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Background South Africa is an upper middle-income country, but has one of the widest GINI co-efficients in the world. It faces a heavy burden of disease and poor health outcomes remain a challenge for millions of South Africans. Slow economic growth, rapid urbanization and high unemployment could de-rail the efforts to improve access to health care and health outcomes amongst the most vulnerable in the country. Within this context, the introduction of large scale, comprehensive community health worker (CHW) programs, in urban areas are seen to be game changers. However, there is inadequate global evidence on whether such programs work. Methods This is a multi-method, quasi-experimental intervention study measuring the effectiveness of a CHW program in the Ekurhuleni health district; set in an urban province of South Africa, where CHWs support approximately one million people. Health indicator performance was compared in clinics with good coverage of CHWs and those with low or no CHW support. Poor and vulnerable households with CHW support were compared to those with no CHW support. Results Over a nine-year period since implementation, clinics with CHW programs improved better than clinics without; on identified pregnancy, child health, infectious disease and non-communicable disease indicators. Odds ratios showed that households with good CHW coverage had better social support, health-seeking behavior, morbidity and mortality than households without. p-values were statistically significant (&amp;lt;0.05) for social support, chronic disease diagnosis and chronic disease control outputs. Conclusions This CHW program has shown its worth as it has been effective in improving early screening, referrals, diagnosis and disease control across a number of health conditions in an urban setting. Key messages Large-scale comprehensive CHW programs are a good investment towards achieving universal health coverage for all by improving access and care to the poor and vulnerable. Community Health Worker services in households are effective and should be a legitimate level of health care delivery in developing countries.

Are large scale, urban, comprehensive CHW programs effective? The South African experience