title: Limits and opportunities to community health worker empowerment: A multi-country comparative study.
abstract: In LMICs, Community Health Workers (CHW) increasingly play health promotion related roles involving 'Empowerment of communities'. To be able to empower the communities they serve, we argue, it is essential that CHWs themselves be, and feel, empowered. We present here a critique of how diverse national CHW programs affect CHW's empowerment experience.
  
  
  
  We present an analysis of findings from a systematic review of literature on CHW programs in LMICs and 6 country case studies (Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, Mozambique). Lee & Koh's analytical framework (4 dimensions of empowerment: meaningfulness, competence, self-determination and impact), is used.
  
  
  
  CHW programs empower CHWs by providing CHWs, access to privileged medical knowledge, linking CHWs to the formal health system, and providing them an opportunity to do meaningful and impactful work. However, these empowering influences are constantly frustrated by - the sense of lack/absence of control over one's work environment, and the feelings of being unsupported, unappreciated, and undervalued. CHWs expressed feelings of powerlessness, and frustrations about how organisational processual and relational arrangements hindered them from achieving the desired impact.
  
  
  
  While increasingly the onus is on CHWs and CHW programs to solve the problem of health access, attention should be given to the experiences of CHWs themselves. CHW programs need to move beyond an instrumentalist approach to CHWs, and take a developmental and empowerment perspective when engaging with CHWs. CHW programs should systematically identify disempowering organisational arrangements and take steps to remedy these. Doing so will not only improve CHW performance, it will pave the way for CHWs to meet their potential as agents of social change, beyond perhaps their role as health promoters.
authors.affiliation: Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands. Electronic address: S.Kane@kit.nl.
authors.forename: Sumit
authors.initials: S
authors.lastname: Kane
authors.affiliation: Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
authors.forename: Maryse
authors.initials: M
authors.lastname: Kok
authors.affiliation: Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
authors.forename: Hermen
authors.initials: H
authors.lastname: Ormel
authors.affiliation: LVCT Health, Research and Strategic Information Department, P.O Box 19835-00202, Nairobi, Kenya.
authors.forename: Lilian
authors.initials: L
authors.lastname: Otiso
authors.affiliation: University Eduardo Mondlane, Department of Community Health, P.O. Box 257, Maputo, Mozambique.
authors.forename: Mohsin
authors.initials: M
authors.lastname: Sidat
authors.affiliation: Research for Equity and Community Health (REACH)Trust, P.O. Box 1597, Lilongwe, Malawi.
authors.forename: Ireen
authors.initials: I
authors.lastname: Namakhoma
authors.affiliation: Eijkman Institute for Molecular Biology, and Faculty of Public Health, Hasanuddin University, Makassar, Indonesia, Jalan Diponegoro 69, Jakarta, 10430, Indonesia; Faculty of Public Health, Hasanuddin University, Makassar, Indonesia.
authors.forename: Sudirman
authors.initials: S
authors.lastname: Nasir
authors.affiliation: REACH, P.O. Box 303, Hawassa, Ethiopia.
authors.forename: Daniel
authors.initials: D
authors.lastname: Gemechu
authors.affiliation: James P. Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh.
authors.forename: Sabina
authors.initials: S
authors.lastname: Rashid
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, United Kingdom.
authors.forename: Miriam
authors.initials: M
authors.lastname: Taegtmeyer
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, United Kingdom.
authors.forename: Sally
authors.initials: S
authors.lastname: Theobald
authors.affiliation: Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
authors.forename: Korrie
authors.initials: K
authors.lastname: de Koning
mesh_terms: D001291:Attitude of Health Personnel; D001459:Bangladesh; D002983:Clinical Competence / Q000592:standards; D003150:Community Health Workers / Q000523:psychology*; D005002:Ethiopia; D006293:Health Promotion / Q000379:methods; D006297:Health Services Accessibility / Q000592:standards; D006801:Humans; D007214:Indonesia; D007630:Kenya; D008295:Malawi; D009042:Motivation; D009073:Mozambique; D011209:Power, Psychological; D017009:Professional Autonomy; D016730:Program Development / Q000379:methods / Q000592:standards*; D036301:Qualitative Research; D000078329:Workforce
keywords: Agents of social change; Community health workers; Empowerment; Performance