By: Mark Mwenda
Community Health Workers (CHWs) play an indispensable role in bridging the gap between healthcare systems and underserved communities, especially in regions with limited access to formal healthcare services. This comprehensive analysis of Community Health Worker programs focuses exclusively on the Asia region, drawing on 89 resources published in 2024 alone. With rapid changes in healthcare needs and the ongoing challenges of global health crises, the role of CHWs in Asia has become more critical than ever. The findings in these recent resources provide valuable insight into how CHWs across Asia are addressing diverse health issues, and how CHW programs are evolving to meet the demands of both rural and urban populations.
This report captures the scale, scope, and diversity of CHW programs across countries in Asia, examining how varying contexts, resource availability, and policy support shape these programs. In addition to highlighting the significant achievements of CHWs in this region, the analysis reveals widespread challenges which affect the reach and sustainability of CHW efforts. By examining these findings in detail, this article provides a picture of the current landscape of CHW programs in Asia and outlines the pressing needs and recommendations for strengthening community health programs.
Scale and Scope of CHW Programs in Asia
The scale and scope of CHW programs across Asia illustrate the diversity and adaptability of these roles in varying health landscapes. India’s Accredited Social Health Activist (ASHA) program stands as a model of national-scale implementation, with CHWs embedded deeply within communities to address a broad range of public health needs. ASHAs provide essential maternal and child health services, ensure treatment adherence for tuberculosis, promote family planning, and support immunization drives, making them integral to India’s public health system (Shrestha et al. 2024; Vora et al. 2024).
Pakistan’s Lady Health Workers (LHW) program also operates on a substantial scale, offering preventive healthcare services across rural and urban settings. LHWs primarily focus on maternal and child health, with additional involvement in immunization campaigns for diseases like polio, expanding the program’s preventive health reach (Shrestha et al. 2024). Bangladesh’s CHWs, coordinated largely by BRAC, target critical areas such as maternal and child health, family planning, and communicable disease control, particularly cholera and diarrheal disease prevention, which are pressing public health issues (Jongdeepaisal et al. 2024; Hossain et al. 2024).
In Southeast Asia, Cambodia and Myanmar face limitations in the scale of their CHW programs due to financial and political constraints. These challenges have slowed the expansion and support for CHW networks in these countries, affecting program sustainability and CHW retention (CHHAM et al. 2024; Dysoley et al. 2024; Shrestha et al. 2024). In Nepal and Vietnam CHWs have been pivotal, particularly in the countries’ mountainous and remote areas (Hoang et al. 2024). Following the 2015 earthquake, Nepal’s CHWs were instrumental in delivering emergency healthcare services and continue to support both disaster recovery and general healthcare needs, highlighting the program’s versatility (Tikkanen et al. 2024).
The Philippines and Indonesia both employ large networks of CHWs to reach underserved populations, particularly in rural and remote areas. In the Philippines, Barangay Health Workers (BHWs) support maternal and child health, family planning, and preventive health education, filling critical healthcare gaps in local communities (Gumba 2024). Indonesia, with a similarly extensive network, focuses CHW efforts on disease prevention, maternal and child health, and health education, especially targeting communities with limited access to healthcare facilities (Dewi et al. 2024).
Key Themes Emerging from Asia’s CHW Programs
Role Flexibility and Task Shifting
One of the major themes emerging from the analysis is the flexibility and task-shifting that CHWs must manage. In many Asian countries, CHWs are tasked with addressing a broad spectrum of health issues, often simultaneously. In India, ASHAs serve as the bridge between the community and the formal health system, delivering services related to maternal and child health, communicable disease prevention, and sanitation promotion, all while also working to manage non-communicable diseases such as diabetes and hypertension (Nayantara 2024; G et al. 2024; Mukesh et al. 2024).
In Nepal, CHWs take on a similarly wide range of responsibilities, from promoting family planning to educating communities about disaster preparedness and managing disease outbreaks (Choudhury et al. 2024). The role of CHWs in Bangladesh extends beyond basic healthcare services to include nutrition support and awareness-building around hygiene practices, which are crucial in reducing the high incidence of waterborne diseases in flood-prone areas (Perry and Chowdhury 2024; Hanson et al. 2024). This flexibility in their roles not only allows CHWs to provide vital services where they are needed most, but it also places a considerable burden on them, often stretching them too thin and impacting the quality of care they can provide (Gumba 2024; Bibhakar, Sinha, and Baba 2024).
Thailand’s CHWs engage in mental health care, which aligns with a growing national focus on mental health awareness (Wongcharoen et al. 2024). Similarly, in the Philippines, CHWs support family planning, mental health education, substance abuse prevention, and support in extreme natural disasters, a significant adaptation to local public health needs (Elizabeth 2024). Task-shifting in Indonesia enables CHWs to take on additional healthcare responsibilities in case of workforce shortages, highlighting their adaptability in resource-limited settings (Ashtiani et al. 2024; Sinaga, Siregar, and Sitanggang 2024).
Training Gaps and Capacity Building
Training, or the lack thereof, emerged as a significant issue across all the countries I reviewed. Evidence shows that ongoing supportive training for CHWs significantly boosts their confidence in attending to their communities, enhances their professional productivity, and increases job satisfaction. Assessments reveal that trained CHWs consistently perform well in terms of skills and knowledge related to the areas they are trained in (Mukesh et al. 2024; Panday, Teijlingen, and Barnes 2024; ud Dina et al. 2024).
While initial training programs exist in most places, they are often limited in duration and scope. For instance, ASHAs in India receive a few weeks of basic training when they start but do not always receive ongoing professional development to keep up with emerging health challenges, such as the rising burden of non-communicable diseases (Nichols 2024; Zaman et al. 2024). This lack of continuous capacity strengthening leaves many CHWs unprepared for the evolving nature of healthcare needs in their communities.
In Bangladesh, the BRAC CHWs undergo initial training but similarly face a shortage of refresher courses or further education opportunities (Perry and Chowdhury 2024). In Cambodia and Myanmar, the situation is even more dire due to political and economic instability, which has led to fragmented and inconsistent training efforts (CHHAM et al. 2024; Reda et al. 2024). This shortage of training not only reduces the effectiveness of CHWs but also lowers their confidence in handling complex health issues like mental health challenges, chronic diseases, and emergency health needs (CHHAM et al. 2024).
In contrast, countries like Nepal and Pakistan have made some strides in improving training for their CHWs, particularly in areas like disaster response and maternal health (Shrestha et al. 2024). Pakistan’s CHW training, though more condensed and focused on essential skills, enables quick scaling in areas where urgent healthcare services are needed (ud Dina et al. 2024). However, even in these countries, there is a clear need for more structured and continuous training to ensure CHWs are well-equipped to deal with the full range of public health issues they encounter.
Compensation and Financial Incentives
Many voluntary CHWs across Asia face significant economic and social pressures that strain their ability to continue volunteering. Challenges such as the cost of volunteering, lack of family and community support, and bureaucratic demands often reduce their motivation. Additionally, inadequate support and limited resources further impact their effectiveness (Bibhakar, Sinha, and Baba 2024; Ogutu et al. 2024; Adeel and M 2024). This sets the stage for one of the most significant issues I found in my analysis: the lack of proper compensation for CHWs.
In many countries, CHWs are either unpaid volunteers or compensated through a system of performance-based incentives. India’s ASHAs are a case in point: they receive payments based on specific tasks they complete, such as accompanying a woman to deliver in a health facility or ensuring a child receives all their vaccinations (Nichols 2024). While this incentive structure can drive productivity, it also creates immense pressure on CHWs, especially in underserved areas where meeting these targets can be challenging due to resource constraints (Bibhakar, Sinha, and Baba 2024).
In Pakistan, LHWs receive a small monthly stipend, which is higher than what is offered to CHWs in countries like Bangladesh and Nepal, but still insufficient to earn a sustainable livelihood. This issue of inadequate compensation leads to high attrition rates in many countries, as CHWs are forced to seek alternative employment to support their families (Panday, Teijlingen, and Barnes 2024, Siddiqi et al. 2024). Moreover, the reliance on performance-based incentives can create inequities, as CHWs in more resource-poor areas may not have the same opportunities to achieve the required targets as their counterparts in better-served regions (Panday, Teijlingen, and Barnes 2024). Indonesia uses mixed funding, (relying on both government and local NGO support) which promotes CHW activities, albeit with modest remuneration that can affect CHW retention (Hasanbasri et al. 2024).
Social and Cultural Barriers
Another theme that repeatedly surfaced in the literature was the significant social and cultural barriers CHWs face, particularly in countries with diverse populations and deeply entrenched traditional practices. In India, for example, ASHAs often struggle to promote modern family planning methods in conservative rural areas where traditional norms favor large families (Moughalian et al. 2024). Similarly, CHWs in Vietnam encounter resistance when promoting healthcare practices that challenge long-standing beliefs about childbirth and maternal health (Pardoel et al. 2024). These cultural barriers can make it difficult for CHWs to provide the care that communities need, even when they have the requisite training and support.
In some areas, CHWs themselves face stigma, particularly if they come from marginalized ethnic or social groups. In India, for example, CHWs from minority groups have reported discrimination from both their peers and the communities they serve, which can undermine their effectiveness and the overall impact of CHW programs (Gopichandran et al. 2024). This is an important observation that underscores the fact that communities are often diverse and CHWs’ identities do not always represent socio-cultural majorities. Addressing these social and cultural barriers is critical to the success of CHW programs across Asia.
At the same time, CHWs often serve as cultural brokers, bridging the gap between healthcare systems and local communities through their ability to communicate effectively and sensitively with community members. For instance, in Laos, CHWs leverage their deep cultural understanding and local knowledge to facilitate conversations on health topics that may otherwise be difficult to address due to social or cultural norms (Liverani et al. 2024). This role allows CHWs to foster trust and open communication, encouraging acceptance of healthcare interventions while respecting cultural beliefs and practices.
Integration with Formal Healthcare Systems
Integration with the formal healthcare system plays a pivotal role in enabling CHWs to address community issues effectively and confidently (Jahan et al. 2024). It facilitates a seamless flow in the transition of care, where CHWs can efficiently refer cases from the community to higher levels of care. This integration helps CHWs clearly understand their roles, boosting their confidence and competence in service delivery (Gupte et al. 2024). Furthermore, it alleviates resource constraints within the healthcare system by minimizing duplication of efforts (CHHAM et al. 2024). Importantly, community members gain trust in the healthcare system as a well-integrated referral pathway ensures they receive timely and convenient services (Hashmi et al. 2024).
The level of integration between CHW programs and formal healthcare systems varies significantly across Asia. In India, ASHAs are relatively well-integrated into the public health system, with a clear referral system that allows them to connect patients to higher-level care when needed (Shrestha et al. 2024). This integration strengthens their ability to provide effective care, particularly in maternal health and immunization services, where they play a crucial role in linking communities with hospitals and health centers (Shrestha et al. 2024).
In contrast, in countries like Cambodia, CHWs often operate in isolation from formal healthcare systems due to weak health infrastructure and political instability (Cassidy-Seyoum et al. 2024). In these cases, CHWs are sometimes unable to access the necessary medical supplies or support needed to provide comprehensive care or make timely referrals, which limits their effectiveness and reduces the trust communities place in them (Cassidy-Seyoum et al. 2024). In Nepal, the integration of CHWs into the formal health system is more robust, but there are still gaps, particularly when it comes to referrals and the availability of advanced medical care (Bhattarai et al. 2024).
CHW Organizing and Advocacy
CHW organizing in the Philippines, India, Indonesia, Bangladesh and Thailand are well-established and integrated into national health systems. They are active in advocating for improved working conditions, training, and funding for CHWs, amplifying their influence on policy (Shrestha et al. 2024). For example, in the Philippines and India, Barangay Health Worker (BHW) networks and ASHAs participate in policy discussions and advocate for greater governmental support (Gumba 2024; Jan N et al. 2024). In Pakistan, however, the lack of a strong CHW association or other organizing body limits their ability to advocate effectively for policy changes or improved working conditions (Khalid 2024).
Oral Health and Oral Cancer
Oral health, particularly the growing concern around oral cancer, has emerged as a significant health issue in several Asian countries, reflecting shifts in disease burden and public health priorities. In countries like India and Pakistan, high rates of tobacco use, particularly in smokeless forms like betel quid, have led to a spike in oral cancer cases, making it a pressing public health concern (Gurushanth et al. 2024). CHWs are increasingly being recognized as key players in early detection and prevention efforts related to oral health.
In India, ASHAs have been integrated into oral health campaigns, where they educate communities on the risks associated with tobacco use and the importance of regular oral hygiene. These CHWs are trained to identify early signs of oral cancer, such as lesions or abnormal growths in the mouth, and refer individuals to specialized health services for further evaluation (Gupte et al. 2024; Gurushanth et al. 2024). Pakistan’s Lady Health Workers (LHWs) have similarly been incorporated into oral health initiatives. They provide basic oral health education and encourage the reduction of risk factors such as tobacco use and poor dietary habits that contribute to oral diseases (Gurushanth et al. 2024). While these programs are still in their early stages, they hold significant potential for improving oral health outcomes in vulnerable populations.
In Bangladesh and Nepal, oral health has not traditionally been a central focus of CHW programs. However, given the increasing recognition of oral diseases as a major public health issue, CHWs in these countries are slowly being incorporated into national oral health campaigns. They are equipped with the knowledge and tools to promote oral hygiene, distribute fluoride toothpaste, and raise awareness about the dangers of tobacco consumption. This is part of a broader strategy to tackle non-communicable diseases (NCDs) that are growing in prevalence across Asia (Kurapati and Anitha 2024; Gurushanth et al. 2024).
mHealth Integration
Another emerging topic in CHW programs across Asia is the integration of mobile health (mHealth) technologies. mHealth tools are being used to enhance the efficiency and reach of CHW activities, especially in remote areas where access to healthcare facilities is limited. The use of mobile phones to track patients, disseminate health information, and provide remote consultations has revolutionized the way CHWs operate, particularly in countries with vast, underserved rural populations.
In India, mHealth technologies have been integrated into the ASHA program to streamline data collection and reporting. ASHAs use mobile applications to track maternal and child health indicators, follow up with patients on medication adherence, and provide real-time health advice through SMS or call features (Ramjee et al. 2024). Similarly, in Pakistan, LHWs use mobile platforms to record patient data and receive updated health protocols, reducing the administrative burden and allowing them to focus more on direct service delivery (Akhtar et al. 2024).
In Bangladesh, the BRAC CHW network has also embraced mHealth technologies, particularly in maternal and child health programs. CHWs use mobile apps to track pregnancies, monitor immunization schedules, and share health education messages with expectant mothers. These tools have proven invaluable in improving the timeliness and quality of healthcare services, particularly in rural areas where CHWs are often the primary source of care (Jongdeepaisal et al. 2024).
Nepal and Cambodia have also piloted mHealth projects, though the scale and success of these initiatives are still being evaluated. In Nepal, CHWs working in mountainous and hard-to-reach regions use mobile devices to communicate with healthcare providers in urban centers, allowing them to receive guidance and support for complex cases (Khatri et al. 2024). Cambodia’s mHealth initiatives have focused on using mobile technologies to strengthen CHW training and ensure that they have access to up-to-date information on communicable diseases, particularly tuberculosis (Dysoley et al. 2024).
China and Singapore also emphasize CHW roles within their digital health frameworks, which support rural and urban populations alike. In China, digital health tools empower CHWs to track healthcare outcomes more effectively, whereas Singapore integrates advanced digital health skills into CHW training to address urban public health needs (Haldane et al. 2024; Phng et al. 2024).
Mental Health
CHWs play an increasingly important role in addressing mental health needs, particularly in countries where mental health resources are limited. In India, ASHAs provide basic mental health support, including psychoeducation, stigma reduction, and referrals to mental health professionals, particularly in rural areas where mental health services are scarce (Jain, Pillai, and Mathias 2024).
In China, CHWs have been instrumental in mental health outreach, particularly in supporting individuals with depression and anxiety through community-based interventions. These CHWs are often embedded in communities, allowing them to effectively address mental health stigma, which is still prevalent, and provide culturally appropriate mental health education (Li et al. 2024). In Nepal, following the 2015 earthquake, CHWs were mobilized to provide psychological first aid and ongoing mental health support, which has become a staple of CHW work in both urban and remote settings (Junkin et al. 2024). In Indonesia, Community Health Workers play a vital role in mental health by identifying mental disorders and promoting compassionate, culturally sensitive care within their communities (Marthoenis et al. 2024). The role of CHWs in mental health across Asia is expanding as they provide essential support, helping bridge the gap in mental health services in regions with limited access to professional care (Adeel and M, 2024).
Key Findings and Reflections on CHW Programs in Asia
One of the most prominent findings from my analysis is the critical role that CHWs play in filling healthcare gaps in Asia, particularly in rural and underserved areas. They are the backbone of healthcare delivery in many of these regions, providing essential services that would otherwise be inaccessible to millions of people. However, the effectiveness of CHWs is often limited by a range of systemic issues, including inadequate training, poor compensation, and a lack of integration with formal health systems.
The scope of responsibilities assigned to CHWs is both a strength and a challenge. On one hand, the flexibility of their roles allows them to address a wide range of health issues, from communicable diseases to maternal health and disaster response. On the other hand, this broad mandate can overwhelm CHWs, particularly when they are not given the necessary training and support to manage such diverse tasks effectively.
Another key reflection is the stark inequity in CHW programs across countries. In more resource-rich countries like India and Pakistan, CHWs are relatively better supported, with more robust training programs, higher levels of integration with the formal healthcare system, and some form of financial compensation. In contrast, CHWs in poorer countries like Cambodia and Myanmar struggle with fragmented support systems, insufficient training, and a lack of basic healthcare infrastructure, which limits their ability to provide effective care.
Cultural barriers also emerged as a significant challenge across the region. In many countries, deeply entrenched traditional practices and social norms create resistance to modern healthcare practices, particularly in areas related to maternal health and family planning. CHWs often have to navigate these complex cultural dynamics, which can complicate their efforts to provide care and gain the trust of the communities they serve.
Recommendations
In light of the findings from this analysis, several recommendations emerge to improve the effectiveness of CHW programs in Asia.
First, governments and organizations should prioritize ongoing, structured training for CHWs. While many programs provide initial training, the lack of continuous professional development leaves CHWs ill-prepared for emerging health challenges. Training programs should be regularly updated to reflect the changing health landscape, including the rising burden of non-communicable diseases, mental health challenges, and the need for disaster preparedness. Additionally, capacity-building efforts should focus on providing CHWs with the tools and knowledge they need to handle these new challenges effectively.
Another critical recommendation is to address the issue of compensation for CHWs. In many countries, CHWs are unpaid or underpaid, which leads to high attrition rates and limits the sustainability of CHW programs. Governments and international organizations should work together to develop fair and sustainable compensation models that recognize the vital role CHWs play in healthcare delivery. This could include shifting away from performance-based incentive systems, which create inequities, and toward more stable, salaried positions that provide CHWs with the financial security they need to focus on their work.
Integration with formal healthcare systems should also be a priority. CHWs cannot work in isolation; they need to be part of a larger, coordinated healthcare system that allows them to make referrals and access the medical supplies and support they need. Governments should invest in strengthening the links between CHWs and formal healthcare facilities, particularly in rural areas where these connections are often weakest. This would not only improve the quality of care provided by CHWs but also help build trust between communities and the formal health system.
Addressing cultural barriers is another important recommendation. Governments and organizations should work closely with community leaders and local stakeholders to develop culturally appropriate health interventions that respect traditional practices while promoting modern healthcare. This will require a nuanced understanding of local cultural dynamics and a commitment to working collaboratively with communities to design healthcare programs that meet their needs.
The use of mHealth in CHW programs is still evolving, but the potential benefits are clear. It can significantly enhance the efficiency, accuracy, and scope of CHW services, especially in areas where healthcare access is limited. However, challenges such as limited digital literacy, connectivity issues, and the cost of technology remain significant barriers that need to be addressed to fully realize the potential of mHealth in Asia.
Lastly, while there is ample evidence showcasing the vital role CHWs play in healthcare delivery, what is missing is not more research, but the political will and genuine support to fully back CHW programs. The existing data and countless success stories provide a clear picture of the positive impact CHWs have on health outcomes. What is now needed is for governments, policymakers, and organizations to move beyond recognition and act decisively. Investing in sustainable policies, funding structures, and improved working conditions for CHWs should be prioritized. It is time to turn knowledge into action by ensuring comprehensive support systems are in place, allowing CHW programs to thrive and continue improving health outcomes across Asia.
Way Forward
The findings of this analysis echo established knowledge about the essential role of CHWs in delivering primary healthcare and addressing health inequities. The themes that emerged from these 2024 resources reinforce the importance of CHW programs not only in Asia but also globally, as they mirror the structure, successes, and challenges seen in CHW programs across other continents. This regional comparison highlights the resilience and adaptability of CHWs, as well as the persistent gaps that hinder the full realization of these programs’ potential.
Given the widespread recognition of the critical role CHWs play, the need for solutions to these longstanding challenges has never been clearer. Stakeholders—including governments, policymakers, international organizations, NGOs, CHW associations, and researchers—must now prioritize actionable guidance to bridge the resource, training, and policy gaps that continue to limit CHW effectiveness. These gaps are well documented and widely evident, and it is time to focus on implementing the structural support and policy frameworks necessary to empower CHWs fully. Such focused intervention will not only enhance the resilience of healthcare systems in Asia but also ensure that CHW programs continue to thrive as invaluable assets to global health.
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