As proponents of Universal Health Coverage (UHC), the 1mCHW Campaign promotes the effective use of community health workers (CHWs) as an important service delivery mechanism for achieving UHC in sub-Saharan Africa. CHWs are a core component of the health workforce, ensuring that essential health services are made available to people everywhere, regardless of their geographic location, education level, social status, or ability to pay. While the motive for CHWs in the context of UHC is clear, sustainable financing of such a program is often viewed as a challenge or barrier to scale-up. To address this gap, the Campaign urges financing organizations to invest in CHWs and tries to motivate governments to demand such support from donors.
The current financing landscape for government-run CHW programs is broad, but can be broken down into four general categories:
Government as funder:
Government-funded programs may provide CHWs with better job security, equal pay across locations, and contribute to greater stability for the program as a whole. Ethiopia’s Health Extension Program, in which Health Extension Workers (HEWs) are Ministry of Health employees, is a successful example of this funding model. However, community health programs are often extremely vulnerable to funding cuts when governments experience financial setbacks or political instability. Additionally, if funds are highly decentralized, monies may be diverted to other areas once they reach the community level.
Community as financer:
Community-based financing (CBF) methods range from community-managed user fees, where individuals pay for health services out of pocket, but the community sets the fee levels; to provider-based health insurance, where cities, towns, or regional hospitals are the sole providers. At the most basic level, a community may provide labor and pay for the construction of a health post where CHWs will be deployed from. Performance-based financing (PBF) is one type of CBF used in Rwanda, where CHWs receive conditional financial incentives based on task completion (e.g., accompanying laboring women to health facilities). In general, however, some argue that there are no existing examples where CBF led to consistent and regular payment of CHWs, and fee-for-service mechanisms are often considered to be open to abuse.
CHW as volunteer:
While this model seems like an attractive way to cut CHW program costs, it has limitations. Depending on the amount of work expected from the CHW, this financing model can be unjust and unsustainable. Volunteer CHW programs also generally have a lower retention rate. However, they remain unaffected by government budget cuts, which may have positive implications on sustainability. Creative strategies to incentivize unsalaried CHWs do exist. The development organization BRAC, for example, allows CHWs to make a small profit from selling medicines and commodities to community members.
Grants and gifts are more likely to cover the initial start up costs of CHW programs, such as planning, policymaking, technical support, and initial training, rather than recurring long-term expenses, such as salaries. Thus, this type of short-term funding is considered to be unsustainable. Conversely, bilateral funding mechanisms often grant governments a great deal of autonomy and can be viable for longer periods of time through longer term contracts and renewals.
In reality, what we often see is a mosaic of different funding schemes for CHW programs, reflecting the unique needs and political landscapes of each country. One thing is clear: financing and equity-driven approaches need to go hand in hand to achieve UHC. Recognizing this, the Global Fund and UNICEF have recently made a commitment to optimize investments in healthcare delivery by coordinating funds for HIV, TB and malaria treatment alongside newborn and child health interventions. At last year’s Global Citizen’s Festival, the GAVI Alliance committed to support CHW training for immunization via grants to Ministries of Health in low income countries. Through these commitments we begin to see financing become an impetus for integrated service delivery – not a barrier. This type of holistic funding through strategic partnerships is exactly what is needed as many governments shift their focus toward UHC in the post-2015 development agenda. The Campaign is hopeful that global financing can function as catalytic investments in CHW systems, as a foundation for comprehensive health service delivery.