community health worker models: a focus on sustainability henry perry

How can we build sustainable large-scale national CHW programs?

Henry Perry, MD, PhD, MPH Senior Scientist

Johns Hopkins Bloomberg School of Public Health

Overview • Historical perspectives on large-scale CHW programs

• Financial sustainability of large-scale CHW programs

– Evidence on financing of CHW programs

• Return on investment in CHWs

• The proposed Financing Alliance for Health

• The way forward

Historical perspective

• Programs in the 1970s and 1980s not well planned – Inadequate supervision and logistical support – Lack of evidence of program effectiveness (no

ongoing M&E or gradual program strengthening) – Lack of political support to sustain costs

• Competition with funding for curative care

and funding for higher-level facilities

Financing of CHWs as a political problem

• Government investments in health care traditionally not seen as a good financial investment

• Ministries of health lack political clout with the finance ministry

• Health systems investments focused on less productive investments (particularly higher-level facility-based care – “hospital centrism”)

Hospital-centrism: health systems built around hospitals and specialists

Source: MOH, Republic of Ghana, A Primary Health Care Strategy for Ghana, 1978

Available at: http://www.mchip.net/sites/default/files/MCHIP_CHW%20Ref%20Guide.pdf

Return on investment in CHWs – 10:1

• Improvement in health status (and increased worker productivity)

• Reduced risk of pandemic or “Ebola-like” events • Savings in the health system by making services

cheaper • Broader social benefits (income for CHWs and their

poor families; women’s empowerment; registration of vital events)

The proposed Financing Alliance for Health

• Serve as catalytic link between ministries of health and global stakeholders (banks, investors, international finance institutions)

• Provide support for the short-to-medium term as donor support diminishes and before countries ready to shoulder the full cost of CHW operations

• Have its technical home in the International Institute for Primary Health Care in Ethiopia

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A partnership to support governments in rapidly financing and scaling CHW programs

Mission • Work with national and sub-national governments to support the design and funding of

ambitious, affordable, and at-scale community health systems, including funding through innovative financing pathways and investments.

Value proposition

• Commitment to partnering with governments and building local capacity

• Expertise in financing, action-oriented nature, commitment to the ten guiding principles established in the CHW Investment Case Report

Types of support

• Financing support: ROI advisory, financial advisory & execution

• Scale-up strategy support: overall plan design, model refinement & expansion, targeted technical support

• Knowledge management and capacity development: south-south dialogues on guiding principles, insights on existing pathways, capturing experiences

Core partners • UNICEF, the UN Special Envoy’s Office, and the MOH Ethiopia are the core partners

driving forward this work

• World Bank, PIH, Last Mile Health, CHAI, and JHU also involved

• Core partners asked to dedicate capacity and help engage countries

COMMUNITY HEALTH FSU MISSION AND SUPPORT

The way forward

• We need a big boost of at least $1 billion from international donors to move the CHW agenda forward (Jeff Sachs)

• We need continued evidence of effectiveness and cost-effectiveness of large-scale CHW programs (Henry Perry)

• We need to build national political support for CHW programs (Henry Perry)

• We need multiple sources of financial support rather than rely on a single source (Henry Perry)