Empowering Community Health Workers: The Backbone of Primary Healthcare Transformation in Nigeria
Nigeria’s primary healthcare system faces deep-rooted challenges that worsen health disparities across the country. About 46% of the population resides in rural areas, where access to quality care is limited by geographical isolation, a severe shortage of healthcare professionals, and socioeconomic barriers such as poverty and low health literacy (World Bank, 2025). These systemic issues contribute to persistently poor health outcomes, including a high maternal mortality rate of 993 per 100,000 live births (2023) and a growing burden of non-communicable diseases (NCDs), which now account for 30% of all deaths (WHO, 2018; 2025).
The foundation of any robust and just health system, particularly in low- and middle-income nations like Nigeria, is an effective primary healthcare system. In the backdrop of persistent challenges in access and outcomes in healthcare, the PHC frontlines are sustained by a passionate and potent force: Community Health Workers (CHWs). As trusted frontline providers, CHWs are in the best position to address these challenges by delivering critical preventive, promotive, and curative services to host communities. Their cultural and linguistic proximity enables them to navigate social health determinants, including gender norms, economic constraints, and educational barriers; an invaluable asset in the realisation of Universal Health Coverage by 2030, an objective outlined in Nigeria's National Health Policy.
Community Health Workers (CHWs) serve as a critical bridge between underserved communities and the formal health system, offering a cost-effective approach to expanding access to care. Through close engagement with local populations, they drive lasting change by promoting preventive practices and addressing context-specific health needs (Kwemoi, 2024). This article draws on global and local evidence to propose a framework for strengthening the role of CHWs, positioning them as foundational to Nigeria’s primary healthcare system. By investing in their capacity and integrating them more fully into an improved health system, Nigeria can advance health outcomes, promote public trust, and move closer to equitable healthcare delivery.
The Foundational Role of CHWs in Nigeria's Health Ecosystem
CHWs are far more than healthcare providers; they are trusted members of the communities they serve. This connection, stemming from shared cultural understanding, language, and lived experiences, enables them to deliver health interventions, disseminate critical information, and catalyse behavioural change with efficacy at the grassroots level (WHO, 2018). Within Nigeria's multifaceted health system, CHWs constitute a substantial portion of the PHC workforce, undertaking an array of functions. These responsibilities span health promotion, disease prevention, diagnostics, treatment support, and referral services (Adepoju et al., 2025).
Their impact on health outcomes is well-documented:
Bridging the Access Chasm: In Nigeria's rural areas and underserved urban peripheries, where formal health facilities are often distant or economically inaccessible, CHWs frequently represent the initial point of contact for healthcare (Adepoju et al., 2025). By delivering services within households and local gathering places, they dismantle geographical barriers, boosting utilisation of critical services such as antenatal care, skilled birth attendance, childhood immunisations, and family planning (Lateef et al., 2024). Evidence from Nigerian States shows that community engagement facilitated by CHWs correlates with increases in essential health service uptake, particularly among vulnerable populations (Bassey & Omoregie, 2024).
Driving Measurable Improvements in Health Outcomes: Through early disease detection, promoting preventive behaviours (e.g., handwashing, exclusive breastfeeding, malaria prevention), and ensuring treatment adherence, CHWs curb morbidity and mortality rates. Their agility enables rapid response to emerging health concerns, contributing to the prevention of localised epidemics and bolstering community resilience during public health crises.
Cultivating Community Engagement and Building Trust: As integral members of the communities they serve, CHWs play a vital role in cultivating trust, delivering culturally sensitive healthcare, and empowering communities to assume ownership over their health (Breakthrough ACTION, 2023). Their understanding of community dynamics is paramount for the acceptance, effective implementation, and long-term sustainability of health interventions.
Strategic Optimisation of Formal Health System Capacity: By managing routine primary care, conducting health education, and triaging complex referral cases, CHWs alleviate the burden on overstretched healthcare professionals and facilities. This delegation allows specialised personnel to focus on critical cases, enhancing the efficiency and responsiveness of the health system.
Hurdles Facing CHWs: The Imperative for Comprehensive Empowerment
Despite their contributions, CHWs in Nigeria navigate a complex landscape fraught with systemic challenges that impede their performance and potential. Addressing these issues is paramount for their empowerment:
Inconsistent Training Quality and Pathways to Practice: While CHWs in Nigeria undergo structured training at pre-service health institutions, primarily schools of health technology and some universities, the quality and consistency of this pre-service training can vary significantly across institutions. These institutions prepare various cadres of community health practitioners, including Junior Community Health Extension Workers (JCHEWs), Community Health Extension Workers (CHEWs), and Community Health Officers (CHOs), each with a distinct curriculum (Dotimi et al., 2023). However, this inconsistency in foundational training can lead to disparities in knowledge and skills among CHWs, creating challenges in delivering standardised, high-quality primary healthcare services. Furthermore, even with foundational training, there is a critical need for ongoing capacity building to bridge emerging knowledge gaps, address new health priorities, and ensure CHWs are continuously equipped to meet evolving community health needs (Mwenda, 2024).
Regulatory Oversight and Its Challenges: The Community Health Practitioners Regulatory Board of Nigeria (CHPRBN) serves as the primary regulatory body for community health practitioners, including JCHEWs, CHEWs, and CHOs. Established by law, the CHPRBN sets professional standards, regulates training, registers practitioners, and ensures ethical conduct. It maintains the professional integrity of the workforce and safeguards public health by ensuring competencies and adherence to guidelines. A key aspect of strengthening oversight includes accreditation of pre-service health training institutions. The USAID/Nigeria Health Workforce Management (HWM) Activity supported CHPRBN in revising and developing an electronic accreditation system for these institutions, aiming to ensure consistent training quality (Banyan Global, 2024). However, challenges persist, including ensuring all practitioners are registered, enforcing continuous professional development, and addressing scope-of-practice issues in remote areas where oversight is difficult.
Chronic Resource Scarcity and Insufficient Supplies: CHWs often lack consistent access to essential drugs, medical equipment, diagnostic tools, and transportation, hampering their ability to deliver timely services, especially in remote areas. This compromises the quality and effectiveness of care.
Inadequate Remuneration, Lack of Incentives, and Ambiguous Career Pathways: Meagre or non-existent compensation demotivates CHWs, many of whom serve voluntarily or receive irregular stipends. This, coupled with limited opportunities for career advancement, contributes to high attrition and undermines CHW programme sustainability. Fair remuneration and clear career pathways are critical for retention.
Challenges in Integration, Supervision, and Professional Recognition: CHWs often face marginalisation from formal health workers, which undermines collaboration and team cohesion. Weak supervision and poor integration into the broader health system lead to fragmented service delivery and inconsistent care quality. When CHWs' contributions are not formally recognised, it can result in low morale and disengagement (Tseng et al., 2019).
Adverse Social and Work Environment Factors: Community Health Workers (CHWs) often contend with practical challenges that can hinder their effectiveness. These include balancing professional responsibilities with family obligations, as well as facing various forms of stigma, ranging from stigma associated with the health conditions they manage (such as chronic, infectious, or mental illnesses), to gender-based, interpersonal, and role-related stigma. Navigating complex community dynamics also presents difficulties, particularly when CHWs are new to an area. While their community connection is a strength, it does not guarantee immediate trust. Building and maintaining trust requires intentional, respectful engagement, consistent demonstration of competence, and sensitivity to community concerns and biases (Johnson et al., 2022; Breakthrough ACTION, 2024).
Blueprint for a Transformed Primary Healthcare System Through Empowered CHWs
To unlock the transformative potential of community health workers, a multipronged, systemic approach is essential:
Standardised, Competency-Based Training and Robust Continuous Professional Development: Comprehensive, competency-based training curricula for CHWs, encompassing all cadres (JCHEWs, CHEWs, and CHOs), must be standardised nationwide, ensuring knowledge, practical skills, and ethical understanding. The USAID/Nigeria HWM Activity collaborated with CHPRBN to revise the Continuing Professional Development (CPD) manual to support lifelong learning and relicensure requirements (Banyan Global, 2024). Training must include regular refresher courses, specialised skill development, mentorship programmes, and pathways for professional growth and upward mobility.
Equitable Remuneration, Comprehensive Incentives, and Defined Career Pathways: Establishing fair, consistent, and competitive compensation packages for CHWs is foundational. This must include not only direct financial remuneration but also non-financial incentives such as recognition, opportunities for further education, and career progression pathways within the broader health system (Colvin et al., 2021). Adequate compensation is a powerful motivator, significantly reduces attrition, and unequivocally signals the value and dignity of their vital work.
Robust, Supportive Supervision and Mentorship Frameworks: Structured supervision models provide CHWs with regular feedback, technical guidance, and emotional support. Mentorship programmes, where experienced professionals guide newer recruits, promote development.
Seamless Integration into the Formal Health System: Seamless integration requires defined roles, responsibilities, and efficient two-way referral pathways. A culture of respect, addressing any existing biases, and collaboration between CHWs and other healthcare providers ensures CHWs are recognised as integral, indispensable members of the primary healthcare team (Ignoffo et al., 2023).
Strategic Leveraging of Digital Health Technologies: Equipping CHWs with digital tools, including mobile health applications for data collection, disease surveillance, health education, and remote monitoring, enhances their efficiency. Locally available solutions in Nigeria, such as ThinkMD (which provides clinical intelligence for health workers to assess, diagnose, and treat patients), MobiDoc (a telemedicine platform connecting users with verified healthcare professionals), and Kangpe (an app for online consultations and health advice), demonstrate the potential of digital innovations to extend healthcare access and support CHWs' work. These technologies can dramatically enhance efficiency, improve data accuracy, expand reach, and facilitate real-time communication, especially in geographically dispersed or hard-to-reach communities.
Development and Digitalisation of CHWs' Job Aids (Standing Orders): Standardised CHW job aids or Standing Orders outline tasks, procedures, and decision-making algorithms for health interventions. A significant stride in this direction was made when the USAID/Nigeria HWM Activity, CHPRBN, and key stakeholders revised the Standing Orders for all three cadres of Community Health Practitioners (JCHEWs, CHEWs, and CHOs) in February 2024, with the new orders officially launched in September 2024 (Banyan Global, 2024). Furthermore, the digitalisation of these job aids, making them accessible via mobile devices or tablets (as seen with the online availability of the revised Standing Orders), offers immense benefits: enabling quick reference, facilitating updates, standardising practice across diverse settings, reducing errors, and serving as a continuous learning tool at the point of care. This systematic approach, extending to the revision and development of an electronic accreditation system for pre-service health training institutions with support from USAID HWM, ensures that the foundation of CHW education is robust and digitally streamlined.
Strengthening Policy and Robust Regulatory Frameworks: Promote and support the development and effective implementation of clear national policies and legislative frameworks that define CHWs’ roles, responsibilities, and scope of practice. Establish and strengthen regulatory bodies to ensure quality assurance, accountability, and ongoing professional oversight of CHW services, protecting public health
The Aig-Imoukhuede Foundation's Strategic Commitment to Empowering CHWs
The Aig-Imoukhuede Foundation, through its strategically conceived and diligently implemented initiatives, is actively engaged in addressing these multifaceted challenges and championing the comprehensive empowerment of CHWs. Our holistic efforts directly complement and reinforce the empowerment of CHWs by:
Revitalising and Strengthening Primary Healthcare Facilities: At the core of the Foundation's strategy is the impactful Adopt-A-Healthcare Facility Programme (ADHFP), a groundbreaking collaborative endeavour with the Private Sector Health Alliance of Nigeria (PSHAN). This ambitious programme aims to establish and equip global-standard PHCs in every Local Government Area across Nigeria. By meticulously revitalising these critical facilities, the Foundation is assiduously cultivating a more enabling and supportive environment for CHWs to operate. This encompasses providing access to improved infrastructure, modern medical equipment, reliable drug supply chains, and, crucially, a stronger, more efficient referral system. The demonstrable success in the revitalisation of facilities across several Nigerian states, evidenced by significant improvements in outpatient attendance, antenatal care registrations, and immunisation rates, directly translates into a more conducive and productive operational environment for the CHWs who tirelessly serve these communities (Aig-Imoukhuede Foundation 2025a).
Investing in Healthcare Worker Training and Capacity Building: Recognising that quality of care is directly linked to the competence of its providers, the Aig-Imoukhuede Foundation actively supports the training and continuous professional development of a wide range of healthcare workers, including CHWs. This commitment extends beyond infrastructure, focusing on building the human capital essential for a high-performing health system. By enhancing the skills and knowledge of these critical personnel, the Foundation ensures that frontline healthcare providers are equipped to deliver evidence-based, quality care.
Developing Transformational Public Health Leadership through the AIG Public Leaders Programme: The Foundation understands that effective public health reforms require visionary and capable leadership. Through the AIG Public Leaders Programme (AIG PLP), public health sector leaders are offered a unique and transformative opportunity to develop their leadership capacity. This meticulously designed program equips them with the critical skills, strategic insights, and essential knowledge necessary to conceptualise, champion, and drive sustainable change within the health sector, with a particular emphasis on primary health care (Aig-Imoukhuede Foundation, 2025b). By nurturing a new generation of adept public health leaders, the Foundation ensures that strategic planning, resource allocation, and policy implementation are guided by expertise and a commitment to systemic improvement, ultimately benefiting CHW programmes and broader PHC delivery.
Advocacy for Sustainable Policy Reforms and Funding Mechanisms: The Foundation vigorously advocates for the implementation of sustainable financing mechanisms. This includes staunch support for the effective utilisation of initiatives like the Basic Health Care Provision Fund (BHCPF). This crucial fund, mandated to earmark resources for critical areas such as human resources for PHC interventions, is a vital lifeline for ensuring adequate remuneration, comprehensive training, and appropriate equipping of CHWs. Such sustained funding is indispensable for the longevity and impact of CHW programmes.
Promoting and Championing Community-Led Health Initiatives: Central to our operational philosophy is the profound importance of empowering existing community structures. We actively support the establishment and strengthening of bodies like Ward Development Committees (WDCs) and champion the robust implementation of the Community-Based Health Workers (CBHWs) Program. By nurturing these programmes and platforms, the Foundation directly empowers CHWs to engage dynamically and meaningfully with their communities, facilitate impactful health education, promote healthy behaviours, and critically, cultivate enduring trust. This ultimately translates into increased utilisation of essential health services and greater community ownership of health outcomes.
Driving Evidence-Based Thought Leadership and Dissemination: Through our rigorous research and strategic media campaigns, the Aig-Imoukhuede Foundation is dedicated to generating, curating, and widely disseminating evidence on effective and scalable PHC models. By meticulously documenting and highlighting successful CHW programmes, their methodologies, and their quantifiable impact, we provide invaluable insights that serve to inform evidence-based policy formulation, guide targeted interventions, and catalyse broader investments for enhanced CHW empowerment across the nation.
Conclusion
Community Health Workers are far from being mere auxiliaries to the health system; they are, in essence, its pulsating heart and resilient backbone. They embody the critical link that connects diverse communities, especially the most vulnerable, to essential health services, thereby driving tangible and positive health outcomes at the most fundamental level. The Aig-Imoukhuede Foundation remains unyielding in its overarching mission to revitalise and transform Nigeria's health sector into a beacon of excellence.
A cornerstone of this ambitious endeavour is the strategic, holistic, and sustained empowerment of CHWs, supported by comprehensive healthcare worker training and the development of strong public health leadership through the AIG Public Leaders Programme. By making deliberate and significant investments in their rigorous training, providing them with unwavering support, ensuring their seamless integration, and continuously showcasing compelling evidence of their profound impact, we can collectively unlock their full, transformative potential. This, in turn, will enable them to consistently deliver world-class primary care, ensuring that every Nigerian, irrespective of their location or socioeconomic status, has equitable access to the quality healthcare they deserve, thereby laying the foundation for a healthier, more prosperous, and more resilient nation.
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