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Bull World Health Organ 2012;91:244253B | doi:10.2471/BLT.12.109660

Research

244

Deployment o community health workers across rural sub-SaharanArica: fnancial considerations and operational assumptionsGordon C McCord,a Anne Liub & Prabhjot Singhc

Introduction

Te evidence is overwhelming that community-based in-terventions are an eective platorm or extending healthcare delivery and improving health outcomes. Such evidenceindicates that a well-implemented community-based healthprogramme can: (i) reduce inant and child mortality andmorbidity; (ii) improve health-care-seeking behaviour (e.g.

increase rates o institutional delivery and immunization); and(iii) provide low-cost interventions or common maternal andpaediatric health problems while improving the continuum ocare.13 Such community-level programmes can be particularlyeective or addressing the most common causes o paediatricmortality and morbidity, such as pneumonia, diarrhoea, un-dernutrition, malaria, human immunodeciency virus (HIV)inection and acquired immunodeciency syndrome (AIDS)and measles.411 Tese community-based health programmesare oen successully executed through community healthworkers (CHWs). Tese are lay people who live in the com-munities they serve and who unction as a critical link betweenthose communities and the primary-health-care system.12 Te

well-documented success o CHW programmes over the lastew decades has increasingly pushed investment in CHWsubsystems to national and international policy platorms aspart o coordinated eorts to improve health-care systems.13

Although several reviews have documented the positiveimpact o CHWs on health outcomes, CHW programme costshave barely been examined, probably because cost data aremuch less widely available than data on programme outcomes.In one revealing review o 53 studies on CHW programmesin the United States o America, only six studies reerenced

costs and the authors considered such data to be insucientto draw any conclusions.14When included, costs are generallyassociated with interventions rather than with comprehensiveCHW programmes; urthermore, estimates do not accountor economies o scale or year-on-year eciencies.15 o date,the ocial costs o national CHW programmes in pioneer-ing countries such as Ethiopia, Malawi or Rwanda have not

been estimated, partly because tracking unit costs is dicultand because methods or isolating the CHW subsystem roman integrated primary-health-care system have been elusive.

Tis paper provides cost guidance or one adaptable confgu-ration o a CHW subsystem: a provider system housed withina larger primary-health-care system that includes clinics andreerral hospitals. Costing is done by unction (e.g. diagnosingand treating malaria) and by local epidemiologic characteristics(e.g. each countrys prevalence o HIV inection), so that compo-nents and assumptions can be easily modifed. National scale-upo CHW programmes and o primary-health-care systems morebroadly is likely to reduce the incidence o many o the diseasesdiscussed in this paper. Tis model allows costs to be easily recal-

culated as incidence rates change. New unctions, such as the careo patients with chronic conditions, could be added and costedonce a vetted CHW protocol or these unctions has emerged.

Methods

Model community health worker system

We designed the model CHW system presented in this paperusing the health system building blocks o the World HealthOrganization (WHO) (able 1), empirical evidence and les-

Objective To provide cost guidance or developing a locally adaptable and nationally scalable community health worker (CHW) systemwithin primary-health-care systems in sub-Saharan Arica.Methods The yearly costs o training, equipping and deploying CHWs throughout rural sub-Saharan Arica were calculated using data romthe literature and rom the Millennium Villages Project. Model assumptions were such as to allow national governments to adapt the CHWsubsystem to national needs and to deploy an average o 1 CHW per 650 rural inhabitants by 2015. The CHW subsystem described wascosted by employing geographic inormation system (GIS) data on population, urban extents, national and subnational disease prevalence,and unit costs (rom the eld or wages and commodities). The model is easily replicable and congurable. Countries can adapt it to localprices, wages, population density and disease burdens in dierent geographic areas.Findings The average annual cost o deploying CHWs to service the entire sub-Saharan Arican rural population by 2015 would beapproximately 2.6 billion (i.e. 2600 million) United States dollars (US$). This sum, to be covered both by national governments and bydonor partners, translates into US$ 6.86 per year per inhabitant covered by the CHW subsystem and into US$ 2.72 per year per inhabitant.Alternatively, it would take an annual average o US$ 3750 to train, equip and support each CHW.Conclusion Comprehensive CHW subsystems can be deployed across sub-Saharan Arica at cost that is modest compared with the

projected costs o the primary-health-care system. Given their documented successes, they oer a strong complement to acility-basedcare in rural Arican settings.

a University o Caliornia, San Diego, United States o America (USA).b Earth Institute, Columbia University, New York, USA.c School o International and Public Aairs, Columbia University, 475 Riverside Drive, Suite 825, New York 10115, USA ..

Correspondence to Prabhjot Singh (e-mail: [email protected]).

(Submitted: 8 July 2012 Revised version received: 28 October 2012 Accepted: 26 December 2012 Published online: 13 February 2013 )

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Bull World Health Organ 2012;91:244253B | doi:10.2471/BLT.12.109660 245

ResearchCommunity health workers in sub-Saharan AricaGordon C McCord et al.

Table 1. Model ramework or a community health worker (CHW) subsystem within the health system

Modelparameter

Inputs Processes Outputs

Servicedelivery

Activities and skills: CCM or malaria, pneumonia, malnutrition,

diarrhoea deworming TB screening assistance in adherence to drugs or HIVinection and TB health promotion and disease prevention

Changing household health behaviour;improving access to disease control/

prevention; improving access to basiccurative health services at the household/community level

Improved community health statusthrough increased coverage o high-

impact interventions

Reerral to primary health clinics and ollow-up;availability o emergency transport

Linking to broader health system(advanced care)

Increased use o advanced care andinstitutional delivery

Healthworkorce

CHWs selected through community/acilitypartnership

Improving access to health services at thehousehold/community level

Improved health through increasedcoverage o high-impact interventions

Senior CHWs (experienced CHWs, selected orsupportive supervision)

Monitoring o quality o care Improved ser vice quality, data reportingand CHW retentionSupportive supervision o CHWs

CHW managers (acility-based workers with

training in management skills)

Monitoring CHW programme, including

system perormance

Improved links to reerral acilities and

community governance structuresLinking to both acilities and communities Improved quality o CHW subsystem

Inormation Health data reporting, and vital statistics trackingby CHW

Monitoring and discussing communityhealth indicators

Data used to inorm programme strategy,engage communities, and improvehealth status

Utilization o inormation by CHW programmemanagers stakeholders (CHWs, supervisors,district health management team, acility sta,etc.)

Using health indicators to inormmanagement

Data used to guide community actionsor health and programme improvements

Inormation eedback mechanisms Inorming communities aboutepidemiology, health status, service deliveryand quality o care

Data used to identiy service deliveryweaknesses and track qualityimprovement results

Giving prompt eedback to community

Mobile technology suite (cell phone, textmessaging, voice) Collecting real-time data Improved quality o servicesFacilitating alerts or emergency care

Providing decision support at point-o-care

Medicalproducts,POCdiagnosisandtechnology

Equipment, consumables and tools to assesssickness and commodities or diagnosis andtreatment (ORS, zinc, ACTs, RDTs, sputumcontainers or TB, deworming drugs [albendazol,praziquantel], antibiotics or pneumonia)

Delivering health service Improved health status o communitymembers through increased coverage ohigh-impact interventions

Conducting surveillance or danger signs

Providing community-based treatment ospecied diseases/conditions

Financing Remuneration o CHWs Supporting CHWs as ull-time proessionals Development o a proessional, paidworkorce with well-dened terms oreerence

Financing or proessionalization (training,uniorms, equipment, commodities, proessionaldevelopment/career advancement)

Regularly training CHWs; Improved CHW motivation andcapabilities to provide quality care (withappropriate tools)

Incentivizing CHWs or high perormanceand retention

Leadershipandgovernance

Community governance structures Supporting local specication andcommunity-based selection and oversight

CHW workorce eciently supervised andmanaged and trained in skills necessaryto improve maternal and child healthindicators;

Governance structures rom ministries o healthand partner organizations

Ensuring CHW programme adherence togovernment policy

Community mobilized and engaged inCHW subsystem.

Quality improvement processes andorganizational culture

Developing culture o quality improvementwithin the workorce

Career ladder, proessional training curricula andnational certication

Attracting strong CHW candidates ; Improved CHW motivation and bettercandidatesMotivating CHWs to execute roles and

responsibilitiesACT, artemisinin-based combination therapy; AZT, zidovudine; CCM, community case management; HIV, human immunodeciency virus; ORS, oral rehydration salts;POC, point-o-care; RDT, rapid diagnostic test; TB, tuberculosis.


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Research

246 Bull World Health Organ 2012;91:244253B | doi:10.2471/BLT.12.109660

sons learnt rom several global CHWprogrammes, and data rom the Mil-lennium Villages Project. In this cost-ing model we ocus on ull-time, paidpublic sector CHWs who are ormallyrecognized as an integral part o the

rural primary-health-care system andwho perorm their work primarily inthe community and through house-hold visits.

Te CHWs in this subsystem visithouseholds to provide community casemanagement or diarrhoea, malaria andmalnutrition, management o pregnancyand health promotion. Tis subsystemis supported by robust supervision,

inormation-driven management anda provider network within the healthsystem. Tis model is also based on theassumption that CHWs receive short

training and strong supervision and thatthe health system is strong. In the par-ticular model costed, we also assumedthat an mHealth platorm was used tocollect data and provide decision sup-port, given the increasing popularity o

mHealth programmes in primary care.Detailed inputs, processes and outputsrom this ramework can be ound inthe One Million Community HealthWorkers report.16

Tis costing exercise also illustratesone possible additional congurationin which a subset o generalist CHWsis urther trained to work closely withskilled birth attendants to enhancematernal care. Although this CHWsubset relies on a skilled clinical teammember or supporting pregnancy and

childbirth, or the sake o discussion weherein reer to these CHWs as child-birth specialists.

Cost inputs for householdservices

We estimated the cost o ully deploy-ing CHW subsystems across the ruralareas o sub-Saharan Arica and developa costing ramework or countries torene and adapt in their own nationalplanning. Fig. 1, Fig. 2 and Fig. 3 illus-trate the algorithm or costing, including

junctures (represented by green boxes)requiring data on population, diseaseincidence and supply and commoditycosts. Unless otherwise indicated, unitcosts were provided by the MillenniumVillages Project.

Results

Costs per community healthworker

Backpack and mobile phone: Each

CHW is given a mobile smartphonecosting US$ 150, a solar chargercosting US$ 40 and a data plan cost-ing US$ 480 per year or supervisorysupport, communication and datacollection. o reduce costs, nationalCHW programmes can establishclosed user groups a nationwidenetwork that allows ree calls andshort message service between iden-tied health sta. Each CHW is alsogiven a backpack costing US$ 10 tocarry supplies.

Training: CHWs receive one yearo training: 3 months in a classroomand 9 months while in service, plussupervision and eedback. Tey also

Fig. 1. Costing algorithm or generalist community health workers (CHWs)

Country (or regional) incidenceof pneumonia, malaria,

NTDs, diarrhoea, TB

Countrys ruralpopulation

MUAC strip costs perchild

Ratio of CHWs topopulation

Phone and backpackcosts per CHW

Phones, phone plans andbackpack costs

Number of casesin rural areas

Medication and diagnosticcosts per case

Medication and

diagnostic costs

Number of CHWs and CHWmanagers

Salary, training andmanagement costs per CHW

CHW training and refreshercourse costs

MUAC strip costs

CHW salaries

CHW manager salaries

MUAC, mid upper a rm circumerence; NTD, neglected tropical disease; TB, tuberculosis.Green boxes indicate junctures requiring data on requiring data on population, disease incidence andsupply and commodity costs.

Fig. 2. Costing algorithm or childbirth specialist community health workers (CHWs)

Births in ruralareas

Ratio of childbirth CHWsto population

Phone and backpackcosts per CHW

Country rural populationand national birth rate

Cost of HIV screening forpregnant women Phones, phone plans and

backpack costs

Number of childbirth CHWsand managers

Salary, training andmanagement costs per CHW

CHW training and refreshercourse costs

CHW salaries

HIV screening costs

CHW manager salaries

HIV, human immunodeciency virus.Green boxes indicate junctures requiring data on requiring data on population, disease incidence andsupply and commodity costs.


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receive a yearly reresher courselasting 20 hours. In the MillenniumVillages Project, training 50 CHWsor 80 hours costs US$ 300. Tisincludes transport, meals, sup-plies and trainers honorarium, asnecessary. We used this gure tocompute an hourly cost. Followingthe experience o Pakistans nationalLady Health Worker programme, we

assumed a 5% student attrition rateduring training.17

Salaries: In the costing model, eachCHW receives a monthly salary oUS$ 80. Tis is the average CHWsalary across Millennium VillageProject settings in 10 countries. Tisgure will fuctuate depending onnational rural wage levels.

Management: Each CHW Manageris assumed to manage 30 CHWsand receives an annual salary oUS$ 9600. Tis 10-old dierence

between CHW and CHW managersalaries represents the average dier-ence across Millenium Village sites.Note that CHW managers could bephysicians in primary-health-careacilities with supplemental train-ing in management, which wouldparlay some o this cost into existingprimary-health-care system budgets.

Overhead: We added 15% to totalprogramme costs in order to accountor the overhead costs at the local,national and international levels o

a global eort to reach ull coverage,or around 1 million CHWs acrosslow-income sub-Saharan Arica by2015. Tis includes components o

the operational design not listed assegregated costs, such as commu-nity engagement and inormationmanagement.

Generalist CHWs are expected to gen-erate various costs. Te cost modellingwe have conducted is based on country-specic disease prevalence rates (andsubnational endemicity data in the case

o malaria). I the prevalence o anydisease drops, the resulting commodityexpenditures will decrease accordingly. Monitoring for undernutrition:

CHWs will use mid-upper armcircumerence (MUAC) strips tomonitor children between the ageso 1 and 5 years or undernutritionat least once every 90 days. We esti-mate a requirement o one MUACstrip per child per year, at a cost perstrip o US$ 0.05.18

Treating diarrhoea: CHWs will

treat episodes o diarrhoea with oralrehydration salts (ORS) and zinctablets. Tey should teach caretakershow to administer ORS and leavetwo packets in the household, alongwith 20-mg tablets, to be taken oncedaily or 14 days (hal a tablet inthe case o children younger than 6months).19 We calculate the aver-age cost per episode to be aroundUS$ 0.42.18 Following publisheddata,20 we assume that childrenunder 5 years o age experience 5 di-

arrhoeal episodes annually, and thatpeople older than 5 years experi-ence 1.28. Tis leads to an estimated1.1 billion diarrhoeal episodes per

year in rural Arica. Notably, diar-rhoeal disease is projected to be themost expensive health conditioncovered by CHWs: US$ 0.79 out oUS$ 2.88 in supply and commod-ity costs per person served by theCHW subsystem. A reduction indiarrhoeal disease incidence wouldhave important cost implications orCHW programmes.

Testing for and treating malaria:In the absence o microscopy, WHOprotocol dictates that all peoplewith ever in malarious areas shouldundergo a rapid diagnostic test(RD) beore being treated withantimalarials. We used the UnitedNations Population Divisions WorldPopulation Prospects demographic

breakdown or 2010 to divide thepopulation in malarious zones intogroups aged 04, 59, 1014 and14+ years. We assume that the 04age group will experience two everepisodes per year; the 59 and 1014age groups, one ever episode peryear, and the 14+ age group, 0.5ever episodes per year. Tese guresare the average annual number oever episodes rom all causes, acrossall malaria endemicity levels. OneRD kit costing US $0.50 is needed

or each o these ever episodes.18,21

We also calculate the costs o treat-ing malaria with artemisinin-basedcombination therapy (AC). Weassume that RD will reveal thataround 30% o the evers are due tomalaria and require AC. Te totalnumber o ever episodes requir-ing treatment or malaria by 2015is estimated at 150 million, which iswithin the range o other publishedestimates. Each case can be treatedwith either artemetherlumeantrine

or artesunateamodiaquine, so weuse the average cost. Te costs pertreatment course are as ollows: orartemetherlumeantrine, US$ 0.45or the 04 age group, US$ 0.90 orthe 59 age group, US$ 1.35 or the1014 age group and US$ 1.80 orthe 14+ age group; or artesunateamodiaquine, US$ 0.23 or inants,US$ 0.45 or children aged 16years, US$ 0.80 or children aged713 years and US$ 1.48 or peopleolder than 13. We used the dosages

recommended by the Roll Back Ma-laria Partnership and average drugprices obtained rom Sano-Aventis(Paris, France), Ipca (Mumbai,

Fig. 3. Costing algorithm or community health worker (CHW) reerral system costs

Countrys ruralpopulation

Population perambulance

Number ofambulances

Vehicle, fuel andmaintenance costs

Ambulance driversalary

Total expenditure invehicle, fuel and

maintenance

Total expenditure inambulance driver

salary

Green boxes indicate junctures requiring data on requiring data on population, disease incidence andsupply and commodity costs.


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ResearchCommunity health workers in sub-Saharan Arica Gordon C McCord et al.

India) and Cipla (Mumbai), with

adjustment to match the age groupsin our analysis. Te total projectedexpenditure is US$ 153 million inRDs and US$ 87 million in ACs,

with national per capita expenditure

varying in accordance with eachcountrys endemicity levels.

Deworming: Using country-leveldata on the prevalence o ascariasis,

trichuriasis and hookworm,22 weapplied the ollowing protocol: i thecountry-level prevalence o any othe three inestations is over 50%,all individuals receive three doses oalbendazole (costing US$ 0.02 perdose) per year.18 I the prevalenceis above 20% and below 50%, theneveryone receives one dose o alben-dazole. For schistosomiasis, i theprevalence is above 50%, everyoneolder than 4 years is treated withpraziquantel once a year.23 I theprevalence is above 10%, everyeligible person is treated once everytwo years. I the prevalence is below10%, only school-age children aretreated twice during their school-aged years (once on entry and once

on exit). Praziquantel costs US$ 0.22a tablet,18 and since the number otablets in the treatment varies rom1 to 5 depending on body weight, weassume an average o 2.5 tablets pertreatment.

Pneumonia: WHO reported 131.3million pneumonia episodes in A-rica in 2004.24 From this we calculatethe number o episodes per personand, on the assumption that inci-dence in a given country remainsconstant, we estimate the number o

pneumonia episodes in the popula-tion covered by CHWs each year.We include timers or each CHWto assess childrens respiratoryrate; respiratory timers rom theUnited Nations Childrens Fund costUS$ 3.50.18 Since they are good or10 000 uses, we assume one timerper CHW per year. Te average costo antibiotics is US$ 0.27 per case.24

Screening for tuberculosis: CHWsshould collect sputum samples romsuspected tuberculosis cases. We

estimate the number o screeningsusing each countrys incidence otuberculosis and assume a positivityrate o 10%. Te cost o screeningone person covers the collection othree sputum samples in contain-ers (one on the rst day and two onthe second day). Te containers arelabelled with a marker and put ina reusable sealable plastic bag. Tecost o each container is US$ 0.054.Each CHW is given two markers orthe year and three reusable sealable

plastic bags every 3 months. Finally,CHWs use two new pairs o surgicalgloves or each screening, since thescreening is conducted over two

Fig. 4. Average annual CHW costs as a unction o population served

OverheadSalariesManagementTraining

Supplies

United

Statesdollars

9.00

8.00

7.00

6.00

5.00

4.00

3.00

2.00

1.00

0.00

Rural population per CHW

500 550 600 650 700 750 800 850 900 950 1000

CHW, community health worker.Note: Costs are or generalist and childbirth specialist CHWs combined.

Fig. 5. Spatial distribution across sub-Saharan Arica o the annual cost o a communityhealth worker programme

100

2 000 5 000

> 10 000

1002 000

5 000 10 000

0

Expenditure (US$)

a These protocols are rom the Millennium Villages deworming protocol.Note: The map shows expenditure in every 2.5 minute cell (roughly 4.6 4.6 km). Costs are calculated asCHW programme cost per rural inhabitant at the country level, then multiplied by the rural population ineach grid cell.


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days. In the Bonsaaso MillenniumVillage in Ghana, markers are pricedat US$ 10 or a pack o 8, plasticbags are priced at US$ 8 or a packo 25 and surgical gloves are pricedat US$ 0.60 a pair.

Te childbirth specialist CHW wouldgenerate the same human resourceexpenditures (training, salary, manage-ment) as the generalist CHW, but dier-ent commodity costs: Screening pregnant women for

HIV infection: All pregnant womenwill undergo at least one HIV test.Following Joint United NationsProgramme on HIV/AIDS cost esti-mates or the prevention o mother-to-child transmission o HIV, we

estimate a cost o US$ 3.90 or eachHIV serological test. I a pregnantwoman tests positive or HIV, theCHW will also test her husbandand children (assumed to be 2, onaverage). HIV-positive individualswill be reerred to the national AIDSprogramme or counselling andtreatment.

Ambulances are included in the costingmodel as a necessary link between theCHWs and the primary-health-caresystem.

Ambulances: One ambulance isassumed to cover a population o50 000 people in a rural area. Basedon experience in Millennium Vil-

lages, an ambulance costs an averageo US$ 36 000. Te ambulancedriver receives an annual salaryo US$ 4782. Ambulance uel andmaintenance costs average US$ 4825per year across Millennium Villages.

In total, it will take an average oUS$ 3750 annually to train, equip andsupport each CHW between 2012 and2015. Maintenance o the CHW pro-gramme aer 2015 will cost US$ 3150per CHW. Tese costs do not includetwo potential CHW services: amilyplanning and HIV screening or thegeneral population. Since public healthspecialists have not reached consensuson whether CHWs should be taskedwith these services, we have separatedthem rom the costing ramework above

and consider them below: Family planning: Te average

cost o amily planning in Arica,including contraceptives, has beenestimated at around US$ 26.90annually per woman o reproduc-tive age (1549 years).25 I general-ist CHWs oer amily planningservices to women in this age group,the total cost comes to an average oUS$ 2.4 billion per year, or US$ 6.36per person serviced by the CHWprogramme.

HIV screening in the generalpopulation: Studies have begundocumenting the benets o ac-tive case nding and outreach by

CHWs.26 Health service provision ismoving towards increased decen-tralization and at some point CHWsmay be tasked with testing thegeneral population or HIV. (Notethat in the costing presented earlier,

pregnant women and their amiliesare already tested through childbirthspecialist CHWs). Although theappropriate requency o testing re-mains to be determined, we assumeone annual test per person to get anidea o costs. Extending HIV test-ing once a year to all HIV-negativepeople older than 14 years costs anaverage o US$ 791 million per year,or US$ 2.12 per rural inhabitant.

Estimated costs of scale-up

by 2015

Te model ramps up CHW coverageevenly rom 2012 to 2015: in 2012 onequarter o the rural population receivesservices, but by 2015 the entire ruralpopulation will be serviced. Note thatin the costing model rural populationand population growth are based onUnited Nations Population Divisiondata, which come rom national statis-tics oces with varying denitions ourban and rural areas. Tus, our model

is based on each countrys denitiono rural and urban. Te number oCHWs per inhabitant will be dierentor each country, especially in light o

Table 3. Factors to be modifed when adapting operational design o model community health worker (CHW) costing system to localcontext

Factor Assumption orexample model

Condition

Low Medium High

Populationdensity

Low Rural Periurban Urban

Facility density Low Rural Periurban Urban

Task load Low General counselling tasks athousehold or outreach centres

General counselling and casemanagement tasks at householdlevel, with data reporting

General counselling and casemanagement tasks at householdand/or health post level, with datareporting and additional specializedtasks

Education andliteracy

Mediumhigh None Primary school Secondary school

CHWintegration withhealth systema

High CHW programme works inisolation rom health system;links to health system weak

Health system recognizes CHWprogramme and provides supportor guidelines.

Health system providescomprehensive support to CHWprogramme, including training,supervision, reerral, equipment

and supplies.Countryownershipand nancialsupporta

High CHWs not recognized aspart o national system; nonancial support provided bygovernment

CHWs recognized as part ohealth system but role notormalized; little or no nancialsupport provided by government

CHWs recognized as part o healthsystem; partial to ull nancing bygovernment

a Functionality denition provided by the Community Health Worker Assessment and Improvement Matrix.32


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:

)CHW(

.

.

650.2015

)GIS(

.) (.

.

dierences in rural population density.For this reason, Fig. 4 shows programmecosts by major category as a unction othe number o rural residents per CHW,which varies rom 500 to 1000 people.

able 2(available at:http://www.who.

int/bulletin/volumes/91/4/12-109660 )shows the country-by-country break-down o the number o CHWs requiredby 2015 and the average yearly costs orsupplies, training, salaries, managementand overhead or the combined work-orce o generalist CHWs and childbirthspecialist CHWs. At a rate o 1 generalistor every 650 rural Aricans and o 1childbirth specialist or every 3500 A-ricans, the average annual cost o CHWsystem ramp-up across Arica is aroundUS$ 2.6 thousand million (billion), or

US$ 6.86 per person covered by CHWservices, or US$ 2.72 per inhabitant. Tecost o training, equipping and support-ing each CHW amounts to US$ 3750per year.

Steady-state system costs listed inthe last three columns oable 2includethe training o new CHWs to keepup with rural population growth andreresher courses or all CHWs in thesystem. Steady-state estimates includecapital costs such as phones, backpacksand ambulances; these are amortized

over 3, 3 and 7 years, respectively.Fig. 5 shows how expenditure is

spatially distributed across rural Arica.o obtain the distribution we used thecosts per rural inhabitant given earlierand 2.5 arc-minute GIS data on popu-lation and urban extents in 2010.27 Weeliminated the urban population andcalculated the average annual cost pergrid cell. Te map allows internationaland national policy-makers to see how

CHW programme expenditures wouldbe distributed within and across sub-Saharan Arican countries.

Discussion

According to studies published by theCommission on Macroeconomics andHealth, the United Nations MillenniumProject and the International ask Forceon Innovative Financing or Health, in alow-income country a primary-health-care system should cost rom US$ 50to US$ 55 per capita per year in 2011prices.2830 According to this model, theCHW subsystem congured in this paperwould cost approximately 5% o the totalcost o a primary-health-care system.

Although this ramework provides

an estimate o CHW-related costs acrosssub-Saharan Arica, country-specic -nancing models refecting the local costso training and deploying the CHWsshould emerge, along with country-specic strategies to suit dierent CHWprogramme characteristics. Nigeria iscurrently planning to deploy a CHWsubsystem nationally.

Te eectiveness o a CHW sub-system depends on how well the rest othe health system unctions. Althoughwe excluded hospitals, clinics and

non-CHW health sta rom our cost-ing model, they provide vital logisticalsupport to CHWs by making availableto them adequate supplies o medicinesand possibilities or patient reerral.When national CHW initiatives havebeen taken to scale without supportinginrastructure, retrospective analysis re-

veals weaknesses in management, supplychain, nancing and other componentso the supporting system.31

Depending on existing policiesor disease prevalence, national CHW

strategies may be designed to trainCHWs to provide supplemental ser-vices beyond those described in thismodel. As countries engage in the

financial and operational planning oftheir CHW programmes, model inputs

will differ in accordance with the localcontext, as exemplified in Table 3. The

adaptation of the model to country-specific needs will become increas-ingly important as ministries of healthprepare their community-based healthworkforces for the management of theincreasing burden of non-communi-

cable diseases. However, the manage-ment of patients with these diseasesby CHWs requires further study and

operational detailing in low-resourcesettings, as well as a dedicated supple-mental source of financing.

In summary, we recommend thatcountries wishing to develop a CHWstrategy perorm a similar costing exer-cise to design programme budgets. Ac-cording to previous studies, investmentin a well-organized and comprehensiveCHW subsystem that is embedded ina primary-health-care system can re-duce maternal and child morbidity andmortality. Our assessment suggests that

the costs o the core elements o sucha system are a raction o the costs oprimary-health-care services overall.Tis costing exercise sets the stage or acosting ramework that can be used todetermine the costbenet and coste-ectiveness o CHW programmes.

Competing interests: None declared.
http://www.who.int/bulletin/volumes/91/4/12-109660http://www.who.int/bulletin/volumes/91/4/12-109660http://www.who.int/bulletin/volumes/91/4/12-109660http://www.who.int/bulletin/volumes/91/4/12-109660


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Rsum

Dploiement des agents de sant communautaires en Arique rurale subsaharienne: considrations fnancires et hypothsesoprationnellesObjectifFournir des conseils en termes de cots pour le dveloppementdun systme dagents de sant communautaires (ASC) localement

adaptable et voluti l chelle nationale, au sein des systmes de soinsde sant primaires en Arique sub-saharienne.Mthodes Les cots annuels de ormation, dquipement et dedploiement des ASC dans les rgions rurales dArique subsaharienneont t calculs en utilisant les donnes publies et celles du projetVillages du Millnaire. Les hypothses du modle sont de nature permettre aux gouvernements nationaux dadapter le sous-systmedASC aux besoins nationaux et de dployer une moyenne dun ASC pour650 habitants de milieux ruraux dici 2015. Le sous-systme des ASC a tchir laide des donnes dun systme dinormation gographique(SIG) sur la population, les tendues urbaines, la prvalence de maladiesau niveau national et inranational,et les cots unitaires (sur le terrain,pour les salaires et le matriel). Le modle est acile reproduire et

congurer. Les pays peuvent ladapter aux prix locaux, aux salaires,

la densit de population et aux charges de morbidit dans direnteszones gographiques.

Rsultats Le cot annuel moyen pour dployer des ASC prenant encharge lensemble de la population rurale dArique subsaharienne dici2015 serait denviron 2,6 milliards (c..d. 2 600 millions) de dollars. Cettesomme, qui doit tre ournie la ois par les gouvernements nationauxet les bailleurs de onds, correspond 6,86 dollars par an et par habitantcouvert par le sous-systme dASC, et 2,72 dollars par an et par habitant.Il audrait en outre compter un montant moyen annuel de 3 750 dollarspour ormer, quiper et assister chaque ASC.ConclusionDes sous-systmes complets dASC peuvent tre dploysen Arique sub-saharienne pour un cot modeste par rapport aux cotsprvus du systme de soins de sant primaires. Compte tenu de leurssuccs attests, ils constituent un complment solide aux structures desoins dans les contextes ruraux aricains.

- :

- ()

-

.

,

(Millennium

Villages). ,

1 650

2015 .

(), ,

,


9/12



,

(

).

. ,

,

.

2015 . 2,6 . (.. 2 600 .) . .

,

, -,

6,86 . ,

, 2,72 . .

, 3 750 .

, .

,

- .

,

,

.

Resumen

Despliegue de trabajadores comunitarios de la salud en zonas rurales del rica subsahariana: consideraciones fnancieras ysupuestos operativosObjetivo Facilitar asesoramiento sobre los costes necesarios paradesarrollar un sistema de trabajadores comunitarios de la salud (TCS)con capacidad para adaptarse a mbitos locales y con fexibilidad a nivel

nacional, en el marco de los sistemas sanitarios de atencin primaria enel rica subsahariana.Mtodos Se estimaron los gastos anuales para la capacitacin, elequipamiento y el despliegue de los trabajadores comunitarios de lasalud en las zonas rurales del rica subsahariana mediante el anlisisde datos procedentes de la literatura, as como del Proyecto Aldeasdel Milenio. Los supuestos del modelo son adecuados para permitira los gobiernos nacionales adaptar el subsistema de los trabajadorescomunitarios de la salud a las necesidades nacionales, as como pararealizar un despliegue medio de un trabajador comunitario de la saludpor cada 650 habitantes en las zonas rurales antes de 2015. El subsistemade trabajadores comunitarios de la salud descrito se calcul medianteel anlisis de datos del sistema de inormacin geogrca (GIS, por sus

siglas en ingls) sobre la poblacin, los territorios urbanos, la incidenciade enermedades a nivel nacional y subnacional, as como los costesunitarios (en el campo de salarios y necesidades bsicas). El modelo

puede congurarse y reproducirse con acilidad. Los pases puedenadaptarlo a los precios, los salarios, la densidad demogrca, as comoa la carga de enermedades locales en distintas reas geogrcas.

Resultados Se estima que el coste medio anual por el desplieguede trabajadores comunitarios de la salud para prestar atencin a todala poblacin de las zonas rurales del rica subsahariana antes de2015 sera de unos 2,6 billones (es decir, 2 600 millones) de dlaresestadounidenses (US$). Dicha suma, que ser cubierta tanto por losgobiernos nacionales como por los socios donantes, se traduce en US$6,86 anuales por habitante, cubierta por el subsistema de trabajadorescomunitarios de la salud, y en US$ 2,72 anuales por habitante. Asimismo,la capacitacin, el equipamiento y el apoyo a cada TCS supondra unamedia anual de US$ 3750.Conclusin Se pueden desplegar subsistemas integrales detrabajadores comunitarios de la salud en todo el rica subsahariana porun coste modesto, si se compara con los costes previstos para un sistema

de atencin sanitaria primaria. A juzgar por los xitos documentados,estos orecen un slido complemento para la atencin en serviciossanitarios en entornos rurales de rica.

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Bull World Health Organ 2012;91:244253B | doi:10.2471/BLT.12.109660 253A


Table2.

Averageannualexpenditureonthecommu

nityhealthworker(CHW)programme(with

1CHW

forevery650ruralinhabitants)

Country

No.

ofCHWs

in2015

Averageannualexpenditurein2012

2015(millionsofUS$)

Averageannualexpenditureafter2015

Sup

plies

Training

Salaries

Manag

ement

Overhead

Total

Perpopulation

served

Total

Perrural

population

Pertotal

population

Angola

15209

1

8.7

5

0.6

1

9.1

3

3.0

4

4.7

2

36.2

4

6.9

7

48.9

0

5.8

8

2.2

5

Benin

9714

1

1.6

1

0.3

9

5.8

3

1.9

4

2.9

6

22.7

3

6.8

5

30.6

2

5.7

7

2.8

7

Botswana

1401

1.5

4

0.0

6

0.8

4

0.2

8

0.4

1

3.1

2

6.5

3

4.1

7

5.4

4

1.9

7

BurkinaFas

o

23623

2

8.9

5

0.9

5

14.1

7

4.7

2

7.3

1

56.1

0

6.9

5

75.6

3

5.8

6

3.9

7

Burundi

15611

1

7.9

8

0.6

3

9.3

7

3.1

2

4.6

5

35.7

5

6.7

0

48.1

1

5.6

4

5.0

9

Cameroon

20536

2

4.8

9

0.8

2

12.3

2

4.1

1

6.3

1

48.4

5

6.9

0

65.4

1

5.8

3

2.9

4

CapeVerde

325

0.2

7

0.0

1

0.2

0

0.0

7

0.0

8

0.6

3

5.6

6

0.8

3

4.6

4

1.4

9

CentralAfricanRepublic

5324

6.3

8

0.2

1

3.1

9

1.0

6

1.6

2

12.4

7

6.8

6

16.8

2

5.7

8

3.4

0

Chad

19255

2

3.5

3

0.7

7

11.5

5

3.8

5

5.9

4

45.6

5

6.9

4

61.4

4

5.8

4

4.6

7

Comoros

1104

0.9

6

0.0

4

0.6

6

0.2

2

0.2

8

2.1

7

5.7

6

2.8

3

4.6

9

3.6

8

Congo

2875

3.2

8

0.1

2

1.7

3

0.5

8

0.8

5

6.5

5

6.6

7

8.7

9

5.5

9

2.0

7

Congo,

DemocraticRepublic

89555

11

1.2

5

3.5

9

53.7

3

17.9

1

27.9

2

214.4

0

7.0

1

289.5

5

5.9

1

3.7

3

Djibouti

658

0.6

8

0.0

3

0.4

0

0.1

3

0.1

8

1.4

2

6.3

0

1.9

0

5.2

9

1.9

9

EquatorialGuinea

887

1.0

1

0.0

4

0.5

3

0.1

8

0.2

6

2.0

2

6.6

6

2.7

0

5.5

8

3.4

5

Eritrea

8721

9.7

5

0.3

5

5.2

3

1.7

4

2.5

6

19.6

3

6.5

9

26.3

4

5.5

2

4.3

7

Ethiopia

139837

15

7.6

6

5.6

0

83.9

0

27.9

7

41.1

9

316.3

2

6.6

2

425.5

7

5.5

7

4.4

0

Gabon

370

0.4

3

0.0

1

0.2

2

0.0

7

0.1

1

0.8

6

6.7

8

1.1

6

5.7

3

0.7

0

Gambia

1481

1.8

0

0.0

6

0.8

9

0.3

0

0.4

6

3.5

0

6.9

1

4.7

2

5.8

3

2.3

8

Ghana

22925

2

6.8

8

0.9

2

13.7

6

4.5

9

6.9

1

53.0

4

6.7

7

71.6

3

5.7

2

2.6

5

Guinea

12719

1

5.4

0

0.5

1

7.6

3

2.5

4

3.9

1

29.9

9

6.9

0

40.4

8

5.8

2

3.4

1

Guinea-Bissau

1404

1.6

8

0.0

6

0.8

4

0.2

8

0.4

3

3.2

9

6.8

6

4.4

4

5.7

8

2.3

9

IvoryCoast

18172

2

1.8

0

0.7

3

10.9

0

3.6

3

5.5

5

42.6

1

6.8

6

57.5

2

5.7

9

2.3

7

Kenya

62048

7

4.8

5

2.4

8

37.2

3

12.4

1

19.0

1

145.9

8

6.8

9

196.5

2

5.7

9

4.2

2

Lesotho

2912

2.6

2

0.1

2

1.7

5

0.5

8

0.7

6

5.8

3

5.8

6

7.5

6

4.7

5

3.4

6

Liberia

5851

7.1

1

0.2

3

3.5

1

1.1

7

1.8

0

13.8

2

6.9

1

18.7

4

5.8

6

4.0

0

Madagasca

r

28412

3

4.4

2

1.1

4

17.0

5

5.6

8

8.7

3

67.0

1

6.9

0

90.7

4

5.8

4

3.9

5

Malawi

27243

3

3.4

9

1.0

9

16.3

5

5.4

5

8.4

4

64.8

1

6.9

6

86.8

0

5.8

3

4.8

0

Mali

20364

2

4.5

3

0.8

2

12.2

2

4.0

7

6.2

3

47.8

6

6.8

8

64.3

1

5.7

8

4.2

8

Mauritania

4160

4.8

6

0.1

7

2.5

0

0.8

3

1.2

5

9.6

0

6.7

6

12.9

6

5.7

0

3.4

7

Mauritius

1418

1.1

3

0.0

6

0.8

5

0.2

8

0.3

5

2.6

7

5.5

2

3.5

1

4.5

3

2.5

9

Mozambique

34966

4

5.7

5

1.4

0

20.9

8

6.9

9

11.2

5

86.3

7

7.2

3

117.0

3

6.1

2

4.4

9

Namibia

2730

3.2

6

0.1

1

1.6

4

0.5

5

0.8

3

6.3

8

6.8

4

8.6

2

5.7

7

3.5

5

Niger

27399

3

4.0

3

1.1

0

16.4

4

5.4

8

8.5

4

65.5

9

7.0

1

88.4

0

5.9

0

4.6

1

(continues.

.

.)


12/12

253B Bull World Health Organ 2012;91:244253B | doi:10.2471/BLT.12.109660


Country

No.

ofCHWs

in2015

Averageannualexpenditurein2012

2015(millionsofUS$)

Averageannualexpenditureafter2015

Sup

plies

Training

Salaries

Manag

ement

Overhead

Total

Perpopulation

served

Total

Perrural

population

Pertotal

population

Nigeria

158659

19

1.0

5

6.3

5

95.2

0

31.7

3

48.5

6

372.8

9

6.8

8

501.9

1

5.7

9

2.8

4

Rwanda

17900

2

0.6

2

0.7

2

10.7

4

3.5

8

5.3

4

40.9

9

6.7

0

54.9

3

5.6

1

4.6

6

SoTomea

ndPrincipe

113

0.1

2

0.0

0

0.0

7

0.0

2

0.0

3

0.2

5

6.5

4

0.3

4

5.4

9

1.8

7

Senegal

14833

1

7.8

1

0.5

9

8.9

0

2.9

7

4.5

3

34.8

0

6.8

7

47.0

1

5.8

0

3.2

3

SierraLeon

e

7217

8.8

6

0.2

9

4.3

3

1.4

4

2.2

3

17.1

6

6.9

6

23.2

0

5.8

8

3.5

4

Somalia

11556

1

3.3

5

0.4

6

6.9

3

2.3

1

3.4

5

26.5

1

6.7

1

35.5

2

5.6

2

3.3

0

SouthAfric

a

35191

4

0.1

3

1.4

1

21.1

1

7.0

4

10.4

3

80.1

3

6.6

6

107.8

7

5.6

1

2.0

7

SouthSudan

15090

1

7.7

2

0.6

0

9.0

5

3.0

2

4.5

5

34.9

5

6.7

8

47.1

7

5.7

2

4.3

1

Sudan

33900

3

9.5

1

1.3

6

20.3

4

6.7

8

10.1

8

78.1

7

6.7

5

105.4

0

5.6

9

2.8

5

Swaziland

1635

2.0

3

0.0

7

0.9

8

0.3

3

0.5

1

3.9

1

7.0

0

5.2

5

5.8

8

4.0

6

Togo

7963

9.6

3

0.3

2

4.7

8

1.5

9

2.4

4

18.7

7

6.9

0

25.4

3

5.8

4

3.3

3

Uganda

59032

7

2.9

4

2.3

6

35.4

2

11.8

1

18.3

4

140.8

8

6.9

8

189.2

3

5.8

6

4.7

5

UnitedRep

ublicofTanzania

67826

8

2.1

6

2.7

2

40.7

0

13.5

7

20.8

3

159.9

6

6.9

0

215.0

5

5.8

0

4.1

1

Zambia

15399

1

9.2

9

0.6

2

9.2

4

3.0

8

4.8

3

37.0

6

7.0

4

49.5

3

5.8

8

3.2

9

Zimbabwe

13731

1

6.7

6

0.5

5

8.2

4

2.7

5

4.2

4

32.5

3

6.9

3

43.8

8

5.8

5

3.1

1

Total

1089334

130

5

44

654

218

332

2552

3437

Costperinhabitantserved

3.5

1

0.1

2

1.7

6

0.59

0.8

9

6.8

6

5.6

3

US$,United

Statesdollar.

chws in africa bullwho 4-13 (2)

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