{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T08:02:57Z","timestamp":1790323377873,"version":"4.1.0"},"reference-count":15,"publisher":"AOSIS","issue":"1","license":[{"start":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T00:00:00Z","timestamp":1790294400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:p>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\u2019s 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.<\/jats:p>","DOI":"10.4102\/jphia.v17i1.1920","type":"journal-article","created":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T07:28:30Z","timestamp":1790321310000},"update-policy":"https:\/\/doi.org\/10.4102\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Africa\u2019s unpaid outbreak frontline workers: The political economy of community health worker neglect"],"prefix":"10.4102","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3402-1961","authenticated-orcid":false,"given":"Eric N.","family":"Ikoona","sequence":"first","affiliation":[{"name":"Executive Director Office, National Public Health Agency, Freetown, Sierra Leone"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0594-2956","authenticated-orcid":false,"given":"Lucy","family":"Namulemo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2580","published-online":{"date-parts":[[2026,9,25]]},"reference":[{"key":"ref0","unstructured":"Africa CDC. Mpox public health emergency of continental security. Addis Ababa: Africa Centres for Disease Control and Prevention; 2024 [cited 2026 Jun 17]. Available from: https:\/\/africacdc.org\/news-item\/africa-cdc-declares-mpox-a-public-health-emergency-of-continental-security-mobilizing-resources-across-the-continent\/"},{"key":"ref1","doi-asserted-by":"crossref","unstructured":"Ngongo N, Dereje N, El Teriaky M, et al. Reinforcing community health workers program in Africa for universal health coverage and global health security: A call for concerted efforts. PLoS Glob Public Health. 2024;4(9):e0003727. https:\/\/doi.org\/10.1371\/journal.pgph.0003727","DOI":"10.1371\/journal.pgph.0003727"},{"key":"ref2","doi-asserted-by":"crossref","unstructured":"Nsanzimana S, Remera E, Nkeshimana M, et al. Marburg virus disease in Rwanda, 2024 - Public health and clinical responses. N Engl J Med. 2025;393(10):983\u2013993. https:\/\/doi.org\/10.1056\/NEJMoa2415816","DOI":"10.1056\/NEJMoa2415816"},{"key":"ref3","doi-asserted-by":"crossref","unstructured":"Namukose E, Bowah C, Cole I, et al. Active case finding for improved Ebola virus disease case detection in Nimba County, Liberia, 2014\/2015: Lessons learned. Adv Public Health. 2018;2018:6753519. https:\/\/doi.org\/10.1155\/2018\/6753519","DOI":"10.1155\/2018\/6753519"},{"key":"ref4","unstructured":"World Health Organization. Ebola virus disease \u2013 Democratic Republic of the Congo: External situation report 97. Geneva: WHO; 2020 [cited 2026 Jun 17]. Available from: https:\/\/www.who.int\/publications\/i\/item\/10665-332434"},{"key":"ref5","unstructured":"Miller NP, Milsom P, Johnson G, et al. Community health workers during the Ebola outbreak in Guinea, Liberia, and Sierra Leone. J Glob Health. 2018;8(2):020601. https:\/\/doi.org\/10.7189\/jogh.08.020601"},{"key":"ref6","doi-asserted-by":"crossref","unstructured":"Oliver J, Ferdinand A, Kaufman J, et al. Community health workers\u2019 dissemination of COVID-19 information and services in the early pandemic response: A systematic review. BMC Health Serv Res. 2024;24:711. https:\/\/doi.org\/10.1186\/s12913-024-11165-y","DOI":"10.1186\/s12913-024-11165-y"},{"key":"ref7","doi-asserted-by":"crossref","unstructured":"Salve S, Raven J, Das P, et al. Community health workers and COVID-19: Cross-country evidence on their roles, experiences, challenges, and adaptive strategies. PLoS Glob Public Health. 2023;3(1):e0001447. https:\/\/doi.org\/10.1371\/journal.pgph.0001447","DOI":"10.1371\/journal.pgph.0001447"},{"key":"ref8","doi-asserted-by":"crossref","unstructured":"Alhassan JAK, Wills O. Public health surveillance through community health workers: A scoping review of evidence from 25 low-income and middle-income countries. BMJ Open. 2024;14(4):e079776. https:\/\/doi.org\/10.1136\/bmjopen-2023-079776","DOI":"10.1136\/bmjopen-2023-079776"},{"key":"ref9","doi-asserted-by":"crossref","unstructured":"Ballard M, Johnson A, Mwanza I, et al. Community health workers in pandemics: Evidence and investment implications. Glob Health Sci Pract. 2022;10(2):e2100648. https:\/\/doi.org\/10.9745\/GHSP-D-21-00648","DOI":"10.9745\/GHSP-D-21-00648"},{"key":"ref10","doi-asserted-by":"crossref","unstructured":"Kallon LH, Raven J, Wurie HR, Mansour W. From policy to practice: A qualitative study exploring the role of community health workers during the COVID-19 response in Sierra Leone. BMC Health Serv Res. 2023;23:1228. https:\/\/doi.org\/10.1186\/s12913-023-10272-6","DOI":"10.1186\/s12913-023-10272-6"},{"key":"ref11","doi-asserted-by":"crossref","unstructured":"O\u2019Donovan J, Baskin C, Stansert Katzen L, et al. Costs and cost-effectiveness of community health worker programs focussed on HIV, TB and malaria infectious diseases in low- and middle-income countries (2015-2024): A scoping literature review. PLOS Glob Public Health. 2025;5(5):e0004596. https:\/\/doi.org\/10.1371\/journal.pgph.0004596","DOI":"10.1371\/journal.pgph.0004596"},{"key":"ref12","unstructured":"Third International CHW Symposium. The Monrovia call to action [homepage on the Internet]. Monrovia; 2023 [cited 2026 Jun 29]. Available from: https:\/\/chwsymposiumliberia2023.org\/the-monrovia-call-to-action\/"},{"key":"ref13","unstructured":"Mwangangi M, R\u00f8ttingen J-A. The Lusaka Agenda: Conclusions of the Future of Global Health Initiatives process. Future of Global Health Initiatives; 2023 [cited 2026 Jun 29]. Available from: https:\/\/d2nhv1us8wflpq.cloudfront.net\/prod\/uploads\/2023\/12\/Lusaka-Agenda.pdf"},{"key":"ref14","unstructured":"Africa CDC. State of community health worker programmes in Africa: A multi-country assessment. Addis Ababa: Africa Centres for Disease Control and Prevention; 2021."}],"container-title":["Journal of Public Health in Africa"],"original-title":[],"deposited":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T07:28:34Z","timestamp":1790321314000},"score":1,"resource":{"primary":{"URL":"https:\/\/publichealthinafrica.org\/index.php\/jphia\/article\/view\/1920"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,25]]},"references-count":15,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1,1]]}},"URL":"https:\/\/doi.org\/10.4102\/jphia.v17i1.1920","relation":{},"ISSN":["2038-9922","2038-9930"],"issn-type":[{"value":"2038-9922","type":"print"},{"value":"2038-9930","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,25]]},"article-number":"a1920"}}