Costs and cost-effectiveness of community health workers: evidence from a literature review.
OBJECTIVE
This study sought to synthesize and critically review evidence on costs and cost-effectiveness of community health worker (CHW) programmes in low- and middle-income countries (LMICs) to inform policy dialogue around their role in health systems.


METHODS
From a larger systematic review on effectiveness and factors influencing performance of close-to-community providers, complemented by a supplementary search in PubMed, we did an exploratory review of a subset of papers (32 published primary studies and 4 reviews from the period January 2003-July 2015) about the costs and cost-effectiveness of CHWs. Studies were assessed using a data extraction matrix including methodological approach and findings.


RESULTS
Existing evidence suggests that, compared with standard care, using CHWs in health programmes can be a cost-effective intervention in LMICs, particularly for tuberculosis, but also - although evidence is weaker - in other areas such as reproductive, maternal, newborn and child health (RMNCH) and malaria.


CONCLUSIONS
Notwithstanding important caveats about the heterogeneity of the studies and their methodological limitations, findings reinforce the hypothesis that CHWs may represent, in some settings, a cost-effective approach for the delivery of essential health services. The less conclusive evidence about the cost-effectiveness of CHWs in other areas may reflect that these areas have been evaluated less (and less rigorously) than others, rather than an actual difference in cost-effectiveness in the various service delivery areas or interventions. Methodologically, areas for further development include how to properly assess costs from a societal perspective rather than just through the lens of the cost to government and accounting for non-tangible costs and non-health benefits commonly associated with CHWs.
Royal Tropical Institute (KIT), P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands. kvaughan@gmail.com.
Kelsey
K
Vaughan
Royal Tropical Institute (KIT), P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands. Maryse.Kok@kit.nl.
Maryse C
MC
Kok
Queen Margaret University, Edinburgh, Scotland. SWitter@qmu.ac.uk.
Sophie
S
Witter
Royal Tropical Institute (KIT), P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands. m.dieleman@kit.nl.
Marjolein
M
Dieleman
D002983:Clinical Competence; D003140:Communicable Disease Control / Q000458:organization & administration; D003150:Community Health Workers / Q000191:economics / Q000458:organization & administration* / Q000592:standards; D003362:Cost-Benefit Analysis; D003906:Developing Countries; D006298:Health Services Administration / Q000191:economics* / Q000592:standards*; D006801:Humans; D008288:Malaria / Q000175:diagnosis / Q000188:drug therapy; D000068101:Maternal-Child Health Services / Q000458:organization & administration; D017063:Outcome Assessment, Health Care; D057766:Policy; D011787:Quality of Health Care; D034121:Reproductive Health Services / Q000458:organization & administration; D014376:Tuberculosis / Q000175:diagnosis / Q000188:drug therapy