Strengthening Primary Health Care throughStrengthening Community Primary Health Health Workers:Care through Community Health Workers: Investment Case and Financing Recommendations JULY 2015 Cover: Village Health Team member in Mpigi, Uganda CREDIT: FROG DESIGN 13 July 2015 We are delighted to present Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations, a jointly authored report representing our collective findings on the urgent need for national governments and development partners to substantially increase investment in Community Health Workers as part of integrated health care systems. We fully endorse the findings and recommendations contained herein, and we are committed to building stronger health delivery systems centered on community-based primary health care. There is a strong case for investment in Community Health Workers, which this report lays out alongside important guiding principles for building and financing these systems. We encourage government leaders to develop investment cases to identify the scale and economic impact that a strong, integrated Community Health Worker program could have in their countries, with special attention to increased employment, productivity, and the empowerment of women. In collaboration with existing efforts such as the One Million Community Health Workers Campaign and in partnership with UNICEF, the World Health Organization, and many partners, we will work to support the implementation of these recommendations. We believe that doing so will help save the lives of millions of women and children, bring us closer to achieving Universal Health Coverage, generate revenue for developing country economies, and help us build more resilient health systems capable of preventing and containing future health crises. His Excellency Hailemariam Dessalegn Her Excellency Ellen Johnson Sirleaf Prime Minister, Federal Democratic Republic of Ethiopia President, Republic of Liberia Raymond G. Chambers Dr. Tim Evans The U.N. Secretary-General’s Special Envoy Senior Director, Health, Nutrition, and Population, for Financing the Health MDGs and for Malaria The World Bank Group Dr. Chelsea Clinton Dr. Paul Farmer Vice Chair, The Clinton Foundation Chief Strategist and Co-founder, Partners in Health Joy Phumaphi Jeffrey C. Walker Executive Secretary, African Leaders Malaria Alliance Vice Chair, MDG Health Alliance Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations i Contributing authors: Dr. Bernice Dahn, Minister of Health, Republic of Liberia Dr. Addis Tamire Woldemariam, Ministry of Health, Federal Democratic Republic of Ethiopia Dr. Henry Perry, Johns Hopkins Bloomberg School of Public Health Dr. Akiko Maeda and Drew von Glahn, The World Bank Dr. Raj Panjabi, Na’im Merchant, and Katy Vosburg, Last Mile Health Dr. Daniel Palazuelos, Partners in Health Dr. Chunling Lu, Division of Global Health Equity, Brigham & Women’s Hospital John Simon, Total Impact Advisors Jerome Pfaffmann, UNICEF Daniel Brown, Austin Hearst, Phyllis Heydt, and Claire Qureshi, Office of the UN Special Envoy for Financing the Health MDGs and for Malaria ii Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations Table of Contents Executive Summary 1 Chapter 1. The Case for Investment in CHWs 4 Chapter 2. Setting the Context for CHW Programs: Concepts and Principles 9 Chapter 3. CHW Financing: Developing a Pathway to Sustainably Finance System Costs 14 Chapter 4. Recommendations 24 Appendix 1. CHW ROI: Methodology, Assumptions, and Limitations 27 Appendix 2. Financing Support Unit 30 Appendix 3. Abridged Case Studies of Large-Scale Community Health Worker Programs 32 Endnotes 53 Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations iii Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations Executive Summary linkages to the health system for hundreds of millions of individuals in Africa and around the world. 4-6 As we enter the final months of the Millennium Despite the progress some countries have made Development Goal (MDG) period, the world is at a in scaling up CHW programs, many countries that critical moment of reflection and aspirational forward would benefit from strong CHW cadres currently thinking. While significant progress has been made have only ad hoc, sub-scale programs. This problem on the health MDGs (including a global reduction in extends even to high-income countries that would the child mortality rate by nearly 50% since 1990 and the maternal mortality ratio by 45% in the same period), it is now clear that we will not meet the . to ensure adequate preparedness targets for these MDGs, goals 4 and 5 respectively.1 Additionally, as the Ebola outbreak slows in West against future epidemics, to continue Africa, the world is attempting to understand how the fight against the top killers of this outbreak became so severe so quickly and how future health crises might quickly be contained. In children and mothers around the this context, world leaders are setting health targets for the next phase of global development that focus world, and to build capacity to handle on championing the achievement of universal health coverage (UHC). the growing burden of chronic, An emerging consensus among global health non-communicable diseases. leaders is that building stronger health delivery systems, with particular emphasis on community- based primary health care, will be required in the benefit from CHW programs to provide cost-effective future—to ensure adequate preparedness against care and battle chronic disease. Countries wishing to future epidemics, to continue the fight against the scale these programs using a coordinated national top killers of children and mothers around the world, strategy face many challenges. Chief among these and to build capacity to handle the growing burden challenges are limited political prioritization of CHWs of chronic, non-communicable diseases. This will and a subsequent lack of financing: insufficient and involve harnessing the potential of multidisciplinary inaccessible international funding as well as limited care teams (including CHWs, mid-level workers, alignment on pathways for domestic financing. and professional health workers) to extend health These challenges were taken up by a high-level 2 services to poor and marginalized populations. panel convened by Prime Minister Hailemariam Within this mix of skills, cadres of trained Community Dessalegn of Ethiopia and Ray Chambers, the Health Workers (CHWs) can play an important United Nations Secretary General’s Special Envoy role in increasing coverage of essential healthcare for Financing the Health MDGs and for Malaria. 3 interventions and enhancing the resilience of health This report states the three key takeaways from this systems to crisis. Indeed, CHWs have been cited panel’s investigation of CHW financing and offers repeatedly by leaders such as Liberia’s President seven recommendations to support countries in the Ellen Johnson Sirleaf as essential in responding to development of strong, integrated CHW programs. health crises, delivering routine care, and providing Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations 1 Key Takeaways • A core enabler of successful programs is that CHWs be considered part of integrated Over the course of this panel’s investigation into community-based primary health care teams CHW financing, three key takeaways emerged: and of a broader, equity-focused health system, rather than standalone agents. I. There is a strong case for investment CHWs and lower-level facilities must have in CHWs as a component of primary sufficient referral capacity so patients can be health care appropriately and reliably treated at higher-level • Investment in CHWs will be essential to facilities when required. achieving UHC, meeting the core capacities of the International Health Regulations (IHR), III. Sources of financing for CHWs exist, but and reaching other critical health objectives. countries must be proactive to assemble a Expanded access to key interventions provided financing pathway for their system by CHWs could prevent up to 3 million deaths • Countries that have successfully financed per year strong national CHW programs with paid, • Investment in CHWs in sub-Saharan Africa can formalized CHWs have done so through result in an economic return of up to 10:1— coordination of numerous traditional financing due to increased productivity from a healthier sources including international donors and population, potentially reducing the risk of domestic resources epidemics such as Ebola, and the economic • Countries may follow a four-step process to impact of increased employment develop a financing pathway in support of • Scale-up of CHWs can create short-term cost their overall health workforce development savings in other parts of the health system, plans: determining the required program scale, including reductions in the number of patients costing the plan year-by-year, setting financing treated at facilities targets for each year by funding source, and • CHW systems yield additional societal benefits identifying specific financing mechanisms to including the empowerment of women and fulfill these targets increases in income for households of paid This panel believes high-performing