Community Health Worker Program Sustainability in Africa: Evidence From Costing, Financing, and Geospatial Analyses in Mali

Abstract

Understanding specific program costs through efficiency analyses and geospatial targeting allows national stakeholders to make strategic, targeted investments, making the first steps toward sustainability. Costs required for community health worker programs can be reduced without sacrificing quality, and spending can be geographically targeted to optimize service use by rural populations. Results from Mali provide an example for other sub-Saharan African countries.

Abstract

Key Findings

• In 2015, cost-saving opportunities of US$6.16 million were identified in 41 of 44 districts.

• Costs required for community health worker (CHW) programs can be reduced without sacrificing quality and spending can be geographically targeted to optimize service use by rural populations.

Key Implications

• Program managers and stakeholders should use geospatial analyses to reflect critically on CHW resource planning and make evidence easier to act upon.

• Key decision makers should assess what efficiency gains in funding can be achieved with geospatial targeting and mapping.

ABSTRACT

Background:

In Mali, community health workers (CHWs) deliver essential community care (ECC) to rural populations. The dominance of external funding for the program threatens the sustainability of this critical workforce as donor financing decreases. This article summarizes results of analyses aimed at assisting Mali's decision makers and leaders in initiating a transition to a sustainable CHW program supported by domestic funding through strategic and rational investment.

Methods:

Data on ECC implementation norms, workforce, coverage, utilization, cost, and geospatial features were collected between 2016 and 2019. The data informed interlinked CHW financing analyses—situational, services costing, efficiency, and geospatial mapping. Analysis showed distribution of reported expenditures, estimates of required CHW funding, cost-saving options, and spatially visualized discrepancies between spending estimates and normative costs.

Results:

Thirteen financing sources contributed to CHW program expenditures, 88% of which were from international donors, for a package of 23 curative, preventive, and promotive interventions. In 2015, the CHW program spent US$13.01 million; an estimated US$8.36 million would have been needed to achieve the same service volume under standard care protocols. Medicines and start-up training had US$6.88 million more than needed; supervision, program management, and recurrent training components were underfunded by US$2.2 million. Cost-saving opportunities of US$6.16 million were identified in 41 of 44 districts. Funding reallocation opportunities (after meeting technical efficiency requirements) were identified in 20 of 44 districts (US$2.56 million). Use of geospatial targeting and mapping suggests district- and village-level reallocation options for theoretical funding surpluses.

Conclusion:

CHW costs can be significantly reduced without sacrificing service technical quality. Spending can be geographically targeted to optimize service use by rural populations. Efficiency analyses provide evidence to build stronger engagement, support improved decision making, efficiently prioritize resources, and target investments for sustainable financing of CHW programs.