National community health worker (CHW) programmes are increasingly regarded as an integral component of primary healthcare (PHC) in low- and middle-income countries (LMICs). At the interface of the formal health system and communities, CHW programmes evolve in context specific ways, with unique cadres and a variety of vertical and horizontal relationships. These programmes need to be appropriately governed if they are to succeed, yet there is little evidence or guidance on what this entails in practice. Based on empirical observations of South Africa’s community-based health sector and informed by theoretical insights on governance, this paper proposes a practical framework for the design and strengthening of CHW programme governance at scale.