Community Health Worker Program Sustainability in Africa: Evidence From Costing, Financing, and Geospatial Analyses in Mali

Patrick Pascal Saint-Firmin; Birama Diakite; Kevin Ward; Mitto Benard; Sara Stratton; Christine Ortiz; Arin Dutta; Seydou Traore

doi:10.9745/GHSP-D-20-00404

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Community health workers in Mali. © 2018 Souleymane Bathieno/Health Policy Plus
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Community health worker in Mali conducts growth monitoring of child. © 2018 Souleymane Bathieno/Health Policy Plus
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FIGURE 1
Funding Needed Versus Expenditure by Community Health Worker Program Input in 2015, Mali
Abbreviation: CHW, community health worker.*Capital costs include cost of providing living and working space to CHWs at the village level.
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FIGURE 2
Proximity of CHW-Covered Villages to Non-Covered Villages and Distribution of Non-Covered Villages in 2015, Mali
Abbreviation: CHW, community health worker.
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FIGURE 3
Geospatial Distribution of Technical Efficiency Opportunities for the Community Health Worker Program in 2015, Mali
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FIGURE 4
Geographic Distribution of Allocative Efficiency Opportunities for the Community Health Worker Program Across Health Districts in 2015, Mali
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FIGURE 5
Geographic Redistribution of Community Health Worker Program Theoretical Funding Surplus, 2015, Mali
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FIGURE 6
Distance-Based Geospatial Redistribution of Community Health Worker Program Funding Surplus, 2015, Mali
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Community health worker in Mali assesses temperature. © 2018 Souleymane Bathieno/Health Policy Plus

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TABLE 1.

Summary of Type of Data Used, Sources, and Collection Periods, Interlinked Analysis of Community Health Worker Programs, Mali

Type of Data and Collection Period	Primary Sources	Secondary Sources
CHW situational analysis (September 2016 to February 2017)
Program level (regions and health districts) - Population breakdown, health system levels, numbers and geographic distribution of CHWs, CHW financing sources and amounts spent, ratios of CHWs per population and community or household	- Questionnaires and data collection sheets filled by: National Statistic Office, National Health Directorate, MOHSA Division of Equipment and Finance, CHW program implementing partners, Regional Health Directorates, local authorities - Interviews with ECC managers, head of Health Facilities Regulation Division, Drug and Pharmacy Director, health district managers	- Baseline year reports from CHW implementing partners, local health information system, national health accounts, ECC national reviews, regional ECC managers - Mali Demographic Health Survey (fifth edition) - Health area microplanning monitoring guide (2014)
Costing CHW provided services (February to April 2017)
Country-level (baseline year) - National and sub-national population figures and growth rate, gender/age breakdown, per household - Annual inflation rate, currency exchange rate CHW specific inputs - CHW cadre information & training, supervision & program management - ECC package, number, and types of services delivered - Standard treatment guidelines - Equipment, medicine, and capital costs Capital costs - Description of assets, expected quantities, replacement frequency, and costs Standard treatment guidelines - Description, target population, time per service, and quantities of tests, medicines, and supplies	- Interview with head of statistics office of Mali National Statistic Office - MOHSA human resources directorate records - Consultative meetings with expert panel	- Mali general population census 2009 - National ECC implementation guide (Dec. '15) - MOH district-level records, local Health Information System report for baseline - Mali Demographic Health Survey 2013, 2018 - Government of Mali reference price listing for goods and services for 2015 - CHW standardized treatment chart for childhood sickness (June 2016)
District-level cost efficiencies, geospatial mapping, and analysis (March to June 2019)
Calculated estimates - Normative cost per CHW service - Number of services per person in target population by type of service in baseline year	Authors	N/A
Geospatial data - Geocoded villages; administrative boundaries for health districts, municipalities, and communes; population	N/A	- United Nations Office for the Coordination of Humanitarian Affairs Humanitarian Data Exchange Portal - Mali National Health Directorate GIS database
Geospatial mapping outputs - Thiessen polygons for CHW covered villages - Point, choropleth, and Euclidean distance maps	Authors	N/A

Abbreviations: CHW, community health worker; ECC, essential community care; MOHSA, Ministry of Health and Social Affairs.

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TABLE 2.

Overview of the CHW Program in Mali, 2015, from Situational Analysis Results

Region	Koulikoro	Kayes	Mopti	Segou	Sikasso	Bamako District^{^a}
Target population (total living in rural areas)	1,477,040	961,289	1,181,486	1,281,147	1,622,344	N/A
Population covered by CHWs	869,282	286,779	680,261	712,351	648,353	N/A
Population covered by CHWs, of rural population, %	59	30	58	56	40	N/A
No. villages	1761	1369	1896	2003	1629	N/A
No. villages covered by CHWs	621	256	306	412	591	N/A
No. health districts covered	10	8	8	8	10	N/A
No. CHCs	196	217	168	195	237	N/A
No. CHCs affiliated with CHWs	161	143	146	172	230
No. active CHWs	526	248	305	448	660	150
CHW of total CHWs, %	23	11	13	19	28	6
No.funding sources	7	7	6	6	6	2
Spending, USD	2,356,633	2,284,933	2,540,402	1,977,545	3,127,960	723,825
Spending of total spending, %	18	18	20	15	24	6

Abbreviations: CHC, community health center; CHW, community health worker.
↵a Bamako is an atypical district that does not meet any criteria stated in the ECC national implementation guide, both in terms of services provided and the determination of the target population. For more information, please consult the CHW landscape analysis report available at: http://www.healthpolicyplus.com/ns/pubs/7153-7273_MaliSituationalAnalysisJuly.pdf

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TABLE 3.

Costing CHW-Provided ECC Services (Selected Outputs), Mali, 2015

	Coverage of needs,^a %	Unit Cost Breakdown (US$)			Total time required to provide services,^b hours	Time available spent on service,^c %	Total cost, US$ (Share of total cost, %)
	Coverage of needs,^a %	Cost per service	Total Direct cost	Total indirect cost	Total time required to provide services,^b hours	Time available spent on service,^c %	Total cost, US$ (Share of total cost, %)
Curative services
Malaria rapid screening test	31.4	3.82	0.85	2.97	55,899	1.28	639,847 (8)
Uncomplicated malaria management	4.0	6.76	3.49	3.26	44,992	1.03	829,141 (10)
Moderate acute malnutrition management	33.6	33.84	24.94	8.90	36,916	0.85	1,249,206 (15)
Preventive services
Newborn follow-up	5.6	3.07	0.11	2.97	26,954	0.62	248,554 (3)
Education on lactational amenorrhea method	6.8	3.84	0.13	3.71	5,224	0.12	48,173 (1)
Oral contraceptives (pill) provision	6.8	4.68	0.97	3.71	6,459	0.15	72,578 (1)
Provision of contraceptive injections	6.8	1.14	0.40	0.74	4,868	0.11	66,600 (1)
Promotive services
Home visits	66.4	6.15	0.21	5.93	80,188	1.84	739,212 (9)
Monitoring and evaluation
Activity reporting	N/A	74.82	3.62	71.20	209,952	4.8	1,963,577 (23)

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TABLE 4.

Technical and Allocative Efficiency Gaps in Kayes Region, Mali, 2015

Health District	Rural Population [A]	Covered Population [B]	Number of CHW [C]	Average Spending per CHW, US$ [D]	Actual Spending on Covered Population, US$ [E] = [C] x [D]	Normative Cost for Covered Population, US$ [F]	Technical Efficiency Surplus (Deficit), US$ [G] = [E] − [F]	Normative Cost for Rural Population, US$ [H] = [F] / [B] x [A]	Allocative Efficiency Surplus (Deficit), US$ [I] = [E] − [H]
Kayes	210,228	61,361	45	9,213.44	414,604.77	196,305.62	218,299.15	672,559.72	(257,954.96)
Bafoulabe	77,332	33,009	34	9,213.44	313,256.94	99,135.01	214,121.93	232,249.03	81,007.91
Diema	99,199	36,222	27	9,213.44	248,762.86	184,383.31	64,379.55	504,959.41	(256,196.55)
Kenieba	106,732	18,313	14	9,213.44	128,988.15	46,319.44	82,668.71	269,959.42	(140,971.27)
Kita	267,635	82,779	82	9,213.44	755,502.02	117,566.54	637,935.49	380,107.51	375,394.51
Nioro	102,444	14,554	8	9,213.44	73,707.51	36,937.50	36,770.02	259,998.97	(186,291.46)
Yelimane	42,043	14,584	13	9,213.44	119,774.71	21,981.85	97,792.86	63,369.65	56,405.06
Oussoubidiagna	55,676	25,957	25	9,213.44	230,335.98	49,890.50	180,445.48	107,011.73	123,324.26

Abbreviations: CHW, community health worker; ECC, essential community care.
a Estimated by dividing the actual number of services provided by the expected number of services.
b Total time required to provide each service is calculated by multiplying the expected time spent on service (in minutes) by the reported service volume for the year. The estimates are then converted in CHW hours.
c Percentage of CHW time available spent on services is calculated by dividing the total time required to provide the services reported for the year and the total time available for providing EC.