In Raven et al.’s  qualitative research, respondents described several problems related to CHW selection. These included the following: nepotism in the selection process, that willing applicants may not meet selection criteria (for example, older women and men may not meet the educational criteria), the difficulty in recruiting young literate CHWs, early dropout due to misinformation about the job and too few people volunteering. Naimoli et al.  discuss the importance of community participation in joint ownership and design of CHW programmes, of which selection is a component.
Turinawe et al.  used an ethnographic approach where they retrospectively analysed the process of selecting Village Health Teams (VHTs) through a process supported by AMREF in rural Uganda. Their research describes how a poorly executed recruitment process for VHTs, which was over-influenced by community elites such as village council leaders, negatively impacted upon CTC providers’ ability to work and the respect and trust of communities towards those who were selected. Elite capture was observed: local leaders selected VHTs in a way that alienated community members who in turn started to question the credentials of those who were selected. VHTs felt under pressure to regulate community members and to report and “arrest” those who, for example, did not have a toilet. Resentment grew and, without the support of the community, the VHTs had low morale and stopped work.
Similarly, in rural Manipur, India, qualitative research by Saprii et al.  showed that the selection of the role of Accredited Social Health Activists (ASHAs) was often skewed by political interests. Most doctors and nurses interviewed felt that there was “biased” selection of ASHAs. Although ASHAs were nominated by the village community, the final selection was viewed as based on favouritism and unduly influenced by local leaders who hoped to one day become permanent government employees. This in turn damaged the legitimacy and ability of ASHAs to continue their work.
More positive examples of engaging communities to support CTC providers emerged from the analysis of a community health system strengthening (CHSS) approach in Uganda and Tanzania by Lunsford et al. . CHSS draws on existing formal and informal networks within a community, such as agricultural or women’s groups, to support CTC providers and address gaps in community-based health services. Community team members supported the CTC providers, encouraging community members to follow advice and referrals from CTC providers, thereby reducing loss to follow-up at all points in the continuum of care. The results were encouraging: during implementation, more pregnant women registered for antenatal care and tested for HIV, health extension workers conducted more postnatal visits and more households had functioning latrines and proper latrine use increased. The model offers a framework for bringing representatives from existing community networks, CTC providers and health facility staff together to form a community team charged with identifying challenges in service delivery, testing solutions and monitoring changes.
The CHSS approach has synergies with the natural helper model proposed by Turinawe et al.  as a way to avoid elite capture. In this model, naturally existing informal helping networks, including volunteers already trusted by the people being served, are used to inform CTC provider selection and support the CTC providers in conducting their tasks, resulting in positive and supportive relationships.