Community health workers are the most cost-effective component of most health systems and the most consistently underfunded.
What Community Health Workers Do
Community health workers — lay members of communities trained to provide a defined set of health services, health education, and health system navigation — occupy a specific structural role that formal health workers cannot fill. They provide the cultural familiarity, trust, and proximity that make health services accessible to populations who would not access the formal health system through formal channels. They identify people who need services who are not presenting to the health system. And they serve as the interface between the formal health system and the community. The evidence base for their effectiveness is extensive and consistent: well-supported programmes produce significant improvements in health outcomes at costs per outcome substantially lower than equivalent outcomes achieved through facility-based care.
The Underfunding Pattern
Despite the evidence base, community health worker programmes are consistently underfunded relative to the formal health workforce. The political economy of health spending favours the formal health sector — hospitals, equipment, specialist training — whose advocates are organised, professional, and politically articulate, over the community health sector whose workforce is less politically powerful. The result is a health system that overinvests in expensive hospital-based care serving the minority of health need that presents to facilities and underinvests in the community-based care that determines most of the population health outcomes the system's purpose is to improve.
Community health workers are the health system's most cost-effective component and its most consistently neglected one. The gap between their documented effectiveness and their institutional support is the gap between what health systems say they are for and what they actually fund.
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