“If that goes away, the house of cards falls”: challenges and solutions to ensuring CHW sustainability

The Community Health Workers (CHWs) for COVID Response and Resilient Communities (CCR) project supported CHWs to strengthen community resilience to combat COVID-19 and address health disparities. This qualitative, participatory case study aimed to identify the sustainability challenges and solutions faced by health organizations and care teams integrating CHWs as change agents. From June to August 2024, 27 interviews were conducted with CHWs (n = 9), program staff (n = 9), and program partners (n = 9), each having expertise in CHW workforce capacity. This study targeted two domains (funding stability and strategic planning) of the Public Health Program Capacity for Sustainability Framework. Data were analyzed using thematic analysis. Funding stability coalesced around three sub-themes: (1) barriers to funding stability, (2) solutions to overcoming funding instability, and (3) the cascading impact on CHWs and communities. Strategic planning was categorized into two prominent sub-themes: (1) the systematic development of organizational strategic plans and (2) the use of data to support action-driven approaches for ensuring the sustainability of the CHW workforce within and across organizations. The findings provide strategies and actionable steps that organizations need to take to fully sustain the CHW workforce within their health systems, including: full inclusion of CHW participation in every decision-making phase; the inclusion of CHW sustainability plans within organizational strategic plans; and rigorous participatory evaluations of CHW-led interventions to demonstrate how CHWs are making an impact on health disparities and promoting health equity. The implementation of all or part of these strategies has important implications for health system transformation and advancing health equity.