Thanks so much, Nick! We published a massive multi-paper cost-effective review only weeks after you shared your original post! You can dig into all the papers/numbers/methodology here: https://joinchic.org/resources/cost-effectiveness/
TL;DR: The numbers are medians across 380 scenarios in 130 studies. As I said in the footnote, data is heterogeneous (mostly due to platform design differences, including salaries). Ranges are big and depend on context, but would say a) your $0.95 BOTE is a fair floor for a professional program at modest catchment, but b) that your earlier take (CHWs are “often not cost-effective,” they treat “few patients per month,” they can only treat “a handful of conditions in young children”) is not reflected in these data.
Re: DALYs: you’ll see in the papers that vertical evidence is already in EA terms (e.g. there are DALY numbers for iCCM) but none of the 42 horizontal integrated scenarios in the BMJ GH piece report cost per DALY. The research I’d most want EA to fund is a prospective platform-economics evaluation: does bundling 6–8 service lines on one salaried CHW compound DALYs and lower cost-per-DALY the way fixed-cost-sharing predicts? (or to your point, maybe not?)
My bigger point though is that maybe this is already a good enough bet based on the vertical DALY evidence we both already accept (i.e. why not apply hits-based giving on the handover: catalytic financing to professionalize a salaried, skilled, supervised, supplied workforce via national, government). Esp, as this has what a hit almost never has, which is a decade of cost-effectiveness evidence already behind it. If the handover lands, the donor pays once and the government runs the whole portfolio forever (and the vertical $/DALY figures are the floor). Have added 2 footnotes re:the above.
I think It wouldn’t cost much at all to make forward a pretty robust cost-effectiveness model for a CHW which rolls out a wide range of interventions. (I think Living Goods +- others might well have decent models already here?). I think you could even build this yourself? Some of the package would be easy to do because data is there (malaria, diarrhoea, pneumonia treatment, family planning antenatal care), while screenings and referrals are much harder to quantify and might have to be left out of the analysis pending better data.
I agree the bet argument is pretty good if the goal is government adoption. Regardless of the nuance of cost-effectiveness, CHWs will always be more cost-effective than most health things govt. could do and it would likely displace less cost-effective things. Unfortunately I don’t think EA funders have seriously considered scale through govt. something worth chasing as a bet, but I really like the idea.
Thanks so much, Nick! We published a massive multi-paper cost-effective review only weeks after you shared your original post! You can dig into all the papers/numbers/methodology here: https://joinchic.org/resources/cost-effectiveness/
TL;DR: The numbers are medians across 380 scenarios in 130 studies. As I said in the footnote, data is heterogeneous (mostly due to platform design differences, including salaries). Ranges are big and depend on context, but would say a) your $0.95 BOTE is a fair floor for a professional program at modest catchment, but b) that your earlier take (CHWs are “often not cost-effective,” they treat “few patients per month,” they can only treat “a handful of conditions in young children”) is not reflected in these data.
Re: DALYs: you’ll see in the papers that vertical evidence is already in EA terms (e.g. there are DALY numbers for iCCM) but none of the 42 horizontal integrated scenarios in the BMJ GH piece report cost per DALY. The research I’d most want EA to fund is a prospective platform-economics evaluation: does bundling 6–8 service lines on one salaried CHW compound DALYs and lower cost-per-DALY the way fixed-cost-sharing predicts? (or to your point, maybe not?)
My bigger point though is that maybe this is already a good enough bet based on the vertical DALY evidence we both already accept (i.e. why not apply hits-based giving on the handover: catalytic financing to professionalize a salaried, skilled, supervised, supplied workforce via national, government). Esp, as this has what a hit almost never has, which is a decade of cost-effectiveness evidence already behind it. If the handover lands, the donor pays once and the government runs the whole portfolio forever (and the vertical $/DALY figures are the floor).
Have added 2 footnotes re:the above.
I think It wouldn’t cost much at all to make forward a pretty robust cost-effectiveness model for a CHW which rolls out a wide range of interventions. (I think Living Goods +- others might well have decent models already here?). I think you could even build this yourself? Some of the package would be easy to do because data is there (malaria, diarrhoea, pneumonia treatment, family planning antenatal care), while screenings and referrals are much harder to quantify and might have to be left out of the analysis pending better data.
I agree the bet argument is pretty good if the goal is government adoption. Regardless of the nuance of cost-effectiveness, CHWs will always be more cost-effective than most health things govt. could do and it would likely displace less cost-effective things. Unfortunately I don’t think EA funders have seriously considered scale through govt. something worth chasing as a bet, but I really like the idea.