Thanks so much, Justin, for taking the time to read and engage w/these great questions! A couple of thoughts:
1) Re: example of ntl level evidence: I used to live/work in Liberia and it’s a great example of such a transition. They adopted proCHWs based on advocacy + pilot evidence from Konobo district post ebola in 2016. Malaria prevalence then fell from28% (2011) to 10% (2022) across nationally-representative surveys. Multi-driver (nets, seasonal malaria chemoprevention, artemisinin therapies, the Liberian program all contributed), the platform is the delivery channel. David Walton of PMI said it was one of the fastest declines they ever documented.
On a more meta scale: 15+ years ago only a handful of countries had proCHW policy (Brazil, Ethiopia). People used to laugh at the suggestion :) Now 55+ countries have such policies following coordinated, multi-country 10 yr campaign targeting international guidelines, funding, and ntl policy. Contribution, not attribution etc etc but after 100 yrs of basically no movement whatsoever on this, it’s something.
2. Predictors: Literal PhDs written on this! (Finnemore & Sikkink on norm diffusion = excellent). We at CHIC have two realist synthesis papers on this in process (one on how CHW associations organize to shift government behavior, e.g. mechanisms = a combined legal/association/protest pressure in a political opening), one on the political economy of domestic CHW financing, e.g. mechanisms = design choices at program inception etc.) Some common ingredients: a ministerial champion; a unified professional voice/constituency (e.g. see Chenoweth & Stephan on the 3.5% threshold);
3. Counterfactual: Not sure I agree. The 2015 Konobo baseline (from the Liberia example above): a near-total dose-response collapse with distance to facility...odds of even one antenatal visit dropped to 0.04 in the farthest quartile. i.e. the hard-to-reach half of rural sub-Saharan Africa is closer to “no formal contact” than to “competent ministry already delivering care.”
4. A broader observation: The donor’s operative counterfactual is policy stuck vs policy moves: paper policy plus volunteer workforce plus indefinite donor dependence, OR a 5–7 year catalytic grant plus the four predictors gets a country onto a professional workforce on a recurrent domestic budget for 30+ years. Liberia made the transition; the 32% to 10% drop is the outcome.
We are all well served by remembering: a) Unit cost is alever, not a constant: antiretroviral therapy went from 10k to 90 bucks per patient per year in a decade—due to funded, coordinated efforts b) Domestic financing is also a lever: the proCHW dashboard I linked above shows proCHW policy does not track w/gdp per capita (e.g. if Liberia did it...!).
Yes to the EA-style cost-effectiveness analysis! Would love help building it. If anyone is interested in this or wants to offer a view on what it needs , I’d love to connect.
I’ll pick up on specifically the Liberia thread, because I think it provides an interesting context to explore!
My (again, very rough) understanding is that much of the Liberian CHW program was funded/run externally to Liberia (lots of international donor dollars from bilaterals, implementation details were handled by partners like Last Mile Health or others depending on the state). I think a lot of this has gone off the rails post-USAID, essentially revealing this wasn’t really a domesticated program (which doesn’t mean it is inherently bad, just worth being clear-eyed about if true).
Assuming that understanding is correct, I think this is somewhat instructive: Liberia may be a good example of where proCHWs have worked, but it is not a great example of where ‘lobby the government with a 5 year catalytic grant and then the government will pay for it forever’ has worked. As we think about what specific interventions we might want to get funded in this space, what we’re analyzing with CEAs, etc., I think it will be important to accurately model what we really want. Do we want:
i) to do a pure policy change play ii) to directly fund an NGO to do proCHWs iii) some mixture of both and so on—there’s a ton of options here!
My guess is in the right context any of these could be cost-effective (or at least they are equally probable to be so), but that ensuring we have evidence for each part of the theory of change we attempt to enact will be vital.
Thanks, Justin for the question about Liberia. Two responses, and a question for you/where I think we converge:
“Domesticated” requires policy ownership + budget commitment + workforce embedded in government. Liberia has all three. Co-financing ≠ failure of domestication—every health system is co-financed. Countries routinely face fiscal-space problems and (post-2025) are in one now. That the gov’t is doubling down on the program in the face of this stress + trying to find a way forward would seem to prove the ownership and durability point.
Liberia is evidently not the only example. Next door in Cote d’Ivoire cost per person fell 20% per year post proCHW policy adoption, then a Prime Ministerial directive opened fee-free care to 13 million people, World Bank covered the first months, domestic financing took over (and all of this during the current contraction). Kenya is another recent example: 100k CHWs onto monthly stipends plus insurance, under domestic commitment, post-aid-cut announcement. Ethiopia is decades of domestic commitment etc etc.
Agreed on your taxonomy and would suggest we probably we want both: meet direct needs now via NGOs and ensure we can meet them even more cost effectively in the future via policy change. The latter requires modelling handover probability; a long time horizon on the benefit side (i.e. credit DALYs averted across the program’s full multi-decade lifetime, post-handover incl, discounted for durability risk); and (probably) unit cost modelled as a variable that integration can drive down? Do you know of anyone working on similar models in other issue areas?
Thanks so much, Justin, for taking the time to read and engage w/these great questions! A couple of thoughts:
1) Re: example of ntl level evidence: I used to live/work in Liberia and it’s a great example of such a transition. They adopted proCHWs based on advocacy + pilot evidence from Konobo district post ebola in 2016. Malaria prevalence then fell from28% (2011) to 10% (2022) across nationally-representative surveys. Multi-driver (nets, seasonal malaria chemoprevention, artemisinin therapies, the Liberian program all contributed), the platform is the delivery channel. David Walton of PMI said it was one of the fastest declines they ever documented.
On a more meta scale: 15+ years ago only a handful of countries had proCHW policy (Brazil, Ethiopia). People used to laugh at the suggestion :) Now 55+ countries have such policies following coordinated, multi-country 10 yr campaign targeting international guidelines, funding, and ntl policy. Contribution, not attribution etc etc but after 100 yrs of basically no movement whatsoever on this, it’s something.
2. Predictors: Literal PhDs written on this! (Finnemore & Sikkink on norm diffusion = excellent). We at CHIC have two realist synthesis papers on this in process (one on how CHW associations organize to shift government behavior, e.g. mechanisms = a combined legal/association/protest pressure in a political opening), one on the political economy of domestic CHW financing, e.g. mechanisms = design choices at program inception etc.)
Some common ingredients: a ministerial champion; a unified professional voice/constituency (e.g. see Chenoweth & Stephan on the 3.5% threshold);
3. Counterfactual: Not sure I agree. The 2015 Konobo baseline (from the Liberia example above): a near-total dose-response collapse with distance to facility...odds of even one antenatal visit dropped to 0.04 in the farthest quartile. i.e. the hard-to-reach half of rural sub-Saharan Africa is closer to “no formal contact” than to “competent ministry already delivering care.”
4. A broader observation: The donor’s operative counterfactual is policy stuck vs policy moves: paper policy plus volunteer workforce plus indefinite donor dependence, OR a 5–7 year catalytic grant plus the four predictors gets a country onto a professional workforce on a recurrent domestic budget for 30+ years. Liberia made the transition; the 32% to 10% drop is the outcome.
We are all well served by remembering:
a) Unit cost is a lever, not a constant: antiretroviral therapy went from 10k to 90 bucks per patient per year in a decade—due to funded, coordinated efforts
b) Domestic financing is also a lever: the proCHW dashboard I linked above shows proCHW policy does not track w/gdp per capita (e.g. if Liberia did it...!).
Yes to the EA-style cost-effectiveness analysis! Would love help building it. If anyone is interested in this or wants to offer a view on what it needs , I’d love to connect.
Many thanks again and hopefully talk more!
I’ll pick up on specifically the Liberia thread, because I think it provides an interesting context to explore!
My (again, very rough) understanding is that much of the Liberian CHW program was funded/run externally to Liberia (lots of international donor dollars from bilaterals, implementation details were handled by partners like Last Mile Health or others depending on the state). I think a lot of this has gone off the rails post-USAID, essentially revealing this wasn’t really a domesticated program (which doesn’t mean it is inherently bad, just worth being clear-eyed about if true).
Assuming that understanding is correct, I think this is somewhat instructive: Liberia may be a good example of where proCHWs have worked, but it is not a great example of where ‘lobby the government with a 5 year catalytic grant and then the government will pay for it forever’ has worked. As we think about what specific interventions we might want to get funded in this space, what we’re analyzing with CEAs, etc., I think it will be important to accurately model what we really want. Do we want:
i) to do a pure policy change play
ii) to directly fund an NGO to do proCHWs
iii) some mixture of both
and so on—there’s a ton of options here!
My guess is in the right context any of these could be cost-effective (or at least they are equally probable to be so), but that ensuring we have evidence for each part of the theory of change we attempt to enact will be vital.
Thanks, Justin for the question about Liberia. Two responses, and a question for you/where I think we converge:
“Domesticated” requires policy ownership + budget commitment + workforce embedded in government. Liberia has all three. Co-financing ≠ failure of domestication—every health system is co-financed. Countries routinely face fiscal-space problems and (post-2025) are in one now. That the gov’t is doubling down on the program in the face of this stress + trying to find a way forward would seem to prove the ownership and durability point.
Liberia is evidently not the only example. Next door in Cote d’Ivoire cost per person fell 20% per year post proCHW policy adoption, then a Prime Ministerial directive opened fee-free care to 13 million people, World Bank covered the first months, domestic financing took over (and all of this during the current contraction). Kenya is another recent example: 100k CHWs onto monthly stipends plus insurance, under domestic commitment, post-aid-cut announcement. Ethiopia is decades of domestic commitment etc etc.
Agreed on your taxonomy and would suggest we probably we want both: meet direct needs now via NGOs and ensure we can meet them even more cost effectively in the future via policy change. The latter requires modelling handover probability; a long time horizon on the benefit side (i.e. credit DALYs averted across the program’s full multi-decade lifetime, post-handover incl, discounted for durability risk); and (probably) unit cost modelled as a variable that integration can drive down? Do you know of anyone working on similar models in other issue areas?