Abstract
Background: National community health worker (CHW) programmes are increasingly regarded as an integral component
of primary healthcare (PHC) in low- and middle-income countries (LMICs). At the interface of the formal health system
and communities, CHW programmes evolve in context specific ways, with unique cadres and a variety of vertical and
horizontal relationships. These programmes need to be appropriately governed if they are to succeed, yet there is little
evidence or guidance on what this entails in practice. Based on empirical observations of South Africa’s community-based
health sector and informed by theoretical insights on governance, this paper proposes a practical framework for the design
and strengthening of CHW programme governance at scale.
Methods: Conceptually, the framework is based on multi-level governance thinking, that is, the distributed, negotiated
and iterative nature of decision-making, and the rules, processes and relationships that support this in health systems.
The specific purposes and tasks of CHW programme governance outlined in the framework draw from observations and
published case study research on the formulation and early implementation of the Ward Based Outreach Team strategy in
South Africa.
Results: The framework is presented as a set of principles and a matrix of 5 key governance purposes (or outputs). These
purposes are: a negotiated fit between policy mandates and evidence, histories and strategies of community-based services;
local organisational and accountability relationships that provide community-based actors with sufficient autonomy and
power to act; aligned and integrated programme management systems; processes that enable system learning, adaptation
and change; and sustained political support. These purposes are further elaborated into 17 specific tasks, distributed across
levels of the health system (national, regional, and local).
Conclusion: In systematising the governance functions in CHW programmes, the paper seeks to shed light on how best to
support and strengthen these functions at scale.