Considerations for Transforming the Status Quo in Community Health Financing

Community Health Financing Practices That Cause HarmCommunity Health Financing Practices That Accelerate Impact

High transaction costs: Complexity of donor processes (different funding windows, application deadlines) and documentation requirements. Funding sometimes only reaches communities months or even a full year after an emergency starts

Example: For any country’s annual budget, multiple donors contribute 10%–12% each toward the budget. These funders have asynchronous funding cycles, documentation requirements, metrics, application lengths, and processes.

Pooling: Donors pooling funding not only reduces transaction costs but also facilitates greater alignment and the flexibility to respond to unexpected crises such as pandemics. Aligning grant requirements and templates to reduce application burden would best leverage limited government bandwidth.

Example: One example of this is the Risk Pool Fund, “a collaborative experiment that makes fast, flexible funding available to pre-selected non-profits that are encountering an unexpected obstacle that threatens impact.”44

Ear-marked and inflexible: Funding single disease areas (e.g., malaria) independently from the larger health system leads to inefficiency in limited resources

Example: In one country, a CHW who has not received payment for months has received 5 smartphones to track disease-specific indicators. Not only is the value of the smartphones higher than the CHW’s stipend payment, but the smart apps do not capture all duties, so the CHW has to carry both hard copy tools and the phones.

Unshackle: Give unrestricted funding or reduce restrictions on grants. Holding entire programs accountable for their performance is a more rigorous form of accountability than restricting line items. Examine any necessary restrictions for potential negative unintended consequences/spillover effects.

Example: Collaborative funding for digital health across multiple technology providers to support pandemic preparedness and digital response from Rockefeller and other philanthropic entities. It appears that this collaborative, rather than competitive, funding model will continue in the wake of the pandemic and could be a strong model for building robust digital health systems. Similarly, several funders committed to providing unrestricted funds during the pandemic—such efforts should broaden and continue.

Contrary to evidence: RFPs and grant applications are not consistently designed and evaluated based on evidence-based guidelines like the CHW AIM tool and the WHO CHW guideline. Programs give priority to new or “innovative” approaches, at the expense of tried and true practices known to improve CHW program performance, like fair pay, ongoing training, and dedicated supervision.

Example: A large foundation involved in the CHW space funded a vertical (malaria-specific), volunteer-based “project” in a country with an existing professionalized CHW program.

Evidence-based: Provide funding based on evidence-based guidelines and tools like CHW AIM to design RFPs and evaluate investment opportunities.

Example: In Mali, the Global Fund pays for dedicated CHW supervision, based on government policy and studies published on results in trial sites. While the funding was originally for 1 year, it has now been renewed as part of a larger 3-year national funding package, NFM3.

Late to pay: Ineffectively designed mechanisms lead to late payment of CHWs and their supervisors and delayed procurement of the tools they need. This can destroy morale and program effectiveness.

Example: We have seen funder lateness, as well as primary recipient (NGO) lateness to pay due to contingencies placed by the funder (for example, a paper report may need to travel from a remote village to the capital before a regular monthly salary is released, leading to months of delay). One author of this article is a CHW working on the COVID-19 vaccination campaign in Malawi where wages have been delayed for 3+ months—a fact he and his colleagues find profoundly demotivating.

Optimize disbursement: Optimize, and when needed, redesign disbursement processes to prevent delayed payment and procurement.

Example: In Cambodia, a funds-flow analysis helped identify why these bottlenecks are occurring and what actions are needed to prevent them in the future (e.g., development of SOPs, expenditure tracking systems, standardized funds request forms).45 In Liberia, mobile money payments to CHWs were instituted to prevent delays. 46

Appropriation of sovereignty: Funding that does not align with and support national and sub-national government-led strategy can undercut government sovereignty, leadership, and effectiveness.

Example: Almost no private philanthropic funders require CSOs/NGOs to (1) prove/substantiate in applications how their plans align and support national strategy, (2) confirm government partnership (e.g., via partnership agreement already signed).

Align with and support: government strategy and invest to build up the national system.

Example: In 2021, the U.S. President’s Malaria Initiative announced the removal of restrictions on the funding of CHW salaries.47

Pressured exploitation: Funding restrictions have a wide array of unanticipated negative consequences. Multiple major funding agencies will not fund salaries at all, making it difficult for governments to implement global recommendations or to create long-term financing pathways for CHW payment, which often require a mix of international and domestic investment.

Example: We have witnessed funders pressure governments and grantees to reduce pay for CHWs and their supervisors to well below minimum wage. Such pressure undermines years of work that went into establishing norms for fair and effective payment of community health workers and makes it much harder for governments to do the right thing (Notably, NGO CEOs are almost never asked to justify the sustainability of having funding agencies paying their salary yet are asked constantly to justify the sustainability plan for CHWs, who are predominantly women living in poverty.)

Short-circuiting change: Short grant and/or financing cycles move grantees toward the easiest strategies for getting funding quickly out the door (such as procuring a large quantity of a given commodity) and away from transformative, high-impact investments

Example: While the speed of disbursement is critical and often lacking, duration of commitment is also often lacking. Delayed, slow disbursement of funds, particularly during Ebola 2014 and COVID-19 in 2020–2021, has negatively impacted outbreak response. Relatedly, short-duration commitments create pressure for less effective quick fixes and subvert government efforts to make transformative change in their health care systems.

Stay: Longer term, predictable investments support governments and their partners to commit to creating enduring, high-impact community health systems. Longer duration commitments allow governments to invest in recruiting, training, accrediting paid, professionalized CHWs in alignment with WHO guidelines and CHW AIM scorecard.

Example: Thomas J. White, cofounder of Partners in Health, funded work in Haiti for his entire life. Institutional funders typically fund in months or years, not decades.

  • Abbreviations: AIM, Assessment and Improvement Matrix; CEO, chief executive officer; CHW, community health workers; COVID-19, coronavirus disease; CSO, civil society organization; NFM3, new funding model 3; NGO, nongovernmental organization; RFP, request for proposal; SOP, standard operating procedure; WHO, World Health Organization.