Mind the Global Community Health Funding Gap

Abstract

Community health workers play a critical role in providing both essential health services and pandemic response. Community health demonstrates a strong return on investment, but funding for this sector is limited and fragmented. Understanding the underlying costs of a community health system is crucial for both planning and policy; the data demonstrate a strong investment case.

FIGURE 1

Updated Annual Total Costs of At-Scale Community Health Worker Program Resource Needs in Sub-Saharan Africa,^a by Model US$Billions Abbreviations: CHW, community health worker; FAH, Financing Alliance for Health.^a Key driving factors of cost are rural versus rural and urban coverage (62% versus 100% of sub-Saharan Africa population) and higher cost per community health worker (11% difference).

FIGURE 2

Cost Comparison of National Community Health Programs Across 9 Countries^a in Sub-Saharan Africa, GDP Per Capita, US$ Abbreviation: GDP, gross domestic product.^a Countries X and Y are masked - awaiting formal government approval to share the data.

FIGURE 3

Average Community Health Worker to Population Ratio in 9 Countries in Sub-Saharan Africa ^a Excludes country Y in the average number; model only costed one cadre who play more of a supervisory role and that serve entire population but did not include volunteer CHWs because the program has not been costed. Costs are based on recurrent costs including commodities. Costs reflected are final year costs for the duration of the community health strategy (and hence final year of costing model). This assumes that at the final year, the program will be fully scaled, hence will have reached the steady state. Steady state costing values are adjusted to 2019 US$for comparison. Countries X and Y are masked - awaiting formal government approval to share the data.

FIGURE 4

Community Health Annualized Program Costs Showing Salaries and Incentives as the Main Cost Drivers Across 9 Countries in Sub-Saharan Africa^{a,b a} Commodities and salaries/incentives were the main cost drivers accounting for between 50%–90% of costs. Countries X and Y are masked; awaiting formal government approval to share the data.^b Key insights: overhead costs were relatively higher for countries with whole directorates; inclusion of mobile phones resulted in relatively higher costs; countries with longer training programs had relatively higher training costs.

FIGURE 5

The Average Annual Cost per Capita Served Across 9 Countries in Sub-Saharan Africa, US$^{a a} The annual average cost per person served ranged from $1.50–$13.0. Excludes country Y in the average number; model only costed one cadre who play more of a supervisory role and that serve entire population but did not include volunteer CHWS because the program has not been costed; costs are based on recurrent costs including commodities; costs reflected are final year costs for the duration of the community health strategy (and hence final year of costing model). This assumes that at the final year, the program will be fully scaled, hence will have reached the steady state. Steady state costing values are adjusted to 2019 USDs for comparison. Countries X and Y are masked; awaiting formal government approval to share the data.

FIGURE 6

Cost Efficiency of Community Health Programs With Scale in 9 Countries in Sub-Saharan Africa^{a a} As the number of people served increases, cost per person served decreases. South Africa is an outlier with both a higher population and higher cost structure for its community health program, which is based on high-cost ward-based outreach teams, a multidisciplinary platform integrated into primary care. Excluding South Africa, the trendline goes downward indicating economies of scale likely due to shared fixed costs.

FIGURE 7

Health Impact of the Community Health Worker Program in Rwanda

FIGURE 8

The 8 Design Principles to Design Optimized Community Programs

FIGURE 9

Correlation Between Country Income Status and Health Spending, Across 9 Countries in sub-Saharan Africa, Gross Domestic Product Per Capita, US$