Malawi, West Africa, Kenya and a fifty-year retrospective on the whole community-health-worker movement: four unconnected stories, all circling the same unresolved question — who is the community health worker, who supervises them, and who pays?

The most direct is a Malawian consultant’s open question to HIFA’s 20,000 members: what can other countries learn from Malawi’s Health Surveillance Assistants, the cadre that has carried the country’s immunisation, surveillance and maternal-health outreach for decades, and that Prestor Kubalalika describes as straining under workload, transport and recognition pressures familiar to anyone who has managed a CHW programme anywhere on the continent. Nigerian physician Uzodinma Adirieje makes a related but different case for West Africa: an estimated 70–80% of people in Lagos, Accra and Dakar consult a herbalist, traditional birth attendant or faith healer before they ever reach a biomedical clinic. His argument isn’t that this should change — it’s that formal systems keep treating this informal workforce as a gap to close rather than infrastructure already in place, and that the resulting blind spots are measurable: delayed obstetric transfers, lower vaccination uptake among children whose caregivers rely solely on traditional advice, and outbreak signals (Lassa fever cases, for instance) that never reach a surveillance system because nobody trained the healer to recognise and report them. Ghana’s National Health Insurance Scheme gets cited as one of the few attempts to formally credential and reimburse this workforce, which is a smaller claim than it sounds — a pilot toward integration, not evidence that integration works at scale.

On Johns Hopkins epidemiologist Henry Perry’s periodic HIFA circular, the frame shifts from strain to celebration: fifty years since the Jamkhed Comprehensive Rural Health Project in Maharashtra first argued that medical knowledge should never be a doctor’s monopoly, the CHW professionalization movement now has real institutional weight behind it — the Community Health Impact Coalition giving CHWs like Kenyan advocate Margaret Odera a seat at policy tables, CHW Central as a functioning knowledge hub, and a dedicated pre-conference workshop at October’s APHA meeting on mobility, misinformation and digital tools in CHW work. A separate preprint on Kenya’s devolved county health system, built around “Community Dialogue Days” and “Action Days,” offers a leadership framework for formalising the community-participation side of decentralised PHC governance — the kind of structure SA’s own provincial NHI rollout will eventually need an equivalent of.

Read individually, each of these is a reasonable, well-intentioned story. Read together against what’s actually known about how CHWs are financed across the continent, they describe a movement whose rhetoric has outrun its money by a wide margin. A funding-trends analysis published this year found that government spending on CHW programmes across 37 sub-Saharan African countries averaged just US$0.20 billion a year between 2016 and 2022 — under a fifth of total CHW financing — while external donor assistance averaged US$0.94 billion and, worse, 76.4% of that donor money went to vertical, disease-specific programmes that made up fewer than a fifth of all CHW projects. More than 85% of CHWs across the region remain unpaid. The persistent annual financing gap the same analysis identifies — roughly US$4.3–4.7 billion — is not a rounding error; it’s the actual distance between “CHWs are the backbone of PHC” as a stated value and CHWs as a funded, salaried cadre with career progression.

What makes this more than an abstract donor-accounting problem is how little the diagnosis has moved. A commentary published this March in The Lancet Regional Health – Africa lists “formalizing CHW remuneration, strengthening supportive supervision, and expanding competency-based training” as one of five concrete steps needed to revitalise African PHC — and cites, among its evidence, a 2023 paper making substantially the same argument about the systemic constraints holding UHC back in Africa. The fact that the same fix is still being called for three years on says less about the diagnosis being wrong than about how hard it is to fund. And the honest complication, which the professionalization narrative tends to skip past, is that “just pay them” isn’t a clean answer either: researchers studying unpaid CHW labour across the region have described the reliance on volunteerism in genuinely contested ethical terms — as something closer to exploitation than altruism when it substitutes for a funded health system — while separate evidence on compensation design warns that poorly structured, irregular or token payments can demotivate CHWs more than paying nothing at all. Professionalizing this workforce is necessary. It is not, on its own, sufficient, and it isn’t cheap.

None of this makes Kubalalika’s question, Adirieje’s integration framework, Perry’s advocacy roundup or Kenya’s participation model less worth reading — if anything, it makes them worth reading against the financing numbers rather than instead of them. AfroPHC members with SA’s own ward-based outreach team experience have a genuinely useful answer to give Malawi’s open thread; the harder conversation is what it would take to fund that answer at the scale the continent actually needs.

A few more stories worth flagging: