Community Health Worker Programs to Improve Healthcare Access and Equity: Are They Only Relevant to Low- and Middle-Income Countries?

Document Type : Original Article


Southgate Institute for Health Society and Equity, Flinders University, Adelaide, SA, Australia


Community Health Workers (CHWs) are proven to be highly effective in low- and middle-income countries with many examples of successful large-scale programs. There is growing interest in deploying CHW programs in high-income countries to address inequity in healthcare access and outcomes amongst population groups facing disadvantage. This study is the first that examines the scope and potential value of CHW programs in Australia and the challenges involved in integrating CHWs into the health system. The potential for CHWs to improve health equity is explored.

Academic and grey literature was searched to examine existing CHW roles in the Australian primary healthcare system. Semi-structured telephone interviews were conducted with a purposive sample of 11 people including policymakers, program managers and practitioners, to develop an understanding of policy and practice.

Literature on CHWs in Australia is sparse, yet combined with interview data indicates CHWs conduct a broad range of roles, including education, advocacy and basic clinical services, and work with a variety of communities experiencing disadvantage. Many, and to some extent inconsistent, terms are used for CHWs, reflecting the various strategies employed by CHWs, the characteristics of the communities they serve, and the health issues they address. The role of aboriginal health workers (AHWs) is comparatively well recognised, understood and documented in Australia with evidence on their contribution to overcoming cultural barriers and improving access to health services. Ethnic health workers assist with language barriers and increase the cultural appropriateness of services. CHWs are widely seen to be well accepted and valuable, facilitating access to health services as a trusted ‘bridge’ to communities. They work best where ‘health’ is conceived to include action on social determinants and service models are less hierarchical. Short term funding models and the lack of professional qualifications and recognition are challenges CHWs encounter.

CHWs serve a range of functions in various contexts in Australian primary healthcare (PHC) with a common, valued purpose of facilitating access to services and information for marginalised communities. CHWs offer a promising opportunity to enhance equity of access to PHC for communities facing disadvantage, especially in the face of rising chronic disease.



Watch the Video Summary here.


Main Subjects



  1. World Health Organization (WHO). Strengthening the performance of community health workers in primary health care. Geneva: WHO; 1989.
  2. Perry HB, Zulliger R, Rogers MM. Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Annu Rev Public Health. 2014;35:399-421. doi:10.1146/annurev-publhealth-032013-182354
  3. Javanparast S, Baum F, Labonte R, Sanders D. Community health workers’ perspectives on their contribution to rural health and well-being in Iran. Am J Public Health. 2011;101(12):2287-2292. doi:10.2105/ajph.2011.300355
  4. Rice-Marquez N, Baker TD, Fischer C. The Community Health Worker: Forty Years of Experience of an Integrated Primary Rural Health Care System in Brazil. J Rural Health. 1988;4(1):87-100. doi:10.1111/j.1748-0361.1988.tb00304.x
  5. WHO. Primary Health Care: report of the International Conference on Primary Health Care Alma-Ata, USSR. Geneva: The World Health Organization, 1978.
  6. World Health Organization (WHO). Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. Geneva: World Health Organization, 2008.
  7. Lehmann U, Van Damme W, Barten F, Sanders D. Task shifting: the answer to the human resources crisis in Africa? Hum Resour Health. 2009;7:49. doi:10.1186/1478-4491-7-49
  8. Whitehead M. The concepts and principles of equity and health. Int J Health Serv. 1992;22(3):429-445. doi:10.2190/986l-lhq6-2vte-yrrn
  9. Thiede M, Akweongo P, McIntyre D. Exploring the dimensions of access. In: McIntyre D, Mooney G, eds. The Economics of Health Equity. Cambridge: Cambridge University Press; 2007.
  10. Necochea E, Badlani M, Bossemeyer D. Systematic Management of Human Resources for Health: An Introduction for Health Managers. The Johns Hopkins University; 2013.
  11. World Health Organization (WHO). WHO Estimates of Health Personner: Physicians, Nurses, Midwives, Dentists, Pharmacists. Geneva: World Health Organization; 2004.
  12. Australian Institute of Health and Wellbeing (AIHW). Australia’s Health 2014. AIHW; 2014.
  13. APHA. Recognition and support for community health workers’ contributions to meeting our nations health care needs. Washington, DC: American Public Health Association; 2001.
  14. Bureau of Labor Statistics. Occupational Employment Statistics. United States Department of Labor; 2012.
  15. American Public Health Association (APHA). Recognition and support for community health workers’ contributions to meeting our nations health care needs. Washington DC: APHA; 2001.
  16. Bureau of Labor Statistics. Occupational Employment Statistics. USA: United States Department of Labor; 2012.
  17. Davis TP Jr, Wetzel C, Hernandez Avilan E, et al. Reducing child global undernutrition at scale in Sofala Province, Mozambique, using Care Group Volunteers to communicate health messages to mothers. Glob Health Sci Pract. 2013;1(1):35-51. doi:10.9745/ghsp-d-12-00045
  18. Hall J. Effective community-based interventions to improve exclusive breast feeding at four to six months in low- and low-middle-income countries: a systematic review of randomised controlled trials. Midwifery. 2011;27(4):497-502. doi:10.1016/j.midw.2010.03.011
  19. Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev. 2010(11):Cd007754. doi:10.1002/14651858.CD007754.pub2
  20. World Health Organization (WHO). Task shifting : rational redistribution of tasks among health workforce teams : global recommendations and guidelines. Geneva: World Health Organization; 2008.
  21. Onwujekwe O, Dike N, Ojukwu J, et al. Consumers stated and revealed preferences for community health workers and other strategies for the provision of timely and appropriate treatment of malaria in southeast Nigeria. Malar J. 2006;5:117. doi:10.1186/1475-2875-5-117
  22. World Health Organization (WHO). The cost-effectiveness of close-to-community health programmes: What do we know and where are the gaps? Global Health Workforce Alliance; 2015.
  23. Najafizada SA, Bourgeault IL, Labonte R, Packer C, Torres S. Community health workers in Canada and other high-income countries: A scoping review and research gaps. Can J Public Health. 2015;106(3):e157-164. doi:10.17269/cjph.106.4747
  24. Andersen MR, Yasui Y, Meischke H, Kuniyuki A, Etzioni R, Urban N. The effectiveness of mammography promotion by volunteers in rural communities. Am J Prev Med. 2000;18(3):199-207.
  25. Mock J, McPhee SJ, Nguyen T, et al. Effective lay health worker outreach and media-based education for promoting cervical cancer screening among Vietnamese American women. Am J Public Health. 2007;97(9):1693-1700. doi:10.2105/ajph.2006.086470
  26. Perez LM, Martinez J. Community health workers: social justice and policy advocates for community health and well-being. Am J Public Health. 2008;98(1):11-14. doi:10.2105/ajph.2006.100842
  27. Gary TL, Bone LR, Hill MN, et al. Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes-related complications in urban African Americans. Prev Med. 2003;37(1):23-32.
  28. Kangovi S, Mitra N, Grande D, et al. Patient-centered community health worker intervention to improve posthospital outcomes: a randomized clinical trial. JAMA Intern Med. 2014;174(4):535-543. doi:10.1001/jamainternmed.2013.14327
  29. Fedder DO, Chang RJ, Curry S, Nichols G. The effectiveness of a community health worker outreach program on healthcare utilization of west Baltimore City Medicaid patients with diabetes, with or without hypertension. Ethn Dis. 2003;13(1):22-27.
  30. Whitley EM, Everhart RM, Wright RA. Measuring return on investment of outreach by community health workers. J Health Care Poor Underserved. 2006;17(1 Suppl):6-15. doi:10.1353/hpu.2006.0015
  31. Walker DG, Jan S. How do we determine whether community health workers are cost-effective? Some core methodological issues. J Community Health. 2005;30(3):221-229.
  32. Torres S, Spitzer DL, Labonte R, Amaratunga C, Andrew C. Community health workers in Canada: innovative approaches to health promotion outreach and community development among immigrant and refugee populations. J Ambul Care Manage. 2013;36(4):305-318. doi:10.1097/JAC.0b013e3182a5480f
  33. Torres S, Labonte R, Spitzer DL, Andrew C, Amaratunga C. Improving health equity: the promising role of community health workers in Canada. Healthc Policy. 2014;10(1):73-85.
  34. AIHW. The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples 2005. Canberra: Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics (ABS); 2005.
  35. Australian Bureau of Statistics (ABS). Gender Indicators, Life expectancy. Canberra: ABS; 2012.
  36. National Aboriginal and Torres Strait Islander Health Council. National Strategic Framework for Aboriginal and Torres Strait Islander Health. Canberra, ACT: NATSIHC; 2003.
  37. Echevarria A. Towards Identifying and Accessing Small and Emerging Communities in the Northern Sydney Area: A Review of Literature. Sydney: Multicultural Health Service, Northern Sydney Health; 2002.
  38. Watson K, Young J, Barnes M. What constitutes ‘support’ for the role of the Aboriginal and Torres Strait Islander child health workforce? Aust Health Rev. 2013;37(1):112-116. doi:10.1071/ah11079
  39. Clifford A, Shakeshaft A. Evidence-based alcohol screening and brief intervention in Aboriginal Community Controlled Health Services: experiences of health-care providers. Drug Alcohol Rev. 2011;30(1):55-62. doi:10.1111/j.1465-3362.2010.00192.x
  40. Biggs JS, Farrell L, Lawrence G, et al. Applying process mapping and analysis as a quality improvement strategy to increase the adoption of fruit, vegetable, and water breaks in Australian primary schools. Health Promot Pract. 2014;15:199-207.
  41. Mitchell M, Hussey LM. The Aboriginal health worker. Med J Aust. 2006;184(10):529-530.
  42. Rose M, Jackson Pulver LR. Aboriginal Health Workers: professional qualifications to match their health promotion roles. Health Promot J Austr. 2004;15(3):240-244. doi:10.1071/HE04240
  43. Bird M, Henderson C. Recognising and Enhancing the Role of Aboriginal and Torres Strait Islander Health Workers in General Practice. Aborig Isl Health Work J. 2005;29(3):32-34.
  44. Moore L, Webb R, Abbott P, Zonka B. Cooking Classes for Diabetes: A Partnership between Daruk Aboriginal Medical Service and the Western Sydney Institute of TAFE. Aborig Isl Health Work J. 2006;30(6):11-13.
  45. Thompson SC, Shahid S, Greville HS, Bessarab D. “A whispered sort of stuff”: a community report on research around Aboriginal people’s beliefs about cancer and experiences of cancer care in Western Australia. Perth: Cancer Council Western Australia; 2011.
  46. Johanson R, Hill P. Indigenous health: A role for private general practice. Aust Fam Physician. 2011;40(1-2):16-19.
  47. King M, King L, Willis E, Munt R, Semmens F. Issues that impact on Aboriginal health workers’ and registered nurses’ provision of diabetes health care in rural and remote health settings. Aust J Rural Health. 2013;21(6):306-312. doi:10.1111/ajr.12062
  48. King M, King L, Willis E, Munt R, Semmens F. The experiences of remote and rural Aboriginal Health Workers and registered nurses who undertook a postgraduate diabetes course to improve the health of Indigenous Australians. Contemp Nurse. 2012;42(1):107-117. doi:10.5172/conu.2012.42.1.107
  49. Browne J, D’Amico E, Thorpe S, Mitchell C. Feltman: evaluating the acceptability of a diabetes education tool for Aboriginal health workers. Aust J Prim Health. 2014;20(4):319-322. doi:10.1071/py14040
  50. Si D, Bailie RS, Togni SJ, d’Abbs PH, Robinson GW. Aboriginal health workers and diabetes care in remote community health centres: a mixed method analysis. Med J Aust. 2006;185(1):40-45.
  51. Segal L, Nguyen H, Schmidt B, Wenitong M, McDermott RA. Economic evaluation of Indigenous health worker management of poorly controlled type 2 diabetes in north Queensland. Med J Aust. 2016;204(5):1961e-1969.
  52. Schmidt B, Campbell S, McDermott R. Community health workers as chronic care coordinators: evaluation of an Australian Indigenous primary health care program. Aust N Z J Public Health. 2016;40 Suppl 1:S107-114. doi:10.1111/1753-6405.12480
  53. McDermott RA, Schmidt B, Preece C, et al. Community health workers improve diabetes care in remote Australian Indigenous communities: results of a pragmatic cluster randomized controlled trial. BMC Health Serv Res. 2015;15:68. doi:10.1186/s12913-015-0695-5
  54. Abbott P, Gordon E, Davison J. Expanding roles of Aboriginal health workers in the primary care setting: seeking recognition. Contemp Nurse. 2008;27(2):157-164. doi:10.5555/conu.2008.27.2.157
  55. Position Description: Primary Health Care Worker. Western NSW Local Health District; 2011.
  56. Boughtwood D, Shanley C, Adams J, et al. The role of the bilingual/bicultural worker in dementia education, support and care. Dementia (London). 2013;12(1):7-21. doi:10.1177/1471301211416173
  57. Roche AM, Duraisingam V, Trifonoff A, et al. Sharing stories: indigenous alcohol and other drug workers’ well-being, stress and burnout. Drug Alcohol Rev. 2013;32(5):527-535. doi:10.1111/dar.12053
  58. Ella S, Lee KK, Childs S, Conigrave KM. Who are the New South Wales Aboriginal drug and alcohol workforce? A first description. Drug Alcohol Rev. 2015;34(3):312-322. doi:10.1111/dar.12199
  59. Allan J. Engaging primary health care workers in drug and alcohol and mental health interventions: challenges for service delivery in rural and remote Australia. Aust J Prim Health. 2010;16(4):311-318. doi:10.1071/py10015
  60. D’Aprano A, Silburn S, Johnston V, Oberklaid F, Tayler C. Culturally Appropriate Training for Remote Australian Aboriginal Health Workers: Evaluation of an Early Child Development Training Intervention. J Dev Behav Pediatr. 2015;36(7):503-511. doi:10.1097/dbp.0000000000000200
  61. Josif CM, Barclay L, Kruske S, Kildea S. ‘No more strangers’: Investigating the experiences of women, midwives and others during the establishment of a new model of maternity care for remote dwelling aboriginal women in northern Australia. Midwifery. 2014;30(3):317-323. doi:10.1016/j.midw.2013.03.012
  62. Smith AC, Brown C, Bradford N, Caffery LJ, Perry C, Armfield NR. Monitoring ear health through a telemedicine-supported health screening service in Queensland. J Telemed Telecare. 2015;21(8):427-430. doi:10.1177/1357633x15605407
  63. Queensland Government. Deadly Ears, Deadly Kids, Deadly Communities: 2009-13. Annual Report for 2011-12. Queensland Government; 2012.
  64. Thompson M, Robertson J, Clough A. A review of the barriers preventing Indigenous Health Workers delivering tobacco interventions to their communities. Aust N Z J Public Health. 2011;35(1):47-53. doi:10.1111/j.1753-6405.2010.00632.x
  65. Paasse G, Adams K. Working together as a catalyst for change: the development of a peer mentoring model for the prevention of chronic disease in Australian Indigenous communities. Aust J Prim Health. 2011;17(3):214-219. doi:10.1071/py10016
  66. Walker D, Tennant M, Short SD. An exploration of the priority remote health personnel give to the development of the Indigenous Health Worker oral health role and why: unexpected findings. Aust J Rural Health. 2013;21(5):274-278. doi:10.1111/ajr.12045
  67. Walker D, Tennant M, Short SD. Listening to indigenous health workers:Helping to explain the disconnect between policy and practice in oral health role development in remote Australia. Health Educ J. 2011;70(4):400-406. doi:10.1177/0017896911428368
  68. Queensland Health. Crocodile smiles: Australian Indigenous Health InfoNet  website.  Published June 2008.
  69. Job Advertisement: Multicultural Health Workers. South Eastern Sydney Local Health District; 2016.
  70. Chronic disease and living well. Ethnic Communities Council of Queensland; 2016.
  71. Poljski C. Diabetes prevention for immigrant and refugee women: Findings from the Diabetes Healthy Living Project. Melbourne: Multicultural Centre for Women’s Health; 2010.
  72. Catts S, O’Toole B, Neil A, et al. Best practice in early psychosis intervention for Australian indigenous communities: indigenous worker consultation and service model description. Australas Psychiatry. 2013;21(3):249-253. doi:10.1177/1039856213480532
  73. Vindigni D, Parkinson L, Walker B, Rivett DA, Blunden S, Perkins J. A community-based sports massage course for Aboriginal health workers. Aust J Rural Health. 2005;13(2):111-115. doi:10.1111/j.1440-1854.2005.00664.x
  74. Queensland Health. Queensland Transcultural Mental Health Centre website. . 2016.
  75. Community Workshops Program. Multicultural Centre for Women’s Health; 2016.
  76. Multicultural HEAL (Healthy Eating Activity and Lifestyle) Program. South Western Sydney PHN; 2016.
  77. Red Cross Tasmania. Bi-cultural health cited June 2016.  
  78. Drummond PD, Mizan A, Brocx K, Wright B. Using peer education to increase sexual health knowledge among West African refugees in Western Australia. Health Care Women Int. 2011;32(3):190-205. doi:10.1080/07399332.2010.529215
  79. Henderson S, Kendall E. ‘Community navigators’: making a difference by promoting health in culturally and linguistically diverse (CALD) communities in Logan, Queensland. Aust J Prim Health. 2011;17(4):347-354. doi:10.1071/py11053
  80. Morgan K, Lee J, Sebar B. Community health workers: a bridge to healthcare for people who inject drugs. Int J Drug Policy. 2015;26(4):380-387. doi:10.1016/j.drugpo.2014.11.001
  81. Treloar C, Cao W. Barriers to use of Needle and Syringe Programmes in a high drug use area of Sydney, New South Wales. Int J Drug Policy. 2005;16(5):308-315. doi:10.1016/j.drugpo.2005.06.005
  82. Landers SJ, Stover GN. Community health workers--practice and promise. Am J Public Health. 2011;101(12):2198. doi:10.2105/ajph.2011.300371
  83. Anderson A, Proudfoot JG, Harris M. Medical assistants: a primary care workforce solution? Aust Fam Physician. 2009;38(8):623-626.
  84. Templeton DJ, Tyson BA, Meharg JP, et al. Aboriginal health worker screening for sexually transmissible infections and blood-borne viruses in a rural Australian juvenile correctional facility. Sex Health. 2010;7(1):44-48. doi:10.1071/sh09035
  85. Deek H, Abbott P, Moore L, et al. Pneumococcus in Aboriginal and Torres Strait Islander peoples: the role of Aboriginal health workers and implications for nursing practice. Contemp Nurse. 2013;46(1):54-58. doi:10.5172/conu.2013.46.1.54
  86. Health Workforce Australia. Growing Our Future: Final Report of the Aboriginal and Torres Strait Islander Health Worker Project. Adelaide: Health Workforce Australia, 2011.
  87. Henderson S, Kendall E, See L. The effectiveness of culturally appropriate interventions to manage or prevent chronic disease in culturally and linguistically diverse communities: a systematic literature review. Health Soc Care Community. 2011;19(3):225-249. doi:10.1111/j.1365-2524.2010.00972.x
  88. Javanparast S, Baum F, Labonte R, Sanders D, Rajabi Z, Heidari G. The experience of community health workers training in Iran: a qualitative study. BMC Health Serv Res. 2012;12:291. doi:10.1186/1472-6963-12-291
  89. Health Workforce Australia. Aboriginal and Torres Strait Islander Health Worker Project. Adelaide: Health Workforce Australia; 2011.
  90. Asweto CO, Alzain MA, Andrea S, Alexander R, Wang W. Integration of community health workers into health systems in developing countries: opportunities and challenges. Fam Med Community Health. 2016;4(1):37-45. doi:10.15212/FMCH.2016.0102
  91. Balcazar H, Rosenthal EL, Brownstein JN, Rush CH, Matos S, Hernandez L. Community health workers can be a public health force for change in the United States: three actions for a new paradigm. Am J Public Health. 2011;101(12):2199-2203. doi:10.2105/ajph.2011.300386
  92. Khanassov V, Pluye P, Descoteaux S, et al. Organizational interventions improving access to community-based primary health care for vulnerable populations: a scoping review. Int J Equity Health. 2016;15(1):168. doi:10.1186/s12939-016-0459-9
  93. Richard L, Furler J, Densley K, et al. Equity of access to primary healthcare for vulnerable populations: the IMPACT international online survey of innovations. Int J Equity Health. 2016;15:64. doi:10.1186/s12939-016-0351-7
  94. Torres S, Balcazar H, Rosenthal LE, Labonte R, Fox D, Chiu Y. Community health workers in Canada and the US: working from the margins to address health equity. Crit Public Health. 2017;27(5):533-540. doi:10.1080/09581596.2016.1275523