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"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.

Ligia Paina

This is the fifth chapter of the CHW Reference Guide, produced under the Maternal and Child Health Integrated Program, the United States Agency for International Development Bureau for Global Health’s flagship maternal, neonatal and child health project. 

The relevance of community health worker (CHW) programs withstands the test of time, as current discussions are shifting from the Millennium Development Goals to the Sustainable Development Goals and to Universal Health Coverage. The “One million community health workers campaign,” among others, is working to support low- and middle-income country governments to increase the number and quality of lay health workers. However, despite the strong enthusiasm for introducing and scaling-up CHW programs and the associated opportunities to increase community access to essential health services, challenges persist in the move from policy to implementation, from pilots to large-scale programs.
The misconception that CHW programs are cheap to implement and sustain has been a major barrier to scale-up of recent initiatives and a key factor in the failures of these programs in the past, particularly in the 1980s. In Chapter 5 of the CHW Reference Guide, authors Henry Perry, Francisco Sierra-Esteban, and Peter Berman help us to move beyond these misconceptions by systematically thinking through what financing CHW programs means in practice and how to understand and analyze costs through planning and implementation.

The authors argue that the failure to consider the “real costs of CHW programs” has led to low effectiveness of CHW programs in the decades following the Alma-Ata call to action. They caution that history might repeat itself if, in the future, we fail to acknowledge the full resources required for the implementation and scale-up of CHW programs, as well as where these resources might come from.

Chapter 5 guides us through the following key questions:

  1. What are the elements of CHW programs that need to be included in cost calculations?
  2. What are the full costs of CHW programs?
  3. What are the different options for the financing of CHW programs and the strengths and limitations of each option? What are some examples of how CHW programs have been financed?
  4. What guidance can be given to assure that financing becomes a sustainable positive element in CHW program development?Table 1.jpg

A helpful typology, aimed at those engaged in planning the development of a CHW program, is provided to facilitate a thorough understanding of investment and recurrent direct and indirect costs (see Table 1 at right, click to enlarge). Special emphasis is placed on indirect costs, which can be incurred even when CHWs are volunteers, i.e., the costs incurred by CHWs themselves (e.g., opportunity costs what a CHW could have earned if she had not been working as a CHW) and the costs to the health system, both in terms of the additional demand generated for health care or the cost of turnover.

Chapter 5 also emphasizes that the evidence on how much CHW programs cost is limited and that the cost estimates depend greatly on the context and the particular costing approach used. There are four elements that the authors suggest should be included in a thorough cost analysis:

  • The monthly salary/compensation/incentive for each CHW
  • The annual cost per CHW – the sum of direct and indirect program costs) necessary to implement the CHW program, divided by the total number of CHWs available.
  • The annual cost per program beneficiary or per capita - the sum of direct and indirect program costs  necessary to implement the CHW program, divided by the total population. 
  • The source of funding (see Table 2 and Annex A, for examples)

As previously stated, context is particularly important. For example, female community health volunteers in Nepal receive free medical care but do not receive a monthly salary, but CHWs in Pakistan earn up to $50 per month and CHWs in Brazil earn between $100 and $200 per month. Full program costs can be framed in terms of the cost per CHW and must include all investment and recurrent costs (e.g., training, salary, supervision, etc.). Cost estimates can become more complicated depending on the type of services provided by the CHW and who is conducting the supervision. These are sometimes compared with the costs that might be incurred to place a medical professional in the same areas – the latter being significantly more expensive. The authors also point out that the scale of the program also matters when costing. As the program scales up, its unit costs might increase as it expands into hard to reach areas, where the marginal cost per person is higher than otherwise.

In terms of sources of funding, it is most important to consider:

  • Who bears the burden of financing
  • Whether the selected financing mechanisms have built-in incentives for efficiency and quality
  • The degree of sustainability and potential risks

The authors identify national governments, communities, and development partners as the main sources of financing for the CHW programs. They note that although CHWs may be unpaid, CHWs are themselves a major funding source for the program, as CHWs are donating their time. Usually, CHW programs, such as the ones described from Bangladesh and Brazil, are supported by several sources of funding.

Finally, Chapter 5 highlights the following principles as guidance for ensuring sustainable financing for CHW programs:

  • Careful planning that takes into account full program costs
  • The establishment of a strong base of political support for long-term financing, especially if the government is a major funding source
  • Developing strong linkages to local, private sources of revenue, anticipating that these can grow faster than central government funding
  • Remunerating and incentivizing the CHWs (e.g., with career opportunities) will decrease the odds of attrition; the lower the attrition, the lower the program costs and the higher the potential for quality services

The case studies provided in Boxes 2 and 3, as well as the ones in Appendix A, provide a wealth of information on the current state of CHW programs and what is known about their costs.

To review, the authors of this chapter make a strong case for:

  • Recognizing that CHW programs and their cost have to be adapted to the local environment
  • Integrating CHW programs into the broader health system – in terms of financing commitments as much as in terms of employment, supervision, and support
  • Donors and national government investing sufficient resources towards proper costing and planning for sustainable financing

Sustainable and predictable financing for CHW programs can help these programs reach their full potential and scale. Strong CHW programs can contribute to systems resilience and scaling up response to crises, such as the Ebola epidemic, and, more broadly, to the current efforts towards Universal Health Coverage. 


For additional resources on this subject, please see Cost and cost-effectiveness of community health workers: evidence from a literature review and Cost-efftectiveness of community-based practitioner programmes in Ethiopia, Indonesia and Kenya.


Ligia Paina currently works as an Assistant Scientist in the Department for International Health’s Health Systems Program at Johns Hopkins University School of Public Health (JHSPH), in Baltimore MD.  Her research aims to improve understanding of how to intervene in complex systems in order to ensure quality and affordable health care access, particularly for poor, rural, and underserved populations.  She is particularly interested in health workforce policy, strengthening organizational capacity, and the dynamics of health systems in transition.


CHW Central is managed by Initiatives Inc. Site start-up was supported by the USAID Health Care Improvement Project in 2011.

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