evidence and other considerations by the GDG
The general lack of specificity regarding the role of CHWs in mobilizing communities poses difficulties in determining which activities are considered as "mobilization". For the purposes of this guideline, "mobilization" is interpreted as a two-way process of empowering communities to take

# Background to the recommendation
Supply chain bottlenecks affect the access of CHWs to essential supplies and medications, placing vulnerable client populations at further risk. Poor supply chain management, including limited or non-existent stock control and forecasting, means that even though drugs may be available centrally, there can be frequent stock-outs at the community level. Various strategies have been adopted to better train and equip CHWs to ensure availability of supplies. However, despite various strategies to improve stock supply, there are many challenges, such as community remoteness and erratic data management.

# Rationale for recommendation
The GDG noted that the included studies identified several strategies likely to be associated with improved supply chain management processes and outputs. As the certainty of the evidence was low, the GDG adopted a conditional recommendation in favour of these strategies. Factors associated with improved supply systems according to the included studies were as follows.
- Adequate supervision. Supervisors were noted to have additional duties involving the review of CHW registers and cross-checking of drug inventories in order to make sure supplies are routinely and adequately replenished.
This helps reinforce CHW competencies regarding drug use (244).
- Correct prescriptions. Having appropriate prescriptions leads to a more accurate and reliable drug resupply for CHWs (244).
action for health, and community involvement is therefore seen as a key criterion (241,242). The resulting paucity of specific evidence limited the conclusions that could be drawn. Therefore, this recommendation is based, to a large extent, on the GDG's view on the potential benefits of CHW involvement in community mobilization efforts.

# Implementation considerations
Evidence from the two studies indicates that community mobilization activities require a unique skill set that is substantively different from that of providing health promotion and clinical services. For CHWs to proactively design and implement community mobilization tasks, they must evidence leadership skills and the ability to strategically champion cooperation between communities and stakeholders. Most typically, CHWs would perform these functions by contributing to wider efforts by multidisciplinary primary care teams.
Successful implementation of community mobilization activities requires forging collaborative relations with local leaders and authorities and recognition by other health workers of the role of CHWs in these tasks.
- Regular reporting. CHWs received a more regular replenishment of drugs when they submitted monthly drug reports on time compared to those who did not submit reports on time or at all (245,246).
- Diagnostic tool availability. Availability of diagnostic tools for CHWs also improved drug resupply (247).
Broader strategies identified across these studies as enablers to improve the availability of commodities and supplies included adequate compensation, appropriate training and feedback, team quality improvement meetings and an enabling work environment.
Evidence from several mixed methods studies showed that mHealth was well supported and effectively used by CHWs.
Phone-based systems improved communication, enhanced supply chain management, and enabled sharing of medicines between CHWs (248,249). MHealth was also found to contribute to more timely and complete reports and to aid supervision of CHWs (155,177,250). The systematic review team rated the overall certainty of the evidence as low.
The systematic review of reviews found evidence suggesting that regular provision of logistical support and supplies (such as drugs and educational materials) is essential to maintain CHW programme effectiveness, productivity, and respect for CHWs by the community. In addition, mHealth was found to be a potentially valuable job aide for noting drug adverse effects, confirming dosage amounts and improving medical knowledge (13,17,124,(251)(252)(253).
The stakeholder perception survey found various strategies for strengthening the supply chain for CHWs to be both acceptable and feasible, with the exception of the use of social media distribution aid, for which the acceptability and feasibility were rated as more uncertain.

# Interpretation of the evidence and other considerations by the GDG
The GDG recognized that an effective supply chain for CHWs is one of the critical factors that represent a precondition for effective service delivery. It also noted the absence of waste management from the literature identified. The GDG was of the view that extending to CHW programmes the national supply chain (as opposed to setting up a separate independent one) represents a key element of health system integration and sustainability.

# Implementation considerations
To ensure appropriate implementation of the identified strategies, and to avoid fragmentation into parallel competing supply chains, relevant CHW commodities should be included in the national pharmaceutical supply plan or equivalent national supply chain plan. Mechanisms to replenish and replace the equipment and supplies of CHWs vary, but any national distribution systems of commodities should address the needs of CHWs on the ground, based on reliable data and forecasting.

# Simplified stock management tools and visual job aides for
CHWs that accommodate low literacy with minimum data points may be instrumental to facilitate recording of data, adequate storage (including keeping perishable supplies at the right temperature), mapping and monitoring for early warning and resupply.
The pre-service education curriculum for CHWs should include, beyond diagnostic and clinical competencies for correct prescriptions, capacity for basic storage, stocking, quality assurance and waste management for essential medicines and supplies, including basic elements of personal safety when handling hazardous supplies (for example, to prevent needle-stick injury).

# Research priorities and guideline update
Every effort has been made to ensure that the policy recommendations contained in this guideline are informed

# Selection, education and certification
To improve CHW selection strategies, more research is needed that specifically assesses which recruitment criteria are most effective for producing improved outputs and outcomes.
Rigorously testing of whether and how community selection improves outputs and outcomes is also required.

# Implications for non-health development outcomes
The research identified was entirely focused on various health-related outcomes. As some of the recommendations highlight, however, policy and investment decisions on health workers have broader implications on several other targets of the SDGs, including job creation, economic growth, gender empowerment and education. There are untapped opportunities for future research to expand the evidence base on some of these aspects, including whether expectations of employment

# Future research and guideline update
Recognizing the potential for additional research to modify and strengthen the evidence base that informed the development of this guideline, the need and opportunity for a potential update will be considered five years after publication.
In calling for additional research on the topic, it is important to recognize that, while more methodologically robust evidence is needed, it is probably unrealistic to envisage that there would be large-scale RCTs to address from a pure effectiveness perspective all the persisting evidence gaps. Furthermore, RCT design is relatively unhelpful in providing insights into the dynamics of complex programmes. More useful would be comprehensive, critical programme case studies.
It is necessary to avoid too narrow a focus on intervention- To ensure that the most relevant and appropriate entry points are identified and guidance on uptake and implementation are effective, the messaging will be tailored to groups of countries as follows:
- countries that already have CHW policies that are aligned with the new guideline;
- countries that already have CHW policies that are not necessarily aligned with the new guideline;
- countries that do not have policies regarding CHWs.
Advocacy, communications and engagement activities will target three groups of stakeholders.
- Primary target audience. The primary target audience of this strategy includes (a) national policy-makers (ministry of health, ministry of finance); (b) planners and managers responsible for health workforce policy, planning and management at national and district or provincial levels that include CHWs in the delivery of health services; and (c) health workforce educators.
- Secondary target audience. The secondary target audience of this strategy includes development partners, funding agencies, global health initiatives, donor contractors, nongovernmental organizations and activists (at global, regional and national levels) who fund, support, implement, or advocate greater and more efficient involvement of CHWs in the delivery of health services.
- Influencers. The engagement strategy will also leverage relevant influencers and champions at the global, regional and national levels to support advocacy and engagement of primary and secondary audiences.
Overarching principles of the communication and advocacy strategy include the following.
- Country ownership is key to successful implementation of the guideline; a range of activities will therefore ensure involvement of ministries of health, ministries of finance and other relevant stakeholders and actors at various levels of the national health systems.
- Partner support should be harmonized at global, regional and country levels to ensure all messages, products and support activities are aligned.
- Clearly articulating and communicating the benefits of adopting the recommendations and the return on investment are essential, as is the focus on building lasting relationships with key stakeholders instead of one-off activities and events.
- Existing event opportunities should be tapped into to maximize efficiencies and increase visibility and awareness at all levels (global, regional, national). While global awareness is important to keep momentum going after the launch, more intense promotion of the guideline and uptake support is needed in the countries where it would have the most impact.
- Concrete mapping suggestions should be developed on how to most effectively implement the guideline recommendations at the country level, as per segmentation of countries, including action plan templates.

# Plans for guideline adaptation, implementation and evaluation
In order to maximize the opportunities for the guideline to be implemented, it will need to be adapted and contextualized, including through a number of derivative products made available in relevant languages to promote uptake at country level.
Beyond the adaptation, simplification and development of user-friendly summaries of messages, a range of accompanying activities will be considered and implemented, subject to resource availability. Some of these activities might be directly implemented and supported by WHO, others by or in collaboration with other agencies and partners involved in the Global Health Workforce Network CHW hub, or other institutions. A non-exhaustive and non-binding list of activities that will be considered includes:
- development of a dedicated online portal;
- a one-stop shop suite of derivative products, including toolkits, to ensure the guideline is easily comprehensible and is taken up by stakeholders (this will include translation of the guideline into the WHO official languages), with the assets filtered through different lenses by audience (such as funders, implementers);
- a launch event with substantive global visibility (potential candidates: 40th Alma Ata anniversary events, WHO regional committees);
- a series of webinars;
- regional workshops bringing together regional and country champions and stakeholders involved with CHWs to assess which countries would most benefit from the guideline and are in a position to take up some of the recommendations;
- selection of a few countries in which to prioritize policy dialogue and capacity-building activities, supported by drafting a regional and country implementation map;
- meetings of country stakeholders involved with CHWs to present the guideline and design a partner support plan (agree on roles and responsibilities and contributions);
- a workshop with government stakeholders (ministry of health, ministry of finance, development partners) for awareness raising and country mapping of existing CHW situation and policies, to create a baseline and, potentially, a roadmap for uptake of the recommendations, and to support the ministry of health in advocacy with the ministry of finance;
- a self-assessment tool based on the recommendations of the guideline that supports countries in developing baseline information related to CHWs, and that can be used to monitor and evaluate implementation of policies and programmes aligned with the recommendations.
Potential toolkit components include:
- technical summary of the guideline and the implications by audience (for example, what the guideline means for implementers, funders, or other stakeholders);
- policy briefs on specific subtopics (such as management and supervision, training and education, contracting, remuneration and career advancement);
- key messages, narrative;
- infographic or video derivative products;
- return on investment -the business case for implementing the guideline;
- practical guidance on how to map the implementation of the guideline, according to baseline conditions of countries in relation to the CHW policy environment;
- repository of partners and how they can help. All efforts will be made to avoid the need for dedicated surveys and ad hoc data collection processes, with priority given to evidence generation through existing mechanisms, such as the National Health Workforce Accounts or piggy-backing on other existing surveys or meetings that could provide an opportunity to gather relevant evidence and information.
After a few years of implementation, and subject to resource availability, commissioning dedicated country case studies on the experience in specific countries in implementation of the guideline will enable more light to be shed on concrete experiences, including enablers and hindering factors, in uptake of the guideline recommendations. This will inform both subsequent efforts at supporting guideline implementation and eventual updates and revisions of the guideline document itself.
In addition to the detailed recommendations specifically developed to address the policy questions examined in the preceding sections, planners, policy-makers, managers and their international partners should consider the following key principles and cross-cutting aspects for the design and successful implementation of CHW policies.

# General implementation considerations 10.1 Key principles
- Countries should use a combination of CHW policies selected based on the objectives, context and architecture of each health system. This guideline is not a blueprint that can be uncritically adopted;
it should rather be seen as a critical overview of evidence and a menu of interrelated policy options and recommendations, which need nevertheless to be adapted and contextualized to the reality of a specific health system.
- CHW programmes and policies will need to be monitored and evaluated over time, and adapted and amended through a dynamic process informed by contextspecific evidence. In order to promote learning and innovation it is important that policy-makers and managers have a willingness to transparently share data on the characteristics of CHWs and their performance, and information on programme implementation and effectiveness.
- CHWs should not be regarded as a way to save costs or as substitutes for health care professionals, but as an element of integrated primary health care teams. The role of CHWs should be defined and supported with the overarching objective of constantly improving equity, quality of care and patient safety.
- In the design and organization of health care, CHWs should be contributing to the provision of integrated, people-centred health services.
- When considering and setting policies that affect CHWs, their voices and perspective should be represented in the policy dialogue.
- Health services do not naturally gravitate towards equitable outcomes. CHWs, by working at the front line of service provision in underserved communities, have the potential to contribute to a reduction in inequality in access to health services and health outcomes; but in order for this potential to be fully realized, equity considerations should be embedded at the outset in programme design, as well as in monitoring and evaluation of implementation and effectiveness.
- In identifying the optimal features of a CHW programme, consideration should be given not only to the traditional performance measures focused on health service outputs, outcomes and impact, but also to the labour rights of CHWs themselves, including safe and decent working conditions, and freedom from all kinds of discrimination, coercion and violence. Some of these aspects are of particular concern and relevance in conflict-affected settings and chronic complex emergencies.

# Operational aspects of CHW programme design and implementation
The starting point for an effective design of CHW initiatives and programmes is a sound situation analysis of population needs and health system requirements. Planners should adopt a whole-of-system approach, taking into consideration health system capacities and population needs and framing the role of CHWs vis-a-vis other health workers, in order to integrate appropriately CHW programmes into the general health system.

# Programme design
- When designing a CHW programme, consideration should be given to its social, cultural, political and financial feasibility.
- The objectives of a CHW programme and the roles of CHWs should be defined within a holistic approach that considers optimal service delivery modalities in a country or jurisdiction, and the corresponding workforce implications.
Within those, the roles and objectives of CHWs should be considered vis-a-vis those of other occupational groups.
- Accordingly, this guideline reiterates and reinforces the principle underscored by the WHO Global Strategy on Human Resources for Health: Workforce 2030, namely that countries should plan for their health workforce as a whole, rather than segmenting planning and corresponding programming and financing efforts by single occupational groups, which carries a risk of fragmentation, inefficiency and policy inconsistency.

# Policy coherence
- CHW initiatives and programmes should therefore be aligned to and be part of broader national health and health workforce policies. As relevant, they should also be linked with national education, labour and community development sectoral or subsectoral policies and frameworks.
- The policies recommended within this guideline should not be considered in isolation from one another. There is a need for internal coherence and consistency among different policies, as they represent related and interlocking elements that complement and can reinforce one another.
- The role of CHWs should be considered in a long-term perspective. Beyond addressing the immediate and pressing needs of health systems, it should be envisaged that the role of CHWs might need to evolve over time in parallel with changes in the epidemiological profile of the population and health system requirements. The education, certification and career ladder elements of CHW programmes should consider these factors and future scenarios, with a view to ensuring employability of these health workers in a long-term perspective, or an exit strategy that considers CHWs as citizens and workers with rights, and treats them with dignity.

# Health system support
- The recommendations in this guideline are rooted in an overarching logic of formalization of CHW roles and their integration into the health system. In order for such formalization to be effective, it is necessary to have clarity on which level of the system (for example, national or local) and programmatic area (for example, human resources for health or community health or others) represents the institutional "anchor" in the health system for the CHW programme.
- Related to the requirement for overarching health system support, it is necessary to have an understanding of the underlying health system capacity to effectively support the CHW programme. The recommendations in the preceding sections implicitly assume that the health system would have the capacity to effectively carry out a range of supporting functions, including to train and supervise, provide competency-based certification, effectively manage, protect from malpractice risks, remunerate in a timely and adequately manner, create the appropriate channels for linkages and referrals, and procure commodities and essential supplies. However, the actual capacity of the health system to perform these functions might vary considerably across different contexts and may fall short.
- Where the CHW programme depends on the health system adequately performing some of its enabling functions as described above, the CHW programme might represent an occasion to put the spotlight on needs and opportunities for support and strengthening of the system.

# Financing implications
- Little evidence was found on resource requirements in the context of the evidence reviews. However, the policy options recommended in this guideline have, in the aggregate, considerable cost implications, and these require long-term dedicated financing: attempting to set up and run a large-scale CHW initiative on a shoestring budget is likely to yield disappointing outcomes.
- The financial feasibility of implementing the policy recommendations contained in this guideline (especially the ones on education and remuneration) might be questioned by some stakeholders. However, it is important to note that even low-income countries have put in place and funded, mostly out of domestic resources, large-scale CHW initiatives (20), and that the deployment of CHWs has been identified as a cost-effective approach (19).
- The key determinant of success in securing adequate levels of investment is the political will to prioritize approaches and strategies that are most likely to lead to improved population health outcomes.
- In some low-income countries where the domestic resource envelope is unlikely to allow self-reliance in the short term, aligning external support to domestic policy needs and health system mechanisms may contribute to the impact and long-term sustainability of CHW programmes.

# Multiple primary health care interventions
Most CHW programmes focused on underserved populations in high-income countries (such as ethnic or racial minorities, the economically marginalized, rural populations or immigrant groups) (1-7). CHW interventions, such as through peer support telephone calls (8) or home visits (9), can be effective for a wide range of health issues, including increasing knowledge about parenting (9), disease prevention (moderate strength of evidence) (1), influenza prevention (9), promotion of home safety (9), increasing parenting self-efficacy (9), patient enrolment in research (10), uptake of early intervention services (10), increasing access to primary health care for screening (2), improving workplace safety (low strength of evidence) (1) and disease prevention (mixed evidence) (1), and reducing urgent care visits (9). CHWs can reduce obesity among postpartum teens (9), improve nutritional eating habits (10), and increase physical activity (11).
CHW programmes can promote equity of health care access and utilization by reducing inequities relating to place of residence, gender, education and socioeconomic position, and supporting more equitable uptake of referrals (12). There is low-quality evidence from Brazil (13).
Deploying lay refugees or internally displaced persons as CHWs to provide basic health services to women, children and families in camps can increase service coverage, knowledge about disease symptoms and prevention, uptake of treatment and protective behaviours, and access to reproductive health information (some evidence, weak quality) (14).
There was no clear evidence for equitable quality of services provided by CHWs, and there was limited information regarding the role of CHWs in generating community empowerment to respond to social determinants of health (12). There is some evidence (moderate quality) that CHWs are effective in providing health education (15) and psychosocial support (15). There is an absence of evidence on the potential of CHWs to support community-based palliative care (16).

# Reproductive, maternal, neonatal and child health
Neonatal and child health CHW interventions can be effective in increasing infantstimulating home environment scores (9), reducing psychiatric diagnoses among children (9), improving child development (10), and improving child well-being (mixed evidence) (1).
CHWs providing community-based care for infants and children in resource-limited settings can reduce neonatal, infant and child mortality and morbidity (for example, from malaria, pneumonia and diarrhoea) (17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27). While there is high-quality evidence that homebased neonatal care reduces neonatal and perinatal mortality in South Asian settings with high neonatal mortality rates and poor access to health facility-based care (22,23), other reviews reported mixed results, with some individual empirical studies included in reviews not showing improvements in CHW intervention areas (18). Evidence of the impact of CHW interventions on neonatal outcomes is promising but of moderate quality (21) and on CHW capacity to provide skilled birth care is of low quality (21). Antenatal and neonatal practice indicators also significantly improved (23). Compared to physicians, trained CHWs may screen for possible bacterial infection in young infants with relatively high sensitivity but somewhat lower specificity (28). There is some evidence of moderate quality that CHWs are effective in the promotion of essential newborn care (15), including skin-to-skin care for newborns (15). CHWs can perform effective case management of child pneumonia (29), although pneumonia management performance is mixed when pneumonia management is integrated with malaria diagnosis and treatment (30).

# Annex 5
Stakeholder perceptions of health systems support for CHW programmes: a survey study. Applying this scale to the retrieved data, most of the outcome measures of the CHW policy options were deemed to be close to the "critical" end of the spectrum of the Likert scale rating, though the highest-ranking outcomes were as follows: improved quality of CHW health services, increased health services coverage, and increased access to care for patients. Most of the policy options under consideration in the guideline were also deemed to be acceptable and feasible for implementation by stakeholders (Table A5.1).
Very few interventions were rated as uncertain in terms of acceptability or feasibility, for instance the selection of CHWs for pre-service education on the basis of age and a minimum secondary level of education. No outcome measure was rated as "not important", nor were any interventions deemed to be "definitely unacceptable" or "definitely unfeasible". 1) Compared to other methods or no assessment at all, how acceptable is the use of this questionnaire to rate the acceptability by stakeholders of implementing CHW policy interventions?

# Selected findings of stakeholder perception survey
2) Using essential and desirable attributes to select CHWs for pre-service training

# Health issue

# High-income countries Low-and middle-income countries
Reproductive, maternal, neonatal and child health

# Neonatal and child health (continued)
The use of CHWs, compared to usual health care services, may increase the number of parents who seek help for their sick child (27).
Women's groups (facilitated by CHWs) practising participatory learning and action, compared with usual care, have a positive impact on reducing neonatal mortality in low-resource settings (but no evidence of impact on reducing stillbirths) (31). Trained traditional birth attendants compared to untrained traditional birth attendants showed significant increases in safe delivery practices and appropriate referral knowledge and practice (32) and are associated with small but significant decreases in perinatal mortality and neonatal mortality due to birth asphyxia and pneumonia (32). However, another review (33) concludes that there is insufficient evidence to establish the potential of training of traditional birth attendants to improve perinatal and neonatal mortality. CHWs in Brazil have demonstrated effectiveness in increasing the frequency of child weighings (13).

# Maternal health
Peer support can be effective for reducing depressive symptoms in mothers with postnatal depression (8) and can positively impact women's perinatal mental health (34).
One study on addressing stress and mental health among pregnant women on Medicaid found that adding a CHW to a nurse home visit programme increased the number of at-risk women reached (6).
Almost all of the intervention studies involving CHWs showed a significant impact on reducing maternal mortality and on improving perinatal and postpartum service utilization indicators (26). Communitybased intervention packages, which almost always involved CHWs, may have a possible effect on reducing maternal mortality, although the pooled result just crossed the line of no effect (24). Women's groups (facilitated by CHWs) practising participatory learning and action, compared with usual care, have a positive impact on reducing maternal mortality in low-resource settings (31). In settings characterized by high mortality and weak health systems, trained traditional birth attendants can contribute to reducing mortality through participation in key evidence-based interventions (32). There is some evidence of moderate quality that CHWs are effective in providing psychosocial support (15). CHWs were effective in delivering psychosocial and educational interventions to reduce maternal depression (35). Non-specialist providers (a classification that includes CHWs) may be effective in reducing perinatal depression (36).
CHW programmes increased the number of children whose vaccinations were up to date (moderate quality) (37).
There is evidence, but low quality or inconsistent, that CHWs can increase immunization coverage through promoting vaccination (27,32,37,38) and providing vaccination themselves (37). There is low-quality evidence that health professionals are confident that CHWs can deliver vaccines or other medicines using compact prefilled autodisposal devices (39).
CHW interventions have been found to reduce unplanned repeat births among adolescents (9,40) but there was no significant association detected in terms of repeated pregnancies (40).
CHWs were able to deliver injectable contraception safely and effectively, with high quality and with high levels of patient satisfaction (41,42), and initiate their use (which involves screening women and counselling them on side-effects), with no difference in the quality of counselling on side-effects between CHWs and clinicbased providers (42). Most (93%) studies indicated that CHW family planning programmes increased the use of modern contraception and most (83%) reported an improvement in knowledge and attitudes concerning contraceptives (43). CHWs can provide counselling on contraceptives, provide contraceptives, and refer to health facilities for more specialized care (43).
Breastfeeding CHW interventions can be effective for increasing breastfeeding continuation (8,44), attempts and duration (9), initiation, duration, and exclusivity (45).
The use of lay health workers, compared to usual health care services, probably increases breastfeeding (27), and there is some evidence of moderate quality that CHWs are effective in exclusive breastfeeding promotion (15). CHWs in Brazil have demonstrated effectiveness in increasing the prevalence of breastfeeding (13) and delaying the introduction of bottle-feeding (13).
Service delivery areas on which there is published evidence of CHW effectiveness (continued)

# Health issue

# High-income countries Low-and middle-income countries

# Noncommunicable diseases
There is weak evidence that CHW interventions improve knowledge of medication label reading among diabetics (1); improve self-management (46) (low strength of evidence) (1); decrease glycaemia (46) (mixed evidence) (5) (modest reduction) (47). There is no evidence that telephone interventions provided by lay and peer support workers improve mental health or quality of life among diabetics (46). For children with type 1 diabetes, CHWs improved glycaemic control and decreased hospitalizations (48).
CHW capacity in addressing diabetes in low-and middle-income countries was not reported in the systematic review literature.
CHW interventions -peer support phone calls (8), home visits (9) -can be effective in increasing cancer screening rates (2,(8)(9)(10)49); knowledge about prostate cancer (but not screening) (9); cancer screening (moderate evidence) (1); planned use of cancer screening tests (mixed evidence) (1); breast self-examination (mixed evidence) (1).
Only one non-systematic review (50) discussed the potential of CHWs to address cancer in low-and middle-income countries, and did not provide evidence of CHW capacity.

# Mental health
CHW interventions can reduce depression (9) and stigma toward depression treatment (one study) (6), improve depression knowledge and efficacy to seek treatment (6), and produce beneficial changes in health status measures in many, but not all, studies (51). CHW interventions in children with chronic conditions may lead to modest improvements in parental psychosocial outcomes (48) and parental quality of life (48).
CHW-led interventions can reduce the burden of mental, neurological and substance use disorders, including depression and post-traumatic stress disorder among adults (evidence from three studies) (52), and can also improve child mental health outcomes (evidence from four studies) (52). Non-specialist providers, usually CHWs, are more effective than usual care or delayed treatment (wait-listed) groups in the provision of mental health treatments, generally for depression or post-traumatic stress (53). Non-specialist health workers, which in this review (36) included both professionals (for example, doctors, nurses and social workers) and CHWs (22 of the 38 studies), compared with usual health care services, have some promising benefits in improving outcomes for general and perinatal depression, post-traumatic stress disorder and alcohol use disorders, and outcome for patients with dementia and their caretakers (evidence mostly of low or very low quality) (36).
Peer support telephone calls can be effective for increasing the number of asthma-free days (9) as well as the use of bedding encasements for asthma patients (moderate strength of evidence) (1). While some CHW interventions for children with asthma decreased rapid breathing episodes, activity limitation, and asthma exacerbations, and increased the number of symptom-free days, results were inconsistent and risk of bias was often unclear (48). Lay and peer interventions for adolescents with asthma could lead to small improvements in asthma-related quality of life (weak evidence) but there was insufficient evidence on asthma control, exacerbations and medication adherence (54).
CHW capacity in addressing asthma in low-and middle-income countries was not reported in the systematic review literature. Task shifting from higher-level providers and clinic-based care to CHWs was generally acceptable to individuals living with HIV (56,57). This may enhance dignity and quality of life (59) and increase retention in care (56,59), without decreasing the quality of care (60) or patient outcomes (such as virologic failure and mortality) (59,61,62). Task shifting and community-based outreach involving CHWs effectively links people living with HIV to care (58).
CHW capacity in addressing malaria in high-income countries was not reported in the systematic review literature.
There is some evidence of moderate quality that CHWs are effective in malaria prevention (15,26). CHWs can perform rapid diagnostic tests with high sensitivity and specificity, and display high levels of adherence to treatment guidelines (29,30,(63)(64)(65). There was insufficient research to enable an effect on morbidity or mortality to be estimated (63).

# CHW interventions have helped decrease the incidence of TB (26).
CHWs probably increase the number of people with TB who are cured, though they do not appear to affect the number of people who complete preventive therapy (27). Community initiatives were highly effective in stigma reduction, treatment support, referral of persons with suspected TB and reducing defaulting (66)(67)(68). Psychosocial support, referral of persons with TB symptoms and household contact tracing in the context of multidrug-resistant TB have been effective in Peru (69).

# Other infections
Home visits from CHWs can be effective in increasing hepatitis B testing (9) and increasing hepatitis B virus testing uptake (moderate quality evidence) (7).
CHW interventions have contributed to the control of neglected tropical diseases (70). They can support the control of Buruli ulcer in sub-Saharan Africa (71).

# Annex 3
Existing WHO guidelines that identify specific roles and services rendered by CHWs

# Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection (WHO HIV, 2016);
and Optimizing health workers' roles for maternal and newborn health (WHO RHR, 2012)
The guidelines for task sharing and delegation provide countries with the guidance on how to most efficiently and rationally use a more diverse skills mix for the delivery of essential HIV/AIDS and maternal and newborn health services.