This chapter explores the recent history of lay people getting involved in health, starting with programmes established top-down by agencies external to the communities they serve – be they government, non-governmental organisations or charitable foundations – with a particular focus on community health workers. It then looks briefly at activities that have grown ‘bottom-up’ as a result of communities initiating action themselves. The aim of the chapter is to provide a context for considering lay health worker programmes designed to improve health in the English public health system and to reflect on learning from the successes and challenges elsewhere. It is acknowledged that many of the role titles found in the international literature often bear little relation to those used in current UK public health practice (see Chapter One). This is partly a reflection of public health policy, both current and past (see Chapter Two), and partly due to the differences in health systems across the world. The authors have tried to highlight parallel roles where appropriate.

The community health worker concept – history and practice

‘Barefoot doctors’ were introduced in China in the 1950s (Zhang and Unschuld, 2008), and some other countries had similar programmes from the 1950s and 1960s, but the term ‘community health worker’, and, indeed, ‘primary health care’, only came into general usage in the 1980s (Frankel and Doggett, 1992). This section traces a brief history of the development of the community health worker concept in the global South, and then the US, before tracing the history of similar programmes in the UK in the following section.

The concept of the community health worker was developed by the World Health Organization working closely with UNICEF (United Nations Children's Fund) over a period of several years in the 1970s (Walt, 1990; Frankel and Doggett, 1992). Health as an aspect of development had been neglected in the 1950s and 1960s when economic growth was seen as the primary, and often the only, goal of development and, furthermore, it was assumed that other benefits, such as health, would ‘trickle down’. When it became clear that this was not happening, and, indeed, inequalities in general were widening, ideas on development started to change, with improvements in health seen as a necessary part of an integrated approach.