A letter from Nan Chen, Co-Executive Director, Africa Frontline First
Dear partners,
It’s an understatement to say that 2025 has been a challenging year in global health. Early in the year, I found myself deeply discouraged. With so many meaningful gains to health systems at risk, with patients’ lives and community health workers’ livelihoods at stake, the future seemed uncertain. Still, as the dust settled, I witnessed community health workers advocating for themselves and their patients. I received messages from government colleagues and partners who were working late nights to reorganize community health budgets to ensure care continued even amidst crisis. I felt a new conviction: one of steadfast trust in our community. In our drive to build strong health systems that extend healthcare to all people, progress remains possible when we work in partnership. Today, I want to share why I have hope, grounded in evidence and rooted in our collective agency—and why optimism belongs at the heart of Africa Frontline First’s vision for the future of community health.
I’m optimistic because the foundation we’ve built is strong.
When I joined Last Mile Health in 2015, we and most of our peer organizations were young startups. The professional community health worker model was still far from widespread, and governments lacked established, go-to partners that could accompany them to integrate health services. Instead, most institutions were siloed and disease-specific.
It took passionate and committed advocacy from this group of peers to build evidence, buy-in, and investment, but our work has paid off. Over the past decade, many of those scrappy startups have become consistent, reliable performers backed by a robust evidence base. Governments, too, have matured, and stronger and better-funded community health programs now exist within most ministries of health. Community health workers have gained global acceptance as a powerful driver in delivering primary care, and clearer norms and regulatory guidelines are in place. This foundation, built through years of partnership, is what’s keeping systems from breaking under today’s strain. As Hans Rosling reminds us, the world can be “bad and better” at the same time. Our job is to widen the space for “better.”
I’m optimistic because I’ve seen the proof.
Africa Frontline First has always been focused on increasing financing for community health, making financing more effective, and sustaining that financing via domestic resources—and building the community health systems to make this all possible. Together, governments, funding partners, and implementing partners are supporting more community health workers, unlocking durable financing, and leveraging it effectively. Now, the partnerships we’ve cultivated mean we can continue to build and sustain strong community health systems even amidst drastic cuts to foreign aid. Here are a few examples of how increased domestic funding, catalyzed by smart and streamlined investment, have driven progress in Africa Frontline First countries:
- The Government of Zimbabwe has committed to putting 20,969 community health workers on the payroll.
- In Guinea, ten municipalities have added a domestic budget line for community health workers.
- Community health workers are now a line item for Uganda’s Ministry of Health, with a new budget in progress.
These commitments represent real strides toward government ownership of community health systems. They also remind us that we are not simply being carried by the currents of geopolitics or donor cycles. Our shared choices shape the river’s flow. They’re possible thanks to the collaborative work of a breadth of partners: from leaders within national governments and regional institutions like the African Union and Africa CDC; to funders including The Global Fund, Johnson & Johnson Foundation, and the Skoll Foundation; to implementing partners including Clinton Health Access Initiative, Financing Alliance for Health, Integrate Health, Last Mile Health, Living Goods, and Muso. We are not alone in this work—and that fuels my optimism. As we contend with the hard reality that fewer resources are available, the phrase “we need to do more with less” has grown familiar. I urge us to say instead, “we need to do more together.”
I’m optimistic because the path ahead is clear—and we are traveling it together.
Since our start, Africa Frontline First has been working to inject philanthropic funding into government-owned, government-led systems. We began with our Catalytic Fund (housed at The Global Fund), which mobilized $219M to strengthen community health systems, scale community health worker programs, and set the course toward sustainability via domestic resources. The reality we now face—government ownership and domestic financing, by necessity—is a model we have always been building toward. Now, we’re following through with the next phase: our Sustainability and Resilience Fund. Designed to drive long-term impact while safeguarding essential community health worker services, it will continue to accelerate system maturity and strengthen community health systems.
Here is how governments can cultivate sustainability and resilience—and how Africa Frontline First countries have put theory into action so far, laying the groundwork for this promising new phase of our work:
On the financing side, governments need to understand where they are today so they can visualize where they want to be tomorrow. This means developing tools and practices like costed operational plans, resource maps, and better coordination with partners and donors at the country level. By the end of 2025, 14 Africa Frontline First supported countries will have finalized their resource mapping, giving them a comprehensive understanding of where the gaps are and how to optimize existing resources. And right now, five Africa Frontline First countries are working on sustainable financing plans: determining what their community health programs cost, identifying what can be covered by existing resources, and laying out tactics for increasing domestic funding alongside making more efficient long-term use of donor funding.
On the programming side, governments need to maintain or increase quality while driving down costs so they can pay for more themselves. This can be done in three key ways: integration, optimization, and sustainability.
- Integration means that rather than having siloed community health workers addressing specific diseases or health topics, programs train community health workers to provide a full package of primary care services. More and more governments are working toward this model and shaping policy around it, paving the way to enormous reductions in cost.
- Optimization means redesigning programs to be more effective and more efficient. In Ethiopia, adopting a blended learning approach for community health workers’ training has reduced costs by 39%, and this approach is now being scaled to a national workforce of more than 40,000. The potential is compelling: for countries that are at the beginning of ambitious training and scaling journeys, these optimizations could represent hundreds of millions in savings.
- Sustainability means leveraging financial tools and cost-saving program adaptations to reach a point where governments understand what their programs cost and how to afford them.
This is optimism as a practice, a choice we make and re-make daily. By strengthening systems, lowering costs, and reshaping incentives, we are bending the river together toward sustainability and sovereignty. Now, we must continue to work together to apply this understanding, driving costs down to where countries can sustain them and investing external funding where it can drive the greatest impact.
We see sustainable financing and stronger programs as part and parcel of changing power dynamics in how programs get funded. By increasing domestic funding for community health programs, we’re shifting decision-making, ownership, and power to country governments and the citizens they serve. Aligned with the sovereignty and workability laid out in the Accra Reset, Africa Frontline First’s vision for community health is more than financial sustainability: it’s about a transformative power shift that ensures countries are in charge of their own futures.
In the face of challenge, optimism is a choice—and it’s our responsibility.
As we close out a challenging year, I’m reminded of a message H.E. Ellen Johnson Sirleaf, former President of Libera, shared at the United Nations General Assembly. “Community health workers don’t have the luxury of uncertainty,” she said, “so we should not sit in inaction.”
I have come to believe that optimism, too, is not a luxury. My optimism isn’t rooted in wishful thinking. It’s rooted in what I see every day: governments stepping up, partners standing firm, and community health workers continuing to deliver care against all odds. Grounded optimism is our shared duty and our invitation to collective action for the community health workers and patients who can’t afford to wait. It’s our responsibility to keep faith in what works, to invest in what lasts, and to act together even when the future feels uncertain.
Our collective action has taken the community health worker model from a small movement championed by a few to a globally recognized best practice. Now, driven by optimism grounded in evidence, we can institutionalize and sustain it.
In partnership,
Nan Chen
Co-Executive Director, Africa Frontline First