Thanks for posting this Madeleine, it is great to see people from outside the traditional EA global health space engaging here!
This isn’t an area I’m super familiar with, but I’ll try to throw in some questions/thoughts to perhaps draw out the argument a bit, because I think this is valuable to think about!
Let’s assume for the sake of discussion here that the creation of a CHW program in an area where core CHW-delivered care (like vaccination, malaria bed nets, SMC, vitamin A, deworming, etc.) is completely unavailable is cost-effective at a typical EA bar.
I think it is interesting that the recommended thing to get funded notably slightly different/more indirect, which is to fund policy change to get governments to pay for the creation of more professional CHW programs. I think I’d be really interested in hearing more about the evidence base behind this recommendation (e.g., the systematic review you linked pertains more to academic/NGO interventions designed to improve CHW performance, rather than efforts to improve government rollout of CHWs). Questions I’d be really interested in hearing some more about:
What evidence do we have of externally funded health systems strengthening campaigns successfully changing government implementation of CHWs, in a way that has both (a) created professional, paid CHW programs and (b) which has then actually changed health outcomes in an identified way afterwards?
I imagine this has worked somewhere—I’m only vaguely familiar with CHIC, but from that vague knowledge I know CHWs have been gaining steam. That said, it certainly hasn’t worked everywhere. My impression for instance is that lots of funders have spent quite a lot of money trying to get a Nigerian CHW program off the ground only to end up with some policy documents that look nice on paper but CHWs not actually getting paid or doing anything meaningful most of the time.
What has defined the difference between contexts where externally funded programs to change government behavior have worked and where they have not? How can we predict in advance which areas are worth spending money on and which are not?
I think it is then interesting to revisit our assumption at the top here. The counterfactual we’re talking about here is probably not zero treatment to CHW treatment. It probably looks more like a reasonably competent government rolls out CHWs in an area that has some existing primary healthcare services—in this situation, how many more people get treatment? At what marginal additional cost? Is that marginal benefit worth that cost?
Super possibly! But just flagging that it isn’t as straightforward as the base case assumption we make might be.
I think intuitively we expect this to be really cost-effective in places that are underserved/hard to reach—but those places probably don’t have super competent government in the first place, and so is our notional health systems strengthening campaign going to help? Maybe! Maybe not! Would love to hear more thoughts.
Anyway in closing—you guys should put together an EA-style CEA of this! I think that’d be the best way to make this case.
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 for posting this Madeleine, it is great to see people from outside the traditional EA global health space engaging here!
This isn’t an area I’m super familiar with, but I’ll try to throw in some questions/thoughts to perhaps draw out the argument a bit, because I think this is valuable to think about!
Let’s assume for the sake of discussion here that the creation of a CHW program in an area where core CHW-delivered care (like vaccination, malaria bed nets, SMC, vitamin A, deworming, etc.) is completely unavailable is cost-effective at a typical EA bar.
I think it is interesting that the recommended thing to get funded notably slightly different/more indirect, which is to fund policy change to get governments to pay for the creation of more professional CHW programs. I think I’d be really interested in hearing more about the evidence base behind this recommendation (e.g., the systematic review you linked pertains more to academic/NGO interventions designed to improve CHW performance, rather than efforts to improve government rollout of CHWs). Questions I’d be really interested in hearing some more about:
What evidence do we have of externally funded health systems strengthening campaigns successfully changing government implementation of CHWs, in a way that has both (a) created professional, paid CHW programs and (b) which has then actually changed health outcomes in an identified way afterwards?
I imagine this has worked somewhere—I’m only vaguely familiar with CHIC, but from that vague knowledge I know CHWs have been gaining steam. That said, it certainly hasn’t worked everywhere. My impression for instance is that lots of funders have spent quite a lot of money trying to get a Nigerian CHW program off the ground only to end up with some policy documents that look nice on paper but CHWs not actually getting paid or doing anything meaningful most of the time.
What has defined the difference between contexts where externally funded programs to change government behavior have worked and where they have not? How can we predict in advance which areas are worth spending money on and which are not?
I think it is then interesting to revisit our assumption at the top here. The counterfactual we’re talking about here is probably not zero treatment to CHW treatment. It probably looks more like a reasonably competent government rolls out CHWs in an area that has some existing primary healthcare services—in this situation, how many more people get treatment? At what marginal additional cost? Is that marginal benefit worth that cost?
Super possibly! But just flagging that it isn’t as straightforward as the base case assumption we make might be.
I think intuitively we expect this to be really cost-effective in places that are underserved/hard to reach—but those places probably don’t have super competent government in the first place, and so is our notional health systems strengthening campaign going to help? Maybe! Maybe not! Would love to hear more thoughts.
Anyway in closing—you guys should put together an EA-style CEA of this! I think that’d be the best way to make this case.
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!