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, 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?