Authored by: Dr. Raj Panjabi, CEO of Last Mile Health Link to Bio
All of the countries with Exemplar CHW programs—Bangladesh, Brazil, Ethiopia and Liberia—have established programs in which CHWs are paid and/or incentivized. The WHO strongly recommends that practicing CHWs be remunerated with a financial package commensurate with the demands of the job and their training. Research indicates that investing in community health as a key component of the primary health care system can be a very cost-effective strategy for achieving health goals.
Low income countries, including Liberia, have debated the benefits of paying community health workers. In this case, Liberia decided to pay CHWs based on evidence from other countries and in-country pilots demonstrating the benefits of a well-paid and professionalized CHW cohort. Liberia’s decision was also informed by the poor performance of its earlier community health volunteers. Liberian officials understood that serving as a health worker can be dangerous, given the national experience with Ebola. As a result, officials have been sensitive to demands that health workers should be paid in a manner that reflects the risks they take and the value of their work. For more information about the discussion within Liberia on if and how to pay CHWs, please refer to Liberia Context.
The question remains, how to balance paying CHWs in a context of limited resources. How can low income countries keep professional CHW programs financially sustainable? Countries can follow a four-step process to develop a financial pathway to support CHW programs: determine the program scale, create an annual cost estimate for the plan, set annual financial targets by funding source, and identify financing mechanisms to fulfill these targets.
In Liberia, the Ministry of Health did a fiscal analysis during the development of its CHW program. It revealed that paying CHWs provided a good value for money. The Liberian government discovered that hiring, training and equipping CHWs and community nurse supervisors would only amount to 3-6% of total health expenditures and would help extend primary health care to over 60% of the rural population that was previously out of reach of health care. Further, paying CHWs can reduce CHW turnover. This is critical for keeping training expenses down and ensuring quality care by experienced CHWs.
Other exemplar countries have found innovative financing structures that help maximize resources. Ethiopia uses a “One Budget” approach to maximize efficiency, reduce duplication and avoid off-budget spending. The government pools donor funds for community health and allocates those funds through one centralized budget under the government’s control. Bangladesh leverages NGO partner resources to fill service area gaps. Brazil established threshold spending requirements on health care for its state and municipal governments, with incentives for implementing the CHW program and improving quality. Successful national financing strategies require government coordination of partners, donors, and stakeholders to capitalize on available internal and external resources.
Exemplar countries have also shown that healthcare financing is not a zero-sum game: paying CHWs does not take jobs from nurses and other healthcare providers. In fact, integrating CHWs into a team-based approach to extending primary health care services can create job opportunities for other health workers, for instance as supervisors. As an example, in Liberia 10% of the community health workforce is nurses, midwives and other frontline clinicians. Investing in CHWs creates incentives to improve overall workforce systems that can be leveraged by other cadres of health workers, a benefit that is likely not costed when calculating the return on investment of the community health system.
Finally, exemplar successes reveal that the challenge of CHW financing is equal parts technical and political/advocacy. Successful programs combine the technical evidence, plans, and investment cases with advocacy aimed at building champions and coalitions to secure financial support.
Other Resources:
- WHO provides guidance to countries on developing an affordable CHW program.
- For additional tailored support contact Exemplars in Global Health, Financing Alliance for Health, AMP Health or Last Mile Health.