Community health worker programs – underrecognized and underfunded. Are novel ways of financing needed?

CHW programs are recognised as integral component of primary health care but financing remains a big hurdle

CHW programs are listed as one of the most valuable tools to reach health goals and make progress towards achieving universal health coverage by 2030 (Perry et al., 2021). A high-level panel, consisting of the United Nations Secretary Special Envoy for Financing the Health MDGs, several African state prime ministers, UNICEF, WHO, World Bank and community stakeholders concluded that there is a strong case for investment in community health workers as a component of primary health care (Strengthening PHC, 2015). Such programs not only have direct health benefits, but have a potential economic return on investment of up to 10:1 as the result of increased productivity of a healthier population, reduced impact of pandemics and increased employment.

The panel also called upon government leaders to seek innovative financing arrangements to scale up CHW programs across the continent and the international community to fund the start-up costs of these programs. However, financing of large scale, nation-wide comprehensive CHW programs remains a major challenge. The 2018 WHO guidelines for CHW programmes (WHO, 2018) emphasise that CHW programmes require long-term and dedicated financing. Attempts to set up and run a large-scale CHW initiative on a shoestring budget are likely to yield disappointing outcomes. The USAID’s Centre for Accelerating Innovation and Impact and the Financing Alliance for Health estimates a funding gap of $2 Billion to build and strengthen community health systems in sub-Saharan Africa (USAID, 2021).

The impact and effectiveness of these programs is however inconsistent at best. A wide body of literature documents failures with programs that saw CHWs as a solution to deliver primary health care (PHC) at low cost.

Such programs not only have direct health benefits, but have a potential economic return on investment of up to 10:1 as the result of increased productivity of a healthier population, reduced impact of pandemics and increased employment.

Incentives and remuneration for CHWs are essential components of successful programs

The WHO guideline recommends that practicing CHWs receive a financial package that reflects the job demands and its complexity, the number of hours, training and the roles that they are asked to undertake. It is estimated that only 15% of CHWs deployed in sub-Saharan Africa programmes receive a regular remuneration or salary while the majority works as volunteers (Masis et al., 2021). CHWs often live and work in rural locations, in communities living close to the poverty line. Expecting CHWs to deliver lifesaving work without entitlement to decent pay is inconsistent with the international agenda on decent work (ILO, Decent Work). Not surprisingly, reviews of programs have found that CHW motivation and performance (or lack of) was closely linked to the degree of satisfaction of the CHWs with the incentives received (Colvin et al., 2021).

To ensure that CHWs feel as valued and respected members of the health system with a clear role and defined responsibilities is an important non-monetary motivator. However, financial recognition is at least as important and there is emerging consensus that CHWs should be adequately paid (Ballard et al., 2021). But lack of political will and especially limited financing remain major hurdles in many low-income countries. While these are unlikely to be adequately addressed in the short term, the development community should in the meantime seek innovative solutions to improve the economic independence of CHWs.

It is estimated that only 15% of CHWs deployed in sub-Saharan Africa programmes receive a regular remuneration or salary while the majority works as volunteers.

The case of village health workers in Lesotho

The government of the small ‘Kingdom in the Sky’ in Southern Africa strengthened the community involvement in primary health care in 1979 through the introduction of the village health worker (VHW) program. With one of the highest rates of HIV infections in the world (23%) and a significant shortage in health human resources, the VHW program played a major role in the scale-up of HIV treatment and care (Rigodon et al., 2012). Today they continue to deliver essential HIV and tuberculosis care to their communities as well as services in maternal and child health care. Originally deployed as volunteers, the government introduced an incentive scheme for the VHWs. A monthly stipend of 300 Maloti ($19) is promised but, the payment often fails to materialize. VHWs report delays of up to four years of backlog in payment of their stipends (Lesotho Times, 2018).

But lack of political will and especially limited financing remain major hurdles in many low-income countries. While these are unlikely to be adequately addressed in the short term, the development community should in the meantime seek innovative solutions to improve the economic independence of CHWs.

Improving economic independence of CHWs in Lesotho, a pilot initiative to finance a nationwide CHW program

Community based chronic care Lesotho (ComBaCaL), a large-scale 5-year project by SolidarMed and various local stakeholders including the Ministry of Health seeks to replicate the success from HIV care in non-communicable disease (NCD) care. The project opted for an alternative novel way to sustainably finance the CHWs. In addition to being entitled to the government stipend, the CHWs recruited in the project are being empowered to become micro-entrepreneurs in their spare time. Initial market research has indicated that many CHWs already have some ‘entrepreneurial ideas’ that can be harnessed and with appropriate support developed into income generating activities.

The project opted for an alternative novel way to sustainably finance the CHWs. In addition to being entitled to the government stipend, the CHWs recruited in the project are being empowered to become micro-entrepreneurs in their spare time.

A pilot is now underway whereby CHWs are introduced to the "Start and Improve Your Business" training (SIYB), developed by the International Labour Organisation. The programme has a strong track record of promoting development of micro enterprises. In the past 40 years, 23.7 million people have received the training and by the end of 2020, it is estimated that the implementation of SIYB had led to the start-up of at least 5.4 million new businesses, creating more than 10.4 million jobs globally (ILO, 2021).

The CHWs in the ComBaCaL project will have access to micro-financing to implement their business idea as well as ongoing supervision and mentoring with the goal to become self-reliant. However, it remains to be seen how they can keep an adequate balance between their role in NCD care and their business. This pilot initiative will provide guidance on how a CHW program can be financially sustainable – independent of long-term donor funding.

References

• Ballard, M., Westgate, C., Alban, R., Choudhury, N., Adamjee, R., Schwarz, R., Bishop, J., McLaughlin, M., Flood, D., Finnegan, K., Rogers, A., Olsen, H., Johnson, A., Palazuelos, D. and Schechter, J., 2021. Compensation models for community health workers: Comparison of legal frameworks across five countries. Journal of Global Health, 11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC79164...
• CHW Central, 2021. Community Health Worker Programs from Afghanistan to Zimbabwe. [online]. Available at: [Accessed 7 May 2022]. https://chwcentral.org/resources/health-for-the-pe...
• Colvin, C.J., Hodgins, S. & Perry, H.B. Community health workers at the dawn of a new era: 8. Incentives and remuneration. Health Res Policy Sys 19, 106 (2021). https://health-policy-systems.biomedcentral.com/ar...
• International Labour Organisation (ILO), 2021. Expanding Entrepreneurship: 23 million and counting Start and Improve Your Business Global Tracer Study 2016-20. https://www.ilo.org/empent/areas/start-and-improve...
• International Labour Organization. Decent Work. Available: https://www.ilo.org/global/topics/decent-work/lang–en/index.htm. [Accessed 7 May 2022].
• Lesotho Times, 2018. Cry the neglected village health workers. https://lestimes.com/cry-the-neglected-village-hea...
  
• Masis, L., Gichaga, A., Zerayacob, T. et al. Community health workers at the dawn of a new era: 4. Programme financing. Health Res Policy Sys 19, 107 (2021). https://doi.org/10.1186/s12961-021-00751-Z
• Perry HB, Hodgins S. Health for the people: past, current, and future contributions of national community health worker programs to achieving global health goals. Glob Health Sci Pract. 2021;9(1):1-9. https://doi.org/10.9745/GHSP-D-20-00459
• Rigodon, J., Joseph, K., Keshavjee, S., Cancedda, C., Haidar, M., Lesia, N., Ramangoaela, L. and Furin, J., 2012. Training Community Health Workers to Scale-Up HIV Care in Rural Lesotho: Implementation Lessons from the Field. World Journal of AIDS, 02(03), pp.135-142. https://www.scirp.org/journal/paperinformation.asp...
• Strengthening Primary Health Care through Community Health Workers (2015): Investment Case and Financing Recommendations. http://www.mdghealthenvoy.org/wp-content/uploads/2015/07/CHW-Financing-FINAL-July-15-2015.pdf. [Accessed 7 May 2022].
• USAID, 2021: Strengthening Primary Health Care though Community Health Workers: Closing the $2 Billion Gap https://www.usaid.gov/sites/default/files/documents/1864/USAID_FAH_Report_digital_version_nov21-508.pdf. [Accessed 7 May 2022].
• WHO guideline on health policy and system support to optimize community health worker programmes. https://apps.who.int/iris/bitstream/handle/10665/275474/9789241550369-eng.pdf?ua=1. [Accessed 7 May 2022]