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.
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.