One Million Health Workers Campaign: Analyzing Costs
Clayton Velicer, MPH
In a February Peers for Progress blog we highlighted the One Million Community Health Workers campaign. Launched in January 2013 by Rwandan President Paul Kagame, Professor Jeffrey Sachs, and Novartis CEO Joseph Jimenez at the World Economic Forum, the campaign’s goal is to raise one million community health workers (CHW) in sub-Saharan Africa by 2015. This ambitious campaign aims to expand and accelerate community health worker programs, scaling up to district, regional, and national levels through a top-down and bottom-up approach.
In that blog, we shared estimates from a technical report that estimated $3,584 is needed to train, equip, and maintain each CHW per year. The total cost of training and maintaining the CHW initiatives across sub-Saharan Africa is estimated to be $2.5 billion. Figures in the report and this article are given in US dollar amounts.
The April 2013 WHO Bulletin featured an article by McCord and Colleagues that did an excellent job of breaking down the potential costs for this program, specifying the areas where the money will be needed based on a model that included empirical evidence, lessons learnt from several global CHW programs, and data from the Millennium Villages Project. The model utilizes full-time, paid public sector CHWs that are formally recognized and integrated into the rural primary health care system.
In following this project, we hope to gain insight into the financial side of scaling up community worker programs that may show positive returns on investment. This blog will talk about the broad spending categories but you can see more specifics in the article. We hope that this financial breakdown will inform readers about budget considerations around scaling up CHW programs around the globe.
Costs per Community Health Worker
- Backpack and mobile phone: In this program, each CHW is issued a backpack and mobile phone. Funds must provide for a mobile smart phone, a solar charger, and money for supervisory support, communication, and data collection. The estimated cost per CHW is $680.
- Training: It is estimated to cost $300 to train each CHW. This provides for transport, meals, supplies and trainer’s honorarium, as necessary. This figure also included estimated student attrition based on the literature.
- Salaries: CHWs will receive a monthly salary of $80. This figure is an average from figures collected across Millennium Village Project settings in 10 countries.
- Management: CHW managers will receive an annual salary of $9600 to manage 30 CHWs each. CHW managers could be physicians in primary healthcare facilities with supplemental training in management, which would shift some of this cost into existing primary healthcare system budgets.
- Overhead: The authors added 15% to account for overhead costs at the local, national and international levels. This includes components of the operational design not listed as separate costs, such as community engagement and information management.
After providing the cost estimates associated with the CHWs themselves, the article also provided costs associated with the services that CHWs provide. This is important for both understanding the budget associated with the program and providing a description of the tasks that CHWs perform.
- Monitoring for undernutrition: CHWs will Use of mid-upper arm circumference strips ($0.05 per strip) to monitor children between the ages of 1 and 5 years for undernutrition. Children will be measured at least once every 90 days.
- Treating diarrhea: CHWs will treat episodes of diarrhea with oral rehydration salts (ORS) and zinc tablets. The average cost per episode was estimated at $0.42 with an estimated 1.1 billion episodes per year in rural Africa. This is projected to be the most expensive health condition covered by CHWs, using $0.79 out of the $2.88 in supply and commodity costs per person.
- Testing for and treating malaria: Based on WHO protocol, all people with fever in areas with should malaria should undergo a rapid diagnostic test (RDT) before being treated with antimalarials. The model predicts that RDT will reveal that around 30% of the fevers are due to malaria and require artemisinin-based combination therapy (ACT). Based on epidemiological data, the total projected expenditure is $153 million in RDTs and $87 million in ACTs.
- Deworming: If the country-level prevalence of any of the three infestations (ascariasis, trichuriasis and hookworm) is over 50%, all individuals receive three doses of albendazole ($0.02 per dose) per year. Countries with lower prevalence require lower levels of dosage. If the prevalence is above 20% and below 50%, then everyone receives one dose of albendazole. For a separate condition, schistosomiasis treatment requires praziquantel ($0.22 per tablet).
- Pneumonia: The WHO reported 131.3 million pneumonia episodes in Africa in 2004. CHW will use respiratory timers ($3.50 each) to assess children’s respiratory rate. One timer, good for 10,000 uses, will be issued to each CHW annually. The pneumonia will be treated with antibiotics with an average cost of$0.27 per case.
- Screening for tuberculosis: CHWs will collect sputum samples from suspected tuberculosis cases. The cost of screening one person covers the collection of three sputum samples. Costs associated with this process included containers for samples, markers for labeling, plastic bags, and surgical gloves.
The authors note that estimated costs do not include two potential CHW services: family planning and HIV screening for the general population because public health specialists have not reached consensus on whether CHWs should provide these services. Overall, the authors estimate the cost of training, equipping, and supporting each CHW to be $3,750 per year.
The authors also conclude that:
“According to studies published by the Commission on Macroeconomics and Health, the United Nations Millennium Project and the International Task Force on Innovative Financing for Health, in a low-income country a primary healthcare system should cost from $50 to $55 per capita per year in 2011 prices. According to this model, the CHW subsystem configured in this paper would cost approximately 5% of the total cost of a primary healthcare system.”
Our recent blogs have discussed the importance of evaluation and dose delivery with peer support and community health workers programs. We took this opportunity to talk about budgeting and cost estimates, because it’s also a critical component of successful programs. The authors use epidemiological data, published literature, and extensive research on supply costs to provide an in-depth analysis. As the initiative moves forward, this budget will provide a reliable baseline for cost comparison to inform further programs. Furthermore, careful documentation of costs will provide data for return on investment. This factor is especially important for healthcare organizations and healthcare systems when considering program adoption. We encourage our readers to share their thoughts and experiences with estimating costs and budgeting for CHW programs.