Reaching the rural: a critical study into the role and performance of community health entrepreneurship

In most low- and middle-income countries, the only way to access primary health care is through so-called ‘community health worker’ programs. Such programs mobilize community spokespersons and train them into volunteer health workers.

In theory, these programs are a crucial health system link: they offer essential services and products at the community level and support prevention through active outreach. In practice, however, these programs perform poorly and tend to collapse due to their dependence on volunteer workers and foreign aid. The programs that are able to endure face a range of other significant challenges, including: overemphasis of one specific theme of intervention (e.g. malaria), dependence on local government prioritization, and dissipating quality of medicines and regular stock-outs.

Community health workers

An alternative way to organize community health care is through community health entrepreneurship. Such a model builds on the notion of social entrepreneurship to organize and govern community health care. In Uganda, for example, existing community health workers in rural areas are enrolled into a social franchising model. In this new model, the community health workers receive additional medical training and are educated in key principles of running a (social) enterprise.

In addition, they will now be part of an ‘end-to-end medicines supply-chain’ that aims to guarantee quality and prevent stock-outs. In their new role, the entrepreneurs provide high-quality primary health services for free and sell essential medicines against (generic) cost price.

Mixed-methods approach

In a mutual endeavour with local partners, this project is the first to systematically explore the functioning of community health entrepreneurship in practice. By using a mixed-methods approach (applying principles from epidemiology, anthropology, health systems research, and public administration) we aim to assess how community health entrepreneurship affects local communities, shapes the performances of community health workers, and interacts with (existing) institutions.

Involved Researchers & Departments

  • dr. Roland Bal, Maarten Kok, & Robert Borst - Health Care Governance, ESHPM

Countries Involved 

The Netherlands, the Republic of Uganda, the Democratic Republic of the Congo, the Republic of Rwanda


Anonymous donor through Erasmus Trustfund & Healthy Entrepreneurs

Contact info

Email address

Roland Bal, Prof., PhD (ESHPM)

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