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.
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!