This is probably the clearest takedown of the “CHW as intervention” category error I’ve read.
From a county health office perspective here in Kenya, there’s one piece that stands out: the transition to government ownership usually doesn’t hit a technical wall or even a funding wall. It hits a political one.
A local government that runs a CHW program well gets far less visible credit than one that opens a shiny new clinic. The clinic gets the ribbon-cutting, the speeches, the photos. A strong CHW program just quietly keeps people from getting sick, which is exactly the point, but politically it’s invisible.
That mismatch is why so many “successful pilots” never go anywhere. Donors fund the launch, governments signal support, everyone says the right things. Then the pilot ends, CHWs stop getting paid, and attention shifts to the next district.
The model you’re describing only holds if someone inside the Ministry of Health has a real career incentive to keep it alive. That’s the piece missing from most EA cost-effectiveness papers. Not because it’s impossible to measure, but because almost nobody is measuring it at all.
Worth asking: who inside the Ministry actually owns the platform after the handshake? If the answer is no one with a budget line, the evidence doesn’t matter.
This is probably the clearest takedown of the “CHW as intervention” category error I’ve read.
From a county health office perspective here in Kenya, there’s one piece that stands out: the transition to government ownership usually doesn’t hit a technical wall or even a funding wall. It hits a political one.
A local government that runs a CHW program well gets far less visible credit than one that opens a shiny new clinic. The clinic gets the ribbon-cutting, the speeches, the photos. A strong CHW program just quietly keeps people from getting sick, which is exactly the point, but politically it’s invisible.
That mismatch is why so many “successful pilots” never go anywhere. Donors fund the launch, governments signal support, everyone says the right things. Then the pilot ends, CHWs stop getting paid, and attention shifts to the next district.
The model you’re describing only holds if someone inside the Ministry of Health has a real career incentive to keep it alive. That’s the piece missing from most EA cost-effectiveness papers. Not because it’s impossible to measure, but because almost nobody is measuring it at all.
Worth asking: who inside the Ministry actually owns the platform after the handshake? If the answer is no one with a budget line, the evidence doesn’t matter.