A 10:1 economic ROI is not enough, CHW experts say

When Community Health Worker (CHW) programs seek crucial funding, they often note their programs have a hefty economic return on investment (ROI). However, leading CHW experts say programs should also emphasize other kinds of returns to help get the resources they need.

It has been argued that CHW programs can deliver an annual ROI of 10:1 on the dollar, a figure that has tended to focus on economic returns, including increases in worker productivity, lower insurance payouts, and higher employment rates. Still, despite the tremendous success of CHW programs around the world, they often face uphill battles when seeking funding from governments and non-government actors.

Dr. Angela Gichaga, CEO of Financing Alliance for Health, said that CHW programs should also emphasize their overall social and health impacts to demonstrate that the programs are not only successful and sustainable, but also affordable.

"For many countries the economics are a strong case that [still] need to be complemented,” Dr. Gichaga said. “The solution is making a case that is not just economic, but also holistic to a given country’s specific social context, whether that is fomenting job development, economic opportunity, rural development or women’s empowerment, or making health more affordable and accessible.”

Danny Abdallah Al-Dean, Health Financing Fellow for Last Mile Health in Liberia, concurred, noting that while a majority of rural Liberians lack access to traditional health care or live more than five kilometers from health facilities, CHWs are filling in these gaps in services and having a huge impact.

“Their interventions are cardinal in making a case for ROI, their success stories – shown in pilots and early implementation – have led to a decline in child mortality, neonatal deaths, malaria cases, and increases in child and maternal health, parental planning, etc. Their stories also demonstrate how quality CHW programs can increase access to essential health services in hard-to-reach areas and can improve the efficiency of the overall health sector, by reducing the burden on primary facilities and local hospitals,” he said, pointing to health returns in Liberia that today see 70 percent of its 700,000 rural residents having access to CHW care.

This has been the case in Bangladesh, where a cadre of 130,000 CHWs have delivered care to more than 100 million rural residents. Or in Brazil, where CHWs provide coverage to nearly 60 percent of the country's population. And, it's also true in Ethiopia, where CHWs have helped the country achieve most of its health-related Millennium Development Goals, including a 67 percent reduction in under-five mortality, a 71 percent decline in maternal mortality ration, a 90 percent decline in new HIV infections and more than a 50 percent reduction in mortality due to tuberculosis.

CHWs play an essential role, especially in LMICs, where health already tends to be an underfunded sector. In 2001, the Abuja Declaration had sub-Saharan countries of the African Union committing to ensure health expenditure would reach 15 percent of national budgets. The goals have not been met by most and, in some cases, expenditures have even decreased. In Liberia, the impact has been an inability to “deliver services in 14 out of 15 counties, with funding sources not always being guaranteed,” Al-Dean said.

Securing financing for CHW programs in this context often proves to be a major challenge, with no silver-bullet solution. But Al-Dean said countries “need to develop a sustainable pathway for community health financing, [including] political will, or the willingness for the government to fully finance community health programs; [managing] unpredictable financing mechanisms; and [improving] coordination of partners’ support amongst stakeholders.”

Improved coordination could be an antidote to the great fragmentation in existing systems. Because governments do not always adequately finance their health systems, they cannot meet their national demand for care. As a result, they turn to non-state players to fund programs - including CHW programs.

But those funders, Gichaga said, often have their own interests and goals, some of which are based on a disease or geography and the result is inefficiencies. “Certain diseases get the Rolls Royce treatment, and others barely have a bicycle. If you do the patient pathway, and put yourself as a patient, the same patient who has a disease that is overly funded – for example, HIV – is now living longer because they are on ARVs and are now experiencing diabetes or hypertension. They will get the Rolls Royce services for HIV, but then lack the necessary medicine for diabetes or hypertension. So that is a challenge,” she said.

Al-Dean has experienced a similar reality in Liberia, where, he says, community health programs have become too heavily donor-financed, in a model that is not particularly sustainable given donors’ priorities can change over time and global health challenges or economic contractions might affect the levels of contribution to the country’s program.

In an already challenging context of health care systems that are underfunded and heavily fragmented, there also exists the belief that countries can improve health outcomes without increasing their budget. “There is a resistance in many governments who say ‘we already give health this much,’ but they are not always able to see the ROI. And there is a perception problem that doesn’t always reflect the reality,” Gichaga said, adding that some of the battle of securing funds lies in better articulation of success.

“We’re not capturing the data that is required to make the case, and we’re not making a complete case," Gichaga said, stating that ministries of health often overemphasize health impact to governmental decision-makers who emphasize finance and resource allocation. "So, there’s a language breakdown between those who make the technical solutions, like the ministries of health, and those who give the funds, like the ministries of finance. There is a perception and reality delta that exists.”

The solution may be in working to help governments and funders understand that the financing in question is a long game - not for community health worker projects and rather, for community health worker programs. Analyzing CHW financing in a manner that shelters them from the shorter-term volatility of national budgets, might be a good way to start, Gichaga said.

“What that means is that a funder wants to come and give money and say, ‘in a year’s time, I want these kinds of results.’ The truth is, if you are really trying to do systems change, who you give the money to, and how long you give the money for, have impacts on the results you will get. So, if you move from a project mentality, where as a funder, you are only giving a non-state player money, and you are giving it for a short period of time, while expecting results at the end, that poses a lot of issues,” she added.

One way to disable the creation of parallel health systems with conflicting priorities, Al-Dean argued, is for funders to detach their contributions from their own objectives or results, which do not always align with national monitoring and performance frameworks and schedules. "The funding request granting process has different timelines with uneven cycles that do not necessarily align with the MOH own programming cycles, generating additional burden and inefficiency in these processes,” he said.

Scaling efficiently may mean improving the way in which funding is secured - while ensuring governments and funders that CHW programs are a long game, with returns far beyond economic. By recognizing both health and social returns on investment, and promoting the defragmentation of health, CHW financing may deliver well beyond a 10:1 ROI.