Key takeaways
- The abrupt termination of USAID has had a substantial impact on community health worker programs in Africa. From our rapid assessment of countries, this means up to 50% of community health worker programs are at risk.
- Fast, coordinated funding is essential to keep community health services running, particularly for salaries, supplies, and essential systems. Multilaterals like Gavi and the Global Fund and philanthropy can play a bridging role.
- The current crisis is an opportunity for re-design. African governments can lead the future financing landscape by shaping decisions and strategies that align with their country’s agenda, needs, and economic realities.
- A shift from reliance on external funding to more sustainable and predictable domestic funding for financing community health systems is crucial. Governments must incorporate community health into national health budgets, and innovative models include earmarked taxes, integrating community health services into health insurance schemes, and public-private partnerships.
- The integration of disease-specific programs into primary community healthcare systems is a cost-effective approach. To improve health outcomes and establish sustainable, resilient healthcare models that are better equipped to address global health threats and financing fluctuations, countries must transition from current vertical programming models.
Introduction
Community health workers are the backbone of primary health systems, providing life-saving care, preventing and responding to disease outbreaks, and safeguarding national and global health security. While community health worker programs have repeatedly been shown to be one of the most cost-effective means of delivering essential primary care, their impact is threatened due to a high dependence on foreign assistance—notably the US government, including the US Agency for International Development (USAID), was responsible for 58.4% of development assistance for health in sub-saharan Africa in 2023.
The abrupt termination of USAID has destabilized the global health financing landscape, with a substantial impact on community health worker programs in Africa. From our rapid assessment of countries, this means up to 50% of community health worker programs are at risk.
Community health worker program budgets across Africa are facing severe risks of falling off a fiscal cliff. Indeed, many are already plummeting. While there is not a clear path to fill the financing gap, we can make smart investments now to prevent the worst-case scenario while we begin reimagining a more sustainable financing future for community health.
The Immediate Impact
Cuts to community health worker programs are already interrupting global disease surveillance and pandemic preparedness. The sudden drop in funding is not merely a budget line item – it’s a blow to the very infrastructure that keeps global communities healthy. Global health security hinges on African governments’ capacity to prevent, detect, and respond to public health threats, including infectious disease outbreaks and pandemics. As evidenced by the COVID-19 pandemic and the Ebola outbreak in West Africa, robust community health systems are indispensable for maintaining essential health services, safeguarding global health security, and preventing disease transmission. Notably, community health workers play a key role in preventing, detecting, and responding to outbreaks, particularly in remote and hard-to-reach communities where disease outbreaks often start. Community health workers also provide critical health education, contact tracing, referral of cases for treatment, and continuity of essential primary healthcare services. Community health workers form a vital link for health systems to identify outbreaks early, thus preventing local epidemics from becoming global pandemics.
The populations most at risk are women, children, and other vulnerable populations. Withdrawal of care provided by community health workers will have a significant impact on primary health systems, especially maternal care and treatment for malnutrition, tuberculosis, malaria, and HIV/AIDS. The disruption in funding for these essential health programs and initiatives will disproportionately affect women, children, and those living in underserved communities in remote areas.
Acting Now to Protect Health
“Action is the antidote to despair.” In the short term, governments and donors can make smart re-allocation choices to prevent the worst-case scenario, while re-imagining a more sustainable financing future for community health in the long term.
A pragmatic analysis shows that foreign aid from governments globally cannot possibly fill the chasm left by USAID in the short term. However, smart re-allocation decisions now can stave off the worst-case scenarios—saving human lives and preserving decades of progress strengthening community health systems. To do so, community health workers need to be paid and supplied. This requires immediate bridge funding for salaries, medicines, and supply chains. The emergency aid investments by organizations like the Global Fund and Gavi must be carefully designed in collaboration with governments to ensure implementation, integration with domestic priorities, and strengthening of foundational health systems.
Fast actions start with clear insights. In 17 countries, Africa Frontline First’s country partners have been supporting governments to design, fund, and implement high-quality national community health plans. Now, these same teams are conducting rapid financing analyses and creating roadmaps for emergency bridge funding, often building from past experience quickly responding to crises like Ebola and COVID-19. In the short term, we hope these insights help governments and their funding partners ensure continuity of care.
A Future Built for Resilience
This funding crisis is also a wake-up call—a chance to reimagine how we finance community health across Africa. Africa Frontline First has been grappling with this question since our inception. In 2023, Africa Frontline First and the Africa CDC outlined major themes and challenges with community health financing such as fragmentation of resources, lack of integration, and the need for a clear path to sustainability. The current crisis reinforces these themes and exacerbates the pain points.
Looking ahead, our mission is to turn this moment of disruption into a springboard for lasting change. We certainly do not have all the answers ourselves. However, we have some early intuitions and animating questions – and welcome collaboration with others considering a new future for community health financing.
Given today’s reality, we think the future of community health financing must do more with less, boost financial resilience, prioritize local agency, and build toward sustainability. This means:
- Empowering Local Leadership: Strengthen government and local capacity to design, implement, and be accountable for the essential health mandate. External aid should actively support local priorities as outlined in the Lusaka Agenda, enabling leaders to direct funds where they are needed most. What powers of local actors and institutions need to be strengthened? How can future aid funding move beyond gap filling?
- Diversifying Revenue Streams: In addition to external aid aligned to country agendas, leverage new sources of domestic funding, such as earmarked taxes and innovative public-private partnerships. Diversified funding not only reduces dependency but also fosters a more stable financial environment for community health programs. What are the key barriers to unlocking new revenue?
- Investing in Integrated Systems: Learn from successful models in countries like Rwanda and Ghana, where disease-specific programs have been merged into primary healthcare systems. This integration not only cuts costs but also improves coordination and service delivery, ensuring that every dollar invested goes further. What will vertical programs need to give up to fast-track integration?
By asking these tough questions and exploring creative solutions, we can transform uncertainty into an opportunity—a future where community health is not just a line item in a budget, but a fundamental pillar of a healthy, self-reliant Africa.
Authored by: Uju Mabel Onyes, Yann Tapsoba, Laura Solia Shellaby, and Nan Chen.