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BackgroundAfghanistan is a country that has been in conflict for decades, resulting in the destruction of much of its social infrastructure including the health system. In 2003, after the intervention of US-led NATO forces, the new government with support from its international partners designed a Basic Package of Health Services to provide services to the majority rural population; its specific focus is on women and children. The workforce to deliver these services consists of Community Health Workers (CHWs). In this paper we aim to 1) describe the CHW program, 2) explore the gender dynamics of the workforce, and 3) identify facilitators and challenges to the program.MethodOur descriptive, qualitative study involved an analysis of policy and administrative documents, in-depth interviews and focus groups, and non-participant observation. Ethical approval for the fieldwork was obtained from the University of Ottawa, and the Afghanistan National Public Health Institute.ResultsThere are more than 20,000 CHWs across the country serving as village primary care providers, functioning as a liaison between the community and health-care facilities, and working as community developers; more than half are women. Noteworthy is a gender hierarchy: as one moves up the hierarchy of supervision and training, management and decision-making, the ratio of women to men diminishes. We found that female CHWs accomplished their tasks vis-à-vis maternal child health with greater ease than their male counterparts, as societal gender dynamics influences task allocation. Volunteerism helps to deploy a larger number of CHWs, but also makes their retention difficult. Community participation facilitates tasks of CHWs, but also poses challenges to the program, such as traditional leaders influencing the recruitment of CHWs that may not be the best choice for the community. Drug supply and support for CHWs is vital to the effectiveness of the program.ConclusionsThis case study of the decade-long, rural health workforce CHW program in Afghanistan suggests that CHWs play an important role in post-conflict, developing countries, potentially contributing to health system strengthening.

OBJECTIVES: Community health workers (CHWs) have been deployed to provide health-related services to their fellow community members and to guide them through often complex health systems. They help address concerns about how marginalized populations in many countries experience health inequities that are due, in part, to lack of appropriate primary health care services, possibly resulting in inappropriate use of higher-cost health services or facilities. This paper reviews studies on CHW interventions in a number of high-income countries, including Canada, to identify research gaps on CHW roles. METHODS:A scoping review using 68 sources of interventions involving CHWs was undertaken. The five-step Arksey and O'Malley model guided this review with the aim of summarizing research findings and identifying research gaps in the existing literature on CHWs in Canada (23 sources). A standardized extraction tool was employed to synthesize the literature. SYNTHESIS:We found that CHWs provide a wide range of health-related services but in a manner that, in Canada, is unrecognized and unregulated. In highincome countries, CHW interventions have contributed to health-related issues in communities and demonstrated potential to both reduce health inequity in marginalized populations and reduce the cost of medical services. CONCLUSION:CHWs are an under-recognized, and therefore underutilized, public health workforce, which has a promising capacity to reduce health inequities in marginalized populations in Canada. There is growing support to suggest that CHW roles need to be better integrated within the broader health and social services systems to enable their full potential to be realized.KEY WORDS: Community health workers; human resources; Canada La traduction du résumé se trouve à la fin de l'article.Can J Public Health 2015;106(3):e157-e164 doi: 10.17269/CJPH.106.4747C ommunity health workers (CHWs) have been deployed in most countries (whether low-, middle-or highincome) to provide health-related services to their fellow community members and to guide them through often complex health systems. They help to address concerns about how marginalized populations and communities in many countries experience health inequities that are due, in part, to lack of appropriate primary health care services, possibly resulting in inappropriate use of higher-cost health services or facilities. [1][2][3][4] The World Health Organization (WHO) defines CHWs as "members of communities where they work, selected by and answerable to the communities for their activities, supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers." 5 The 2006 World Health Report identified the use of CHWs as an important strategy to address the growing shortage of health workers, particularly in low-resource settings, as well as to achieve the health-related Millennium Development Goals. 6 The key research priorities related to CHWs in these settings are to know more about their re...