Community health worker (CHW) programs remain an underutilized tool, despite decades of research demonstrating their potential for providing universal primary health care (PHC) and improving health outcomes. The following are key challenges to effective CHW programs at scale:
Despite evidence that CHWs can deliver interventions in a cost-effective way, compared to strictly facility-based PHC, CHW programs remain a significant cost to the PHC system.
In the context of constrained resources for PHC services, the implementation and scale-up of CHW programs usually relies on external funding (often fragmented across multiple donors, and individual diseases; see figure below). According to a study from the USAID’s Center for Accelerating Innovation and Impact (CII) and the Financing Alliance for Health, around 60 percent of the current funding for CHW programs in sub-Saharan Africa comes from donors.
Given this restricted funding, programs are often designed with volunteers or performance-based incentives for CHWs. The above mentioned study estimates that less than 40 percent of CHWs in sub-Saharan Africa are salaried. This arrangement makes the programs more affordable, but also more fragile and prone to becoming a lower priority for the health system. When funding lapses, such programs are often dismantled.