Recruiting community members with basic training for health promotion and care delivery is increasingly popular among development programs in low- and middle-income countries. This approach has great appeal: it could boost accountability and local ownership, and reduce program costs. Community Health Workers (CHWs) are also increasingly viewed as critical to alleviate projected workforce shortages in the next decades, in addition to being critical resources during health crises like Ebola—as organizations such as Last Mile Health and USAID have noted. Though the potential benefits of the approach are easily touted, the full costs remain murky and are often an afterthought. In particular, many CHWs are not compensated and the value of their time is not reflected in program costs. As a consequence, it is unclear whether CHWs are cost-effective, especially if deployed as an integral component of a health system. It’s high time for governments and donors to account for the invisible costs of CHW programs and to rethink their advocacy for this delivery platform.
Although CHW programs vary widely, the lack of adequate compensation for workers is a widespread problem. Using self-reported data, the One Million Community Health Workers Campaign estimates that only 8.6 percent of CHWs in sub-Saharan Africa are salaried and an additional 46.5 percent are not paid but do periodically receive non-monetary compensation (e.g. clothing or community recognition). Similarly, the Lancet Commission on Women and Health reports on research suggesting that only 7 percent of CHWs in sub-Saharan Africa receive compensation for their work. That’s just the tip of the iceberg for unpaid community work (and also for women, as the Lancet report shows).
This lack of funding may have important ramifications. Relying on volunteers can affect program quality and scale up by contributing to high attrition rates. And continued reliance on unpaid volunteers could undermine individuals’ and governments’ incentives for formal training and employment, which, in a vicious cycle, could contribute to expected shortages of 13 million nurses, doctors, and midwives by 2035. Furthermore—and perhaps most importantly—ignoring the hidden costs of community involvement is unfair to individuals and, at the policy level, biases cost-effectiveness analyses in favor of these programs.
So what can be done? First, governments and donors need to understand that CHWs are not a magic bullet that is costless to countries and communities. Decision-makers at all levels need to recognize the true costs of CHWs and CHW programs. Second, programs should move to cover the work-related costs of CHWs and, after a trail period, compensate CHWs for their time. And finally, while researchers have noted that the full “societal” costs, which includes the costs to individuals, could be quite different from the program costs, we urgently need data to provide further evidence of this issue.
Contrary to the popular saying, time isn’t always money but it does have value—and that should be respected.