By Bernabas Petros and Bethelhem Teshome / Shaping Sustainable Futures conference series
Global health policy loves a good success story. Community health workers are constantly praised as the backbone of efforts to achieve SDG 3 — healthy lives and well-being for all. From Ethiopia’s famous Women Development Army to Malawi’s Health Surveillance Assistants and the UK’s Community Health Champions, these initiatives are regularly showcased as shining examples of “localization” in action.
But there’s a problem. Localization is talked about far more than it is genuinely practiced.
Take a closer look at these three systems: Ethiopia’s Women Development Army operates at massive scale, mobilizing hundreds of thousands of women at the grassroots to promote healthy behaviors, encourage vaccinations, and link communities to formal health services. Malawi’s Health Surveillance Assistants are a more formalized group — salaried government workers embedded in the public system deliver a wide mix of preventive care, disease surveillance, and basic treatment. In the UK, Community Health Champions usually work as volunteers through civil society groups, focusing on reaching marginalized populations and tackling health inequalities in a very different resource-rich environment.
On the surface, comparing them feels almost impossible. They operate on different continents, under completely different political systems, and with vastly different levels of funding and infrastructure. Yet all three are pushed into the same global narrative: that empowering communities is the magic ingredient for better health outcomes.
What happens when we go beyond the success stories?
Insights from comparative research across these countries show that the effectiveness of these programmes cannot be explained simply by numbers of workers trained, how much funding they receive, or how many households they cover. What seems to matter most is how power and decision-making are distributed — and who ultimately sets the agenda.
In some contexts, “community participation” is highly organized — sometimes to the point where it becomes an extension of state or donor priorities rather than genuine local agency. In others, it is more flexible and voluntary, but this often leads to fragmentation and heavy dependence on short-term external funding cycles. Neither model is perfect. Both come with clear trade-offs that strongly shape how communities on the ground engage with health efforts.
Another recurring challenge is the stubborn persistence of knowledge hierarchies. Even today, global health frameworks tend to prioritize standardized, technical solutions designed at the international level. Local knowledge, lived experience, and informal care practices are often treated as secondary. Programmes may be labeled as “community-driven,” but in practice they frequently operate within narrow parameters defined elsewhere — from reporting indicators to intervention priorities.
This raises a sharper question: can SDG localization ever be truly “local” if the terms of engagement, the indicators, and even the definition of success are largely decided outside the community?
Follow the money, and the picture becomes clearer. Funding for community health programmes is often tied to donor priorities, performance targets, and short funding cycles. This creates pressure to deliver quick, measurable results rather than long-term, locally grounded change. It can also limit the flexibility of local actors to adapt programs to their own needs. In some cases, communities are expected to sustain programmes through volunteerism long after external support fades — a model that raises serious questions about equity and sustainability.
Context shapes everything. Historical and cultural factors add even more complexity. Gender norms, for instance, play a major role in who participates and who benefits. Ethiopia’s Women Development Army cleverly builds on existing social structures, which helps explain its impressive reach. At the same time, it can reinforce expectations that place the burden of unpaid health work on women. In Malawi and the UK, different patterns of inclusion and exclusion emerge — linked to class, geography, migration status, or trust in public institutions.
Accountability is another overlooked piece of the puzzle. Many community health workers sit in an ambiguous position — expected to represent the community while also being accountable to the state or external funders. When priorities clash, it is rarely the community’s voice that prevails. This tension can quietly undermine trust, even in programs that appear successful on paper.
What becomes obvious across these cases is that localization is not a neutral technical process. It is deeply political — shaped by power, history, and competing interests.
What should we do differently?
If we want community health systems to deliver better and more legitimate outcomes, we need to move past merely scaling up existing models. Three shifts are essential.
First, we must abandon rigid one-size-fits-all approaches. What works well in one setting rarely translates neatly into another without careful adaptation to local governance structures, social dynamics, and power realities.
Second, meaningful localization requires redistributing real power — not just delegating responsibilities. Communities and local health workers need a genuine role in defining priorities, shaping interventions, and deciding how resources are used. Without that, participation risks becoming little more than implementation support.
Third, we need to rethink what counts as valid “evidence” in global health. Quantitative indicators and performance metrics are useful, but they often miss the most important elements: trust, cultural legitimacy, local ownership, and long-term resilience. If these are not measured, they are easily ignored.
As debates around decolonizing global health continue to grow, community health systems offer one of the clearest windows into these tensions. They sit at the intersection of ambitious global agendas and complex local realities, making visible many contradictions that remain hidden in high-level policy discussions.
The risk is real.
If SDG localization continues along its current path — heavy on rhetoric but light on actual power-sharing — it risks becoming just another development buzzword. Promising on paper, widely promoted, but ultimately disconnected from the communities it claims to serve.
The consequences are not abstract. Weak local ownership often leads to programmess that collapse when donor funding ends, interventions that fail to reflect local needs, and missed opportunities to build resilient health systems from the ground up.
There are already examples of more genuinely community-led approaches across all three countries. The real question is whether the global health community is willing to learn from them — and, more importantly, whether it is willing to let go of control.
Bernabas Petros is a PhD candidate at Addis Ababa University, Center for Sustainable Development (second cohort student). His research focuses on digital health governance, reproductive health, community based health interventions and AI in low-resource settings. He is the founder of Tena Link, a social enterprise developing mobile solutions for menstrual health. He is also a member of the European Association of Development Research and Training Institutes, Working Group on SDG Localization and International Cooperation.
Bethelhem Teshome is a medical doctor, accomplished clinician, and co-founder as well as research and content manager of the Tena link Project, an innovative, research-driven, and community-oriented digital platform designed to address critical gaps in sexual and reproductive health among focus groups and the broader communities in Ethiopia. Her work is distinguished by a culturally sensitive, context-specific, and impact-focused approach that integrates scientific evidence with deep localization. She is also a dedicated lecturer in the Medical Laboratory and Nursing Departments at Yanet College. She has served as a general practitioner, bringing compassionate, patient-centered, and evidence-based care to diverse populations.
Bernabas Petros will be presenting a poster with the title “Decolonizing Sustainable Development Initiatives: A Scopus-Based Comparative Case Analysis of Ethiopia’s Women Development Army, Malawi’s Health Surveillance Assistants, and the UK’s Community Health Champions” at the EADI/IOB General Conference
Image: USAID Ethiopia under a creative commons license from Wikimedia
Note: This article gives the views of the authors, not the position of the EADI Debating Development Blog or the European Association of Development Research and Training Institutes