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?
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?