Costs and cost-effectiveness of integrated horizontal community health worker programmes in low- and middle-income countries (2015-2024): a scoping literature review

Abstract

Background: Community health workers (CHWs) play a vital role in delivering primary health care in low- and middle-income countries (LMICs), addressing multiple diseases through horizontal programmes. Despite their effectiveness, there is a US$4.4 billion annual funding gap for professional CHW programmes. Some countries have adopted these programmes, while others require stronger economic evidence to justify investments. This study updates a 2015 review, critically examining the costs and cost-effectiveness of horizontal CHW programmes in LMICs.

Methods: A scoping review was conducted using 10 databases and grey literature, covering studies published between August 2015 and July 2024. Search terms related to 'Community Health Workers' and 'Economic Evaluations' were used. Studies were screened via Covidence software based on inclusion and exclusion criteria. Data on study methodology, cost and outcomes were extracted, tabulated in Microsoft Excel and analysed.

Results: A total of 18 studies, covering 42 scenarios, were included. Most studies focused on partial economic evaluations, with cost analyses being the most common method. CHW compensation varied widely, with a median monthly salary of US$265 (range US$3033 ($148 (Ethiopia)-$3181 (Malawi)); IQR US$346 (US$203-US$549)). The most commonly reported cost metric was the annual cost per capita, with a median of $6.02 (range: $0.29-$67.95). Sensitivity analyses were conducted in 29% of the scenarios, with six scenarios concluding CHW programmes were cost-effective. However, most did not conclude on cost-effectiveness or affordability, highlighting gaps in the evidence base. Service provision was the most frequently reported outcome, while cost per outcome and affordability were under-reported.

Conclusions: This review highlights gaps in the economic evaluation of horizontal CHW programmes, particularly in cost-effectiveness and affordability. More large-scale evaluations are needed to inform national health policies and support sustained investment in CHW programmes to strengthen health systems and address workforce shortages.

Keywords: Global Health; Health economics; Public Health.

Figure 1. PRISMA flow diagram. CHWs, community health workers; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.