The cost of a CHW programme depends on the employment status of the CHWs, their salaries and benefits, management costs, training costs, logistics, equipment, consumables and infrastructural support.

Very few studies take into account all of the costs of a CHW programme,[1] just as they fail to take into account all of the benefits, such as nurse hours saved, cost savings to individuals and the health system when CHWs avert preventable sicknesses, cost savings associated with reduced burden on health facilities, and others.[2]

Remuneration

There is some discussion of whether CHWs need to be paid at all and, if they are paid, whether payment needs to exceed the small stipends most South African CHWs receive to cover their transport and other basic costs.

The evidence shows that  CHW programmes collapse when the workers either are not paid at all or are not paid enough, when payment is irregular and when the remuneration differs between CHWs. While some programmes around the world are volunteer-based, the programme model cannot be a mix of both paid and volunteer workers.[3] There is also no evidence that volunteer programmes can be sustained long term.[4] For the individuals involved, too, programmes that rely on volunteers or pay only small stipends, experience problems with retention of staff, which has implications for the cost of the programmes (primarily the cost of retraining) and the effectiveness of CHW work.[5]

As noted above, employment within the health system would mean payment at Level 1, notch 1. This would be good for the CHWs themselves and for the sustainability of the programme, although it would mean that coverage would be limited to start with as this is an expensive option.

Management and supervision

Another important CHW programme feature and cost is that of management. It is generally accepted that poor management or supervision and support is the weakest link in many CHW programmes.[6] Despite this, the responsibilities, structures and cost of management is frequently not taken into account in assessing the cost of a CHW programme.

In South Africa, the WBPHCOTs are frequently managed by nurses in their first year out of training. They are expected to supervise CHWs who are much older and more experienced than them. They are not given the same training as the CHWs and are unable to stand up for their teams when, for example, more senior nurses in health facilities want to use CHWs to fill gaps in the staffing at clinics.[7] It is important that we get this aspect of the programme right and that managers/supervisors are appropriately experienced, trained and capacitated to fulfil this role.

Training

Training is a vital component of a CHW programme. It is necessary for programme developers to decide the length and frequency of training; who will conduct the training; and the method of training and how this relates to the roles to be performed by the CHW (for example, if CHWs’ skills are identified and expanded to suit the role or if new skills are taught).

The WBPHCOT Policy envisages training in two phases over 20 days, with opportunities for refresher and specialised training.[8] A significant weakness of the current training programme is that there is no first aid or basic counselling training provided in phase 1. Given that CHWs could be the only easily accessible health worker, particularly in rural areas, the lack of training puts CHWs in a difficult position when their assistance is sought in emergencies. It may be necessary to rethink some aspects of the training programme to make it fit the requirements of the CHWs work. Refresher training should be institutionalised.

Other resource requirements

Other resource requirements include equipment, medicine and transport. The WBPHCOT Policy provides for transport but places the obligation on the operations manager of the clinic with which the WBPHCOT is associated to secure funding to meet transport needs. This is a significant weakness given the numerous other obligations on operations managers.[9]

Finally, a resource and programme design requirement that is often not considered is that of debriefing and trauma counselling for CHWs. CHWs have a high prevalence of exposure to traumatic events, through directly experiencing, witnessing or hearing about these events.[10] There appears to be no provision for debriefing or mentally protecting CHWs from this exposure within the CHW programme.

Adding it all up

Estimating the total cost of a programme is difficult but necessary. The Investment Case gives different cost projections depending on the community served and the means of employment of CHWs. It uses the report on ‛Income Poverty at Small Area Level in South Africa in 2011’ by Noble et al (2014) to identify communities most in need by the percentage of the population in the area living below what is called the ‛upper bound poverty line’ of R1,113 per capita per month. This is a sound approach to decide on coverage of the programme, and should be supported.

Terms of employment to be considered include workday hours and pay-rates: full-time employment or a five-hour day on a stipend, determined by the Ministerial Determination (an eight-hour day on this basis costs R29,880 per CHW per annum), or employment as Level 1, notch 1 employees of the state (an eight-hour day on this basis costs R67,806 per CHW per annum). As noted above, the latter means of employment should be pursued.

In costing the recommended coverage and salary level (employment by the state and coverage of all wards where 60 percent of the population lives below the upper bound poverty line), the Investment Case finds that it would cost R4,896,709,793 (including the costs of all WBPHCOT members, infrastructure, support resources, training and administration, but excluding debriefing). However, while the Investment Case recommends a CHW to population ratio of 1:150 households, its costing is based on the current standard of 1:250 households.

If we were to cost the programme for a ratio of one CHW to 265 people, as proposed by Michel Sidibé, otherwise using the same coverage and other cost assumptions as the Investment Case, the costs would be as follows:

If we were to cost the programme for a ratio of one CHW to 600 people, otherwise using the same coverage and other cost assumptions as the Investment Case, the costs would be as follows:

 

Previous:6: How should CHWs be employed?

 

References

[1] G McCord et al ‛Deployment of community health workers across sub-Saharan Africa: financial considerations and operational assumptions’ Bulletin of the WHO 2012;91:244-253B, p2; U Lehman and D Sanders ‛Community Health Workers: What do we know about them?’ WHO Evidence and Information for Policy, Department of Human Resources for Health; Geneva, January 2007, p16.

[2] K Vaughan et al ‛Costs and cost-effectiveness of community health workers: evidence from a literature review’ Human Resources for Health (2015) 13:71, p1.

[3] D Singh et al ‛The effect of payment and incentives on motivation and focus of community health workers: five case studies from low- and middle-income countries’ Human Resources for Health (2015) 13:58, p9.

[4] U Lehman and D Sanders ‛Community Health Workers: What do we know about them?’ WHO Evidence and Information for Policy, Department of Human Resources for Health; Geneva, January 2007, p1.

[5] U Lehman and D Sanders ‛Community Health Workers: What do we know about them?’ WHO Evidence and Information for Policy, Department of Human Resources for Health; Geneva, January 2007, p14.

[6] U Lehman and D Sanders ‛Community Health Workers: What do we know about them?’ WHO Evidence and Information for Policy, Department of Human Resources for Health; Geneva, January 2007, p17; M Kok et al ‛Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review’ Health Policy and Planning 2015;30:1207-1227, p1217.

[7] Interview with Kirsten Thomson, Associate Researcher at Wits Reproductive Health and HIV Institute.

[8] Draft Municipal Ward Based Primary Health Care Outreach Team (WBPHCOT) Policy Framework and Strategy April, 2015, p28; Draft Investment Case for Ward-Based Primary Health Care Outreach Teams, p45.

[9] Draft Municipal Ward Based Primary Health Care Outreach Team (WBPHCOT) Policy Framework and Strategy April, 2015, p34.

[10] K Thomson Exploring the experience of CHWs operating in contexts where trauma and its exposure are continuous July 2014 Masters Thesis.