Our analysis of the four Exemplar community health worker (CHW) programs in Bangladesh, Brazil, Ethiopia, and Liberia illuminated a number of context-specific best practices that may provide guidance to leaders in similar situations seeking to design, launch, or strengthen CHW programming. These findings may not be as universally applicable as other recommendations, but they may still offer powerful guidance in many settings. 

Coordinate donors and design innovative financing arrangements

Strong, national political leadership has helped donor-reliant countries with Exemplar CHW programs succeed in breaking free of donors’ traditional vertical and disease-specific approaches. Donors typically fund interventions to prevent or treat a particular disease alone, like malaria or HIV. This can hinder governments’ investments in horizontal primary healthcare priorities, including CHW programming.

Vertical vs. horizontal programs

Disease control programs People-centered primary care

Focus on priority diseases

Focus on health needs

Relationship limited to program implementation

Enduring personal relationship

Program-defined disease control interventions Comprehensive, continuous and patient-centered care
Responsibility for disease control targets among specified population Responsibility for health of entire community in the life cycle
Population targets of disease control interventions People are partners in managing their own health

(Adapted from World Health Report 2009, "Now, More than Ever;" World Health Organization)

Liberia is a good example of how a country can counter donors' disease-specific approach. Liberia used tailor-made costing tools to analyze and understand cost implications of design elements, return on investments, and project funding streams for its horizontal community health system, and used this data to create compelling investment cases, pushing funders to follow the government's detailed plans as mapped out by costing tools.

Likewise, Ethiopia's rapid progress was due, in large part, to its ability to manage donors effectively, channeling resources and expertise away from donors' traditional funding silos and toward support for the country's flagship CHW program.

It is worth noting that Bangladesh's patchwork of overlapping, supplementary, and complementary programs are, in some respects, a result of partners' and funders' preference for vertical programs, and Bangladesh's policy of not interfering with NGO or donor work. That Bangladesh is currently moving to achieve more uniformity in programming should not be overlooked.

Middle-income countries with devolved health systems, like Brazil, face a slightly different challenge in this regard. They must secure financial commitments from across government to support programs. This is particularly challenging in devolved health systems, where a significant percentage of health spending is done by regions/states and municipalities. To secure enough funding for its program, Brazil enacted minimum spending requirements for state and municipal governments. Brazil also adopted a funding formula that incentivized municipalities to implement CHW programing. It should be noted that advocacy from Brazil's civil society played a significant role in ensuring that financial support was robust, not just from the central government, but also from states and municipalities.

Each of these strategies helped governments more effectively secure funding, ensure resources were efficiently allocated to fill gaps, and maintain sufficient funding over the long term.

Harness NGO Capacity to strengthen public sector systems

The strong management capacity required to implement and maintain a high-functioning CHW program can appear daunting. But countries with Exemplar CHW programs provide a few potential effective roadmaps. Both Bangladesh and Liberia intentionally leveraged the strength and capacity of NGOs to design, launch, improve, and expand their CHW programs. They did this by following different models.  Bangladesh, through contracts and deep partnerships with NGOs over decades, both strengthened its national program and relied on parallel NGO programs that filled gaps in government delivery. Liberia provided another pathway, relying on NGO partners to pilot and later launch and manage its national program, with the goal of assuming complete government control as capacity allowed.

Program Comparison