Financing options key to sustainability of the CHEWs programme

By Baguma Kajura

The recruitment and training program for close to 15,000 Community Health Extension workers is set to commence next month.

The Ministry of Health's strategy to formulate an adequate and competent Community Health Extension Workers (CHEWs) program for equitable delivery of quality, preventive and selective curative health services and education, is a giant step towards filling the gaps in the first referral cover for rural health services in Uganda.

Empirical evidence in developing and emerging economies like Ethiopia and Brazil have proved  that CHEWs provide the much needed preventive and curative healthcare in resource limited environments as well as resource settings.

The CHEWs who will be trained for six months will be entitled to an incentivized package while their performance is tracked by a feedback mechanism integrated at the community level. In ensuring the success of large-scale CHEWs programs in Uganda, the stakeholders will have to take into perspective the fundamentals of the CHEWs programs that require costing, entire costs of the CHEWs program as well as the financing options available.

Critical to the fundamentals of CHEWs programs are the relevant costs that may include investment and recurrent costs or even direct and indirect costs.  Capital expenditures in this context involve planning of monitoring and evaluation, development of the institutional and staff capacities of the CHEWs and their supervisors as well as orientation of the trained health professionals and nurses at Health Sub-District and lower health service delivery points.  Crucial to the investment costs are issues related to certification, accreditation, quality control, community mobilisation as well as initial costs of equipment, drug kits and medicinal supplies.

Recurring costs of utilities, salaries and benefits entitled to CHEWs and their supervisors as well as ongoing monitoring and evaluation have to be taken into consideration. These costs are often substantial and once funds are too insufficient to maintain a reliable supply chain, the entire CHEW program is bound to falter. There is empirical evidence that health program costs tend to increase as the program goes to scale with the coverage of services exponentially rising.

In having the health program expand into remote areas, the marginal cost of accessing each additional person will ultimately increase. The costs of transporting , training , supplying as well as monitoring are likely to be higher in hard to reach areas  as higher incentives may be required to locate health personnel in these inaccessible areas. Under these circumstances outcome- based remuneration and performance based pay that have had moderate successes in South East Asia can be instituted in the CHEWs implementation strategy. The CHEWs can therefore receive incentives for a good performance based on set objectives for the month.

Government's role in long term financing of the CHEWs strategy will be integral to its success in Uganda. Funding from the central and local government is crucial in terms of ensuring job security for the CHEW personnel and stability of the program. In Brazil, the States and municipalities are required to contribute 12% of the total budgets to health and municipalities, 15% respectively to Community health initiatives.

In Ethiopia, the CHEW programs are funded by national and sub-national entities. Government's support would avert reliance on community financing as fees for health services place greater burdens on the underprivileged communities in the rural areas. The other concern that should be taken into consideration is the challenge of cutbacks in funding when government shortfalls occur coupled with the lack of strong political will.

This hiccup inadvertently calls for public-private partnerships that will be key to ensuring that government achieves Universal Health Coverage (UHC) and ensure sustainability of the program with the services of the CHEWs.  To facilitate this process , the government can partner with NGOs and agencies like UNICEF or  Malaria Consortium  in creating a Community Health planning and costing tool that will aid in calculating the costs of delivering comprehensive community health services in the long run. This tool has registered successes in Malawi and Madagascar where long -term financing plans have continued to support CHEWs initiatives.

CHEWs program funding should be tailored towards strengthening the health systems overall as they improve patient outcomes and reduce costs to health systems.

The writer is a rural development practitioner and researcher