Community health workers: not ‘if’ but ‘how’. Critically analyzing the WHO guideline through the WPR method

In their role as frontline public health workers, community health workers (CHWs) possess a unique position between health services and individuals at the intersection of vulnerabilities, often serving as representatives of their communities. The World Health Organization (WHO) launched a guideline (2018) to optimize CHW programs in national health systems. Remarkable in this guideline is that recommendations seem to target mostly workforce challenges in health systems of Low- and Middle-Income Countries (LMICs). Bacchi (2009) reasons that policies and guidelines play a major role in constructing, reproducing and reifying problems they are supposed to address. Applying Bacchi's post-structural lens 'What is the problem represented to be' (WPR), this study aims to critically examine (1) discourses in the WHO's guideline for CHWs and (2) the impact of these discourses on power dynamics within global health. This study highlights the WHO's assumption that health (in)equity is largely an issue of human resources in health, certainly in LMICs. The WHO further presumes that CHWs can address the health (gender) work force gap, supposed to be located mainly in LMICs. The position taken in the WHO guideline reveals discourses of differentiation - among others between LMICs and HICs, economic efficiency and individual responsibility. The study therewith concludes that the WHO recommendations for CHW programs are not sufficiently acknowledging the full potential of CHWs in addressing health inequities.