Victoria Adewumi, MS, CHW, MPH, Co-Principal Investigator and Co-Executive Director, CHW Center for Research and Evaluation
Noelle Wiggins, EdD, MSPH, Co-Principal Investigator and Co-Executive Director, CHW Center for Research and Evaluation
Community Health Workers (CHWs)—frontline public health professionals who have a unique and trusted relationship with the communities they serve—have proven their ability to help create just, equitable, and thriving communities. As a CHW for over a decade and a CHW ally for over 35 years, we have never witnessed a time of greater interest and investment in the CHW workforce. Amidst a rapidly changing CHW funding landscape, the philanthropic community has an important role to play in assuring that CHWs are able to make an optimum contribution to communities and to the health system.
Despite more than 60 years of evidence for the efficacy of CHW interventions in the US (Rodela et al. 2021), it took the COVID-19 pandemic to create broad awareness of the critical services CHWs provide to fill gaps in our precarious health care delivery systems. Between 2020 and 2022, federal funding through the American Rescue Plan Act and other mechanisms, along with local and regional philanthropy, allowed champions to start or expand CHW programs that made life-saving services and resources available to communities hardest hit by the pandemic. Now, with the immediate crisis abated, many of the most significant funding streams for the CHW workforce have ended and hundreds of CHWs who were hired during COVID-19 have been laid off.
Challenges for the CHW Profession
CHWs in the US have seen this cycle of boom and bust before. CHWs are often viewed as critical during emergencies—witness the early days of the HIV epidemic—but once the initial crisis subsides, attention and funding wane. We believe this is due in part to a fundamental misunderstanding about who CHWs are and what allows them to be so effective in reducing disease burden, addressing the underlying causes of inequity, and improving health across many domains. It is CHWs’ lived experience and shared group identity that allows them to engage deeply with communities that have been historically marginalized and dispossessed. Community is at the core of the profession and who CHWs are and is an essential element of the CHW role.
Unfortunately, not all CHW programs prioritize hiring or training from communities served. During the recent season of funding abundance, the idea that anyone who takes a CHW training can call themselves a CHW has proliferated. We hear of individuals in clinical roles like EMTs and Pharmacy Technicians taking one CHW training course and then billing federal payers under codes originally designated for the CHW workforce.
Training conducted using liberating educational methods such as popular or people’s education (Wiggins 2012) can forge a professional identity and influence how CHWs work in communities, and in some states, training is required for the certifications that facilitate reimbursement. However, training does not “create” CHWs. Vital CHW attributes like empathy and community knowledge are affirmed and enhanced—not conferred—by training or certification (Wiggins and Borbón 1998). Recruitment, hiring, or training of individuals who do not share experience or trust with communities lacks fidelity to the model and will not demonstrate positive or sustained impact.
The way that CHWs are funded—almost exclusively through short-term grants or limited reimbursement for specific activities—presents another challenge and reveals that CHWs are still not fully recognized as integral members of the health workforce (Witmer et al. 1995). Medicare and Medicaid billing opportunities for CHW programs are fraught with challenges, including bureaucratic hassles and an almost universal requirement for a clinical link, which is often infeasible for a workforce that is largely based in non-clinical settings. Even when CHWs can bill successfully, reimbursement rates are often so low that the effort may not be worth the reward.
The increasing clinical framing of the CHW workforce produces further challenges. CHWs’ success or “return on investment” is often measured in terms of savings for health systems, typically through reductions in service utilization. However, a narrow focus on cost effectiveness obscures how CHWs support improved health outcomes for communities and can lead to a narrowing of their roles. CHW involvement in activities like advocacy, community organizing, and policymaking facilitates system realignment to support community well-being. As community subject matter experts, CHWs can accurately diagnose what makes communities sick and work with communities to generate appropriate solutions. Focusing solely on supporting CHWs to navigate community members through fragmented systems or make lifestyle changes to manage chronic diseases is shortsighted and impairs CHW effectiveness.
The funder community has powerful levers to ensure that the CHW workforce stays true to the community-based, social justice roots that allow CHWs to address systemic inequities. We offer six recommendations for philanthropic partners who support CHW programs.
Actions Philanthropists Can Take to Promote CHW Effectiveness
- Assure programs hire with intention. The most effective CHW programs recruit individuals who have the trust and knowledge of the communities they serve. Philanthropic partners supporting CHW programs can encourage program managers to rely on community-based organizations or community leaders to connect them to high quality CHW candidates. Educational requirements and barriers related to judicial involvement should also be addressed (and dismantled) so that potential candidates are assessed primarily on their ability to perform the key functions of the role and connect with the community of focus.
- Encourage programs to support a full range of CHW roles. The dynamic nature of the CHW role can lead to the assumption that the CHW scope of work has not been defined. In truth, CHWs and allies have been engaged in efforts to define their scope of practice for more than 25 years. These efforts have resulted in a set of 10 core roles last updated in 2018 (Rosenthal et al.). These roles should be used when creating CHW scopes of work and job descriptions.
- Think long-term: Short-term grant opportunities can both deter qualified candidates from considering CHW positions and increase attrition. Grant opportunities should be built with grantees as collaborators and with the expectation that programs will seek ways to sustain their CHW workforce over the long haul. Partnerships between philanthropy and government funders could create the ongoing, nationwide, public health focused CHWs programs that would allow CHWs to reach their full potential as a workforce.
- Require programs to pay a living wage: Thriving wages for CHWs that honor their unique contributions to the public health workforce and their expertise in community should be the norm, as should opportunities for job growth within the profession. It is far past time to lay to rest the notion that CHW positions are just “stepping stones” into other “real” health professions.
- Support CHW-led backbone organizations: Like all professionals, to thrive as a workforce, CHWs need professional organizations at the state and national level, training and technical assistance providers, and organizations that conduct research and evaluation about the field that are CHW-led and governed. These organizations cannot survive without philanthropic and governmental support.
- Evaluate CHW programs with measures chosen by CHWs: Measurement drives practice. Therefore, program evaluations should incorporate the indicators CHWs use to measure their success. The CHW Common Indicators (Wiggins et al. 2021; Rodela et al. 2021) facilitate aggregation of process and outcome data across CHW programs regardless of the setting.
We work with national networks of CHWs and connect with CHWs on the ground every day. The CHWs with whom we work describe this work as a calling. This calling has the potential to make a substantial and unique contribution to achieving health equity in the US within our lifetime (Ibe et al. 2021), but for that to happen, we need champions who will help defend and sustain the workforce after the emergency declarations end. Thanks in no small part to the support of grantmakers passionate about community health and well-being, there are more CHWs working and organizing across the country today than ever before. Investment in this workforce by philanthropic partners in ways that are equitable, that are evaluated based on how CHWs define success, and that consider the long-term impact CHWs must have in system realignment and policy change can help communities become healthier, happier, and more resilient.
Ibe, Chidinma A., Debra Hickman, and Lisa A. Cooper. “To Advance Health Equity During COVID-19 and Beyond, Elevate and Support Community Health Workers.” JAMA Health Forum, July 29, 2021.
Rodela, Keara, Noelle Wiggins, Kenneth Maes, Teresa Campos Dominguez, Victoria Adewumi, Pennie Jewell, and Susan Mayfield-Johnson. “The Community Health Worker (CHW) Common Indicators Project: Engaging CHWs in measurement to sustain the profession.” Frontiers in Public Health, June 21, 2021.
Rosenthal, E.L., P. Menking, and J. St. John. The Community Health Worker Core Consensus (C3) Project: A Report of the C3 Project Phase 1 and 2, Together Leaning Toward the Sky. A National Project to Inform CHW Policy and Practice. Texas Tech University Health Sciences Center, El Paso, 2018.
Wiggins, Noelle. “Popular education for health promotion and community empowerment: a review of the literature.” Health Promotion International, 2012.
Wiggins, Noelle, and I.A. Borbón. “Core roles and competencies of community health workers.” In Final report of the National Community Health Advisor Study (pp. 15–49). Baltimore, MD: Annie E. Casey Foundation, 1998.
Wiggins, Nicole, Kenneth Maes, Gloria Palmisano, Keara Rodela, Leticia Rodriguez Avila, and Edith Kieffer. “A Community Participatory Approach to Identify Common Evaluation Indicators for Community Health Worker Practice.” Progress in Community Health Partnerships, July 2021.
Witmer, A., S.D. Seifer, L. Finocchio, J. Leslie, and E.H. O’Neil. “Community health workers: integral members of the health care work force.” American Journal of Public Health, August 1995.