The document discusses financing for community health programs. It summarizes a 2015 report that found a 10:1 return on investment from funding community health workers. The report defined four pillars of the investment case for funding CHWs: achieving global health objectives; long-term economic returns; short-term cost savings; and benefits to society. Current CH funding is estimated to be $0.7 billion annually in sub-Saharan Africa, below the estimated need of $1.1 billion. The document examines financing models for CH programs in Ethiopia, Zambia, Brazil, and Bangladesh.

1. September 2017
Community health financing
Core group meeting, Baltimore

2. The CHW investment case report was developed in 2015
Report signatories
• PM Hailemariam
• President Sirleaf
• Ray Chambers
• Tim Evans
• Chelsea Clinton
• Paul Farmer
• Joy Phumaphi
• Jeff Walker
The CHW Investment Case found a 10:1 ROI from investing in CHWs and called
on governments, financers, and the global community to take action . . .
This is what is today the
Financing Alliance for
Health

3. 3
The investment case defined “four pillars” of the case for
investment in CHWs
Investing in community health workers makes sense:
Requirement to achieve critical global health objectives1
Significant long-term economic return on investment2
Short-term cost savings to finance system scale-up3
Further benefits to society4
Source: “Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations,” July 2015.

4. Contributions to achieving universal healthcare, disease
elimination, and SDG goals
4
1
2
3
4
Requirement to achieve critical global health objectives
Promoting health and well-being: 40% of newborn & child deaths are
from diseases CHWs can prevent and treat – key for SDGs
Preventing and containing health crises: CHWs can play a key role in
surveillance and control – e.g. for Ebola, Zika, etc.
Achieving Universal Health Coverage: UHC cannot be achieved
without additional CHWs
Eliminating diseases: High quality coverage and surveillance – e.g.
through CHWs – is essential for disease elimination
Making healthcare affordable: The WHO has found that CHWs can
deliver care in a cost-effective manner
Source: “Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations,” July 2015.

5. Generation of high economic returns
5
1
2
3
4
Significant long-term economic return on investment
Source: “Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations,” July 2015.
$1
Investing
in CHWs…
$10
…can return up to
in the long-term
1. Productivity
2. Insurance
3. Employment

6. 6
1
2
3
4
Short-term cost savings Societal benefits
Short-term cost savings and other benefits
CHWs have been shown to deliver
higher value for money than facility-
based care across a number of
services:
1. Vaccinations
2. Neonatal care
3. Family planning
4. Malaria
5. Community Management of
Acute Malnutrition (CMAM)
6. HIV
7. Tuberculosis
CHWs deliver further benefits to
society:
1. Empowering women
2. Reducing costs for patients
3. Enabling governments to
conduct civil registration and
gather vital statistics (CRVS)
4. Enabling further service delivery
at the community level
5. Promoting stronger community
participation
Source: “Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations,” July 2015.
Short-term cost savings and further benefits to society

7. 7
Estimated annual
funding need for
community
health programs
Funding
gapEstimated current
annual funding for
community health
programs**
Estimated annual funding to community health in SSA ($ B)
PRELIMINARY ANALYSIS – TO BE VALIDATED
2.0
3.1
0.7 Donors
0.4 Govt
Share of current ~$14B
DAH to SSA***:
8% 22%14%
Despite strong investment case, current CH funding is
insufficient
1.1
(*) Quote from International Financing for Development Conference in Addis Ababa on July 13, 2015 (**) $1.1B based on theoretical model of funding to date.
Govt/donor split based on 60/40 ratio between donor and non-donor sources of funding for primary healthcare in 33 countries.
(***) DAH is only donor spend and does include domestic govt spend which would be higher, thus CH share of total health expenditures would be even smaller.
Source: Institute for Health Metrics and Evaluation (IHME). Financing Global Health Database, 1MCHW report, Dalberg analysis.

8. The same is true for Malaria funding. For example: In
Nigeria ~26% of a ~$48M grant was to be used towards
capacity building health care workers and case
management TA
Estimated annual CH donor funding
TB
RMNCH
Vaccinations
Other
Community
Health**
HIV/AIDs
Malaria
(*) Based on $1.1B estimate for total CH spend and 60/40 ratio of donor to domestic spend on primary healthcare across 33 countries. (**) Includes vertical grants that were targeted 100% for CH activities (vs.
grants that have a community health component), so might actually be an overestimate. Source: Institute for Health Metrics and Evaluation (IHME). Financing Global Health Database, Interviews, Dalberg Analysis
Estimated annual donor funding used
for community health in SSA by primary
health focus of grant ($ Millions)
MAJORITY OF DONOR FUNDING FOR CH COMES VIA
VERTICALIZED GRANTS…
…PRIMARILY FOCUSED ON HIV/AIDS AND MALARIA, BUT
ALSO ON OTHER HEALTH NEEDS LIKE VACCINATIONS
Significant amount of grant work is done at the community
level and the rate has only been increasing over time. For
example: A grant in Democratic Republic of Congo ~25% of
~ $60M planned spending was focused on community care
HIV/AIDS
Malaria
Funders for vaccinations also fund CHWs as part of vertical
grants. For example: ~22% of the ~$11.5M Health System
Support (HSS) grant to Somalia was for building and training
female CHW cadre
Vaccines
12%
49%
15%
6%
3%
14%
2%
0.7 B*
Current CH donor funding comes primarily through vertical
disease allocations, suggesting opportunities
8

9. The FA is researching how countries are financing community
health
Ethiopia
• Estimated ~38K
salaried Health
Extension Workers
(HEWs) who supervise
~4M Health
Development Army
(HDA) volunteers
• Widely credited with
improving Ethiopia’s
health outcomes
• Estimated
$300M/year in
funding for Health
Extension Program
(HEP)
• Donors via pooled
fund are largest
source of funding
• Currently have ~1.6K
Community Health
Assistants (CHAs) and
more than 20K
Community Based
Volunteers (CBVS),
which are mainly
donor supported
• Current estimates
suggest overall CHA
funding at ~$8.9M
• DFID funded almost
all start-up and pilot
costs but government
contributes to more
than 80% of funds
today
• Most recent estimates
suggest ~40K family
health teams through
‘Estrategia Saude da
Familia’ (ESF) with
~266K Community
Health Agents
covering almost 60%
of the Brazilian
population
• 100% of ESF program
costs covered via
municipal, state and
federal funds raised
primarily from tax
revenue
• ESF makes up ~20% of
$5.5B basic health
services budget
• Estimated ~100K
Shasthya Shebika (SS)
Community Health
Worker’s covering
more than 110M of
Bangladesh
population
• The program is
primarily donor
supported but also is
funded via earned
revenues from loans
and sale of basic
health products such
as birthing kits by SS
workers
Zambia Brazil Bangladesh/BRAC
CH
system
CH
funding
Source: See detailed case studies. 9

10. Case study lessons offer insights on success factors
throughout this process
Identify
champions
Resource
mapping
Build buy-
in (make
the case)
Finance/
investment
plan
Strategy,
policies,
costing
Operational Enablers (e.g.,
governance and coordination
structures)
Political Prioritization
• Strong political will and buy-in from top
to bottom, garnered through influential
champions and evidence-based
advocacy, can mobilize funding from
govt and donors alike
• Ministry-led coordination among govt,
partners and donors, spearheaded by a
central directorate and complemented
by local structures, can help to eliminate
inefficiencies and create strong,
integrated programs
• Government financial contributions to
core program components, paired with a
clear plan for sustaining and scaling
domestic resources, helps to signal
commitment and crowd in other funding
• Mobilizing new sources of funding,
including via local tax revenue and social
enterprise models, can help secure
longer-term financial sustainability
• While CH should be govt-led, donors
also have a role to play in fostering
political commitment and catalyzing
financing for integrated programs
A
A
B
B
C
C
D
D
E
E
10

11. Strategy,
policies, costing
Identification
sources of
financing
The case
(incl. ROI)
Finance/
investment
plan
Financial gap
analysis
Steps in financing community health
Country support
• Long-term onsite technical and financing support
• Serving governments via flexible modalities
A
Analytical toolkit
• Refine toolkits to
support country
costings, investment
cases and financing
pathways
B Financing
products/modalities
• Cataloguing existent
options while
building new tools
C Market building/
awareness and education
• Developing funding
baseline, country case
studies and advocacy
D
The Financing Alliance for Health’s aim is to support country
governments in community health financing

12. Overall the FA wants to help governments develop long-term
financing plans leveraging a mix of financing sources
20232019 20202017 20212018 2022
Private company investments
Federal government funding
County government funding
(10% of total budgets)
Donor support
Contributions from insurance schemes (individuals, companies)
National Community Health Assistant Program scale-up cost & financing
In $m

13. 13
• Strong political will and
buy-in
A
B
C
D
E
The FA research might also pose some food for thought for IPs
Lessons learned Questions/Ideas for IPs
• Have you provided your data to the MoH so they can
make a case on investments in CH?
• What do you see as your role in CH
planning/implementation in relation to the MoH? CH
planning/implementation
• Have you discussed “outsourcing” agreements with the MoH
as a sign of their commitment to your work?
• Are you working with the MoH to align your operations into
one CHW scale-up plan and support joint funding proposals
to large donors (e.g. GF)?
• Are you aligning with other Ips and their donor on an
integrated approach?
• Donors also have a role
to play i.e. on
integration
• Ministry-led
coordination
• Government financial
contributions
• New sources of funding
• Are you groups participating in national technical groups?
Are any of those focused or discuss on financing?
• Are you tapping into “newer” types of financing for your
work?
What have been your experiences with CH financing and what
strategies have you seen in your countries of implementation?