When community health programs are well-designed, managed, and sufficiently funded, they can yield substantial health and economic benefits. In addition to contributing to a healthier, more productive population, they can reduce the risk of costly epidemics while generating substantial cost savings for families and health systems.1 On the other hand, when poorly designed or managed and insufficiently funded, community health programs can fail to improve poor health outcomes and advance national health priorities.
Recognizing their potential in strengthening primary care and advancing Universal Health Coverage, countries are increasingly formalizing the role of the community health worker within their health systems. In fact, many countries have passed national community health policies to ensure that community health workers (CHWs) are well trained, incentivized, and equipped to provide a basic package of life-saving services within their communities.
Despite this momentum and growing political commitment, many low-income countries lack sufficient financial resources to start-up and sustain community health programs. They also lack evidence on the long-term costs and return on investment of these programs which can contribute to a reluctance among technical and financial partners to pledge funding amidst other competing priorities.
To help countries generate evidence on the costs and return on investment, UNICEF and Management Sciences for Health (MSH) developed the Community Health Planning and Costing Tool (CHPCT). Based on data entered into the tool, one can calculate the costs and required financing for the introduction, maintenance, or scale-up of community programs over 10 years at the national or sub-national levels. Stakeholders can then use these results to evaluate program performance, plan for future programming, and develop investment cases for introducing or expanding community health services. Since its initial development in 2016, the CHPCT has been used in 14 countries to facilitate the planning and mobilization of financial resources for community health programs (Angola, Burkina Faso, Comoros, Liberia, Madagascar, Malawi, Mali, Mozambique, Sierra Leone, Somalia, South Sudan, Tanzania, Togo, Zanzibar). The tool is open-source and is provided with user manuals and reports on country applications.
In South Sudan, the government has used the CHPCT to design implementation scenarios and mobilize resources for the country’s Boma Health Initiative (BHI), which seeks to train and deploy more than 6,000 CHWs at the Boma—or local government—level. At a recent dissemination meeting in February 2019 in the capital of Juba, partners pledged €1 million toward the implementation of the new BHI following the presentation of the investment case.
In Burkina Faso, the Ministry of Health used the CHPCT to develop a five-year investment case for its new community health strategy, which aims to train and deploy more than 20,000 community health workers nationwide to provide a basic package of services. The Ministry used results to gain buy-in from key partners and present evidence on the estimated funding gaps and anticipated health impact of the program.
And in Angola, the CHPCT has been used to analyze the cost and prepare an investment case to provide evidence for the government and donors to fund the broadening of the community health program to cover malaria, diarrhea, pneumonia and TB services to the areas of greatest need. The results are being used to determine the national plan for community health service expansion.
In these three countries and others where CHPCT has been used, evidence shows that investing in CHWs and expanding access to a package of promotional, preventive, and curative health services would result in a considerable return on investment in terms of reducing under-five and maternal deaths. For example, in Burkina Faso prospective modelling using the Lives Saved Tool shows the population could experience a nearly 20% reduction in under-five mortality and a 16% reduction in maternal mortality if access to community health services is improved. The evidence also showed that efforts would be needed to resolve existing supply- and demand-side bottlenecks for these programs to reach their potential. For example, frequent stock-outs of medicines and supplies as well as delays in payments to CHWs can contribute to poor uptake of services as well as attrition among CHWs, respectively. To expand use of the CHPCT, UNICEF and MSH are developing a French version of the tool and user guides as well as a series of training materials for potential users.
Photo credits: MSH
1 Dahn B, Woldemariam A, Perry H, Maeda A, von Glahn D, Panjabi R et al. Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations 2015. 60 p. Available from: http://www.who.int/hrh/news/2015/CHW-Financing-FINAL-July-15-2015.pdf
About the Authors
Colin Gilmartin is a Senior Technical Advisor, Health Economics and Financing at MSH supporting the design and implementation of programs to advance universal health coverage. He specializes in policy research and analysis, economic evaluation, and financial modelling. Most recently, he supported the Ministries of Health in Burkina Faso, South Sudan, and Madagascar in the development of investment cases for national community health programs. Colin began his career working in rural Burkina Faso as a community health development worker with the U.S. Peace Corps.
David Collins is a Senior Principal Technical Advisor, Health Economics and Financing with over 30 years of experience in international health and development projects, including working as resident health finance advisor to the Ministries of Health of Kenya and South Africa. He works for Management Sciences for Health in health financing and is an Adjunct Associate Professor at Boston University. He provides technical assistance and training to developing countries in all areas of health finance including the development and use of costing tools for modeling integrated packages of hospital, health centre and community services, as well as for modeling vertical program costs, such as for TB, family planning and malaria.