Africa's unpaid outbreak frontline workers: The political economy of community health worker neglect.

Abstract

Community health workers (CHWs) in Africa perform indispensable functions across the outbreak response cycle. These include early case detection, contact tracing, risk communication and zoonotic interface monitoring. They depend on community embeddedness, an asset the formal health system cannot replicate in emergencies. Yet despite a substantial evidence base, more than 80% of Africa's 1.4 million CHWs operate under volunteerism frameworks, without formal employment, salaries or enforceable protections. This is not a consequence of resource scarcity. It is a deliberate programme design choice, endorsed by governments and development partners that extracts community labour from the most precarious workers in the system without commensurate investment. We write from national public health institutions in West and East Africa, sub-regions where outbreak frequency, CHW volunteerism prevalence and weak Joint External Evaluation (JEE) surveillance scores converge. We argue that the evidence for CHW effectiveness is settled and that the policy frameworks for professionalism are in place. The principal remaining barrier is the political economy of global health security financing. The 2023 Monrovia Call to Action and 2023 Lusaka Agenda provide an actionable roadmap. The most tractable path to binding accountability is the formal incorporation of CHW surveillance capacity as a scored metric in the World Health Organization (WHO) JEE process.