Sustainable Financing of Community Health Workers: Could Social Health Insurance be the Panacea?

Community Health Workers (CHWs) form the backbone of health care delivery in many underserved communities. Their role in extending essential health services to remote areas has been widely recognized as a cost-effective strategy to improve health outcomes, particularly in regions with limited access to formal health care facilities, such as Africa. CHWs are also well-equipped to engage communities in preventive and promotive health initiatives while aiding in the management of chronic diseases at the household level. Evidence supports the effectiveness of programs using CHWs to deliver preventive and curative services directly to homes, resulting in heightened service coverage and reduced mortality rates among neonates and children

Despite their effectiveness, CHW programs often face significant challenges related to funding and sustainability. Financing CHW programs incentivizes performance and fosters community ownership, ensuring sustainability and equitable distribution of health care services. Most CHW programs struggle to secure funding which jeopardizes their ability to extend health services to marginalized communities and hinders their effectiveness. Inadequate funding also leads to shortages of essential supplies and medicines, hindering the ability of CHWs to deliver quality care to their communities. Other barriers to CHW financing include reluctance to formalize CHWs as government employees due to budget constraints and fear of strikes. Additionally, lack of fiscal space for health results in low entry-level salaries for formal health care workers, further hindering efforts to integrate CHWs into salaried workforce.  

In sub-Saharan Africa, about USD 1 billion is spent on CHW programs annually, with about 60 percent coming from donors. Reliance on donor funding, which is instrumental in initiating CHW programs, poses challenges in terms of sustainability and long-term impact. The vertical, disease-specific funding approach has limitations, such as duplication of efforts leading to the fragmentation of services and dependence on volatile funding streams. These traditional funding sources, including domestic government budgets and donor contributions, face challenges such as bureaucratic barriers and competing priorities. In contrast, integrated horizontal financing models that prioritize comprehensive primary health care services have shown promise in improving health outcomes and maximizing resource utilization.

Besides donors, other funding models include government, community, and volunteer-based funding. Countries such as Kenya and South Africa have weak financial support for CHW programs, with many others having little to no allocation. In Kenya, where funding of CHWs is a function of devolution, only few counties allocate funds for these services. In South Africa, 3 percent of the total public sector health expenditure was allocated to CHW programs, with approximately 4 percent of primary health care expenditure used for CHWs. These cases of underinvestment in CHW programs, combined with limited political support and budget cuts further impede their effectiveness. Other lower-middle-income countries such as Bangladesh fund their CHW with domestic resources where they sell health-related commodities for profits, therefore, providing income.

The role of domestic funding in supporting CHW programs is illustrated in Zambia. Before 2011, Zambia did not allocate its internal funds to a CHW program; however, with the assistance of donors, a national CHW initiative was developed. The program incurred USD 1.8 million, with a substantial 88 percent of this amount sourced from donors. However, by 2016–17, government funding rose to 81 percent, while donor contribution decreased to 19 percent. This trend suggests a noteworthy shift towards reliance on domestic resources to sustain the CHW program. Similarly, other countries, such as Liberia, Sierra Leone, Rwanda, and Kenya, have begun investing their internal resources into community health services, marking a positive step towards self-sustainability. The Kenyan government allocated 2 percent of universal health coverage funding to strengthen community health services, recognizing their critical role in primary health care. Government funding ensures job security for CHWs and promotes equity but is susceptible to budget cuts and lacks stability. Community financing, while attractive, often proves unsustainable because of limitations in the community's capacity to pay. Finally, volunteer-based financing, although initially cost-effective, raises concerns about equity and long-term sustainability. 

The sustainability of CHW programs is contingent on adequate and stable domestic financing mechanisms that prioritize comprehensive primary health care services. Social Health Insurance (SHI) has emerged as a viable option for boosting domestic financing for health, offering stable funding and equitable access to health care. SHI systems pool financial resources from the population through the government to fund health care services, including those provided by CHWs. By integrating CHW services into the broader health care financing framework, SHI schemes can ensure stable and predictable funding, thereby enhancing the sustainability of CHW programs. Moreover, SHI will facilitate the provision of fair compensation and incentives to CHWs, addressing concerns related to low remuneration and insufficient support.

Although traditional funding approaches face challenges, innovative financing strategies and integrated health care models offer opportunities to enhance the effectiveness and sustainability of CHW initiatives. Overcoming barriers to financing requires collaborative efforts from policy makers, health care providers, and community stakeholders to prioritize investment in CHWs and strengthen primary health care systems. While several African countries have taken steps to implement different forms of social health insurance schemes as part of efforts towards universal health coverage, there is limited evidence on financing of CHWs through this method. SHI holds the potential to get African governments to commit financing for CHWs. 


CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.