[N.b. I used Claude to help format this post; all arguments are mine]
A response to Rethink Priorities HSS report & F/U, with some inspiration from @NickLaing, @Berke and others.
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There is a category error sitting at the centre of the EA Forum conversation on community health workers (CHWs); workers who bring care straight to their neighbor's doorsteps. Rethink Priorities' HSS report models "CHW programs" as an intervention, scores them at roughly 1,000x in Coefficient Giving terms, and notes they do not meet the 2,000x bar. The conclusion that follows is that CHWs are an interesting but second-tier bet.
But CHWs are not an intervention. CHW programs are the delivery platform through which most of the interventions EA already funds—bed nets, vitamin A, deworming—reach billions.
Modelling the platform against its own throughput suggests the model for the throughput wasn’t built to deliver.
A community health worker is not an intervention any more than a nurse is. Whether a CHW program is cost-effective depends, like any other delivery mechanism, on a) what it delivers and b) how it is designed.
A modern, professional CHW program is a primary care delivery point, not a single-disease vertical. The WHO competency-based curriculum—the closest thing the field has to a current job description–sets out the portfolio: childhood illness (diarrhoea, pneumonia, malaria), maternal and newborn health, family planning, nutrition screening, immunisation support, TB and HIV case-finding, NCD screening (hypertension, diabetes), mental health first response, neglected tropical disease case management, and health promotion.
The same worker, in the same household visit, delivers whatever subset the program is designed for.
Any cost-effectiveness analysis that attributes the full fixed cost of that worker to one of those service lines is going to produce an incomplete number.
Facility-based care alone cannot reach everyone. Hospitals struggle to serve remote communities, and in most high-burden countries the realistic counterfactual to a CHW is not a clinic visit — it is no contact with the health system at all.
Where researchers have compared CHW-delivered care head-to-head with facility-based care, the CHW route has been consistently cheaper. Most CHW programs evaluated for HIV, TB, malaria and for reproductive, maternal, newborn and child health were cost-effective against the facility comparator.
The median annual cost to deliver primary care via a CHW platform—across 380 scenarios in 130 studies—is US$0.59 per capita. That is not cost per DALY, and not cost per visit. It is the full annual unit cost, per person per year.
The median cost per beneficiary is $10.03, but of course the cost varies by service package. Integrated horizontal platforms—many service lines through one worker—sit at a median of just $6.02 per capita per year to reach those not close to a facility.
HIV, TB, malaria and RMNCH range more widely; in both areas, CHW programs were cost-effective in over 80% of scenarios assessed.
Bundling is where the savings compound. When Liberia folded NTD case management into an existing CHW platform, cost per diagnosis fell up to tenfold versus running NTDs as a standalone vertical.
The mechanism is platform economics. A CHW's fixed costs—salary, supervision, supplies, transport, data—exist whether she delivers one service line or ten. Vertical analyses load the whole stack onto a single disease; horizontal analyses spread it across everything the worker delivers in one visit.
Pool salaried, supervised, well-supplied, skilled CHWs together with volunteer, unpaid, under-trained ones, and the average tells you little. The "critical components" literature—including the work by yours truly that Rethink cites—has been clear for a decade: compensation, training, supervision, supply-chain integration, and career progression are not optional. Averaging two different things: poorly supported volunteer initiatives and high-performing professional platforms isn't consistent with the documented 4x variation in ROI.
Contrary to what Nick Laing's piece from April '25 implies, this isn't a workforce that is "often not cost-effective." Like nurse-led clinics—which Nick rightly champions!—it is a platform that is cost-effective when designed properly and not cost-effective when it isn't.
The relevant question is not whether to fund "CHWs" but which design pattern to fund, and at what level of the system.
Rethink's way forward
For all the buzz about CHWs, the design pattern with the strongest evidence is the most neglected. A professional CHW platform is salaried (not volunteer), skilled (competency-based training to a published curriculum), supervised (relevant supervisor-to-CHW ratio), supplied (the commodities the job requires), and built into the public primary care system.
So the smart bet is the one Rethink itself names in its own report: "Help fund and establish a public health program until it is transitioned to national government ownership."
For the whole vertical portfolio EA has spent fifteen years building—bed nets, SMC, vitamin A, deworming, child immunisation—that pathway is the scale opportunity.
How countries can get there
How does a country move from volunteer CHWs to a paid, professional, government-owned workforce? Three conditions hold the problem in place, and an EA funder can act on each one.
Guidelines. Until recently, a health minister had no authoritative international consensus describing a well-designed CHW program That has changed. The WHO 2018 guideline, the aforementioned curriculum, and proCHW guidance co-authored by Africa CDC and other norm-setters now give a minister both the cover to make a major workforce decision and the spec to make it well.
Start up capital . Even a willing government faces a chicken-and-egg problem: standing up a salaried workforce needs startup capital before the recurrent domestic budget line can absorb it. The Global Fund and others move money at that scale, often catalyzed by private actors.
Domestic constituency. Professional CHW associations are what turn a presidential commitment into a recurrent budget line that outlasts the president who made it.
Funding a delivery NGO to ship commodities saves lives now, and it is essential. Funding the workforce, the policy uptake and the government adoption that let a country deliver those commodities itself is the complementary lever that outlives any single donor.
This is a bet not dissimilar to hits-based giving: a large, durable return (i.e. a permanent, domestically-financed platform that scales all the verticals and outlives any single donor) with outcomes hard to attribute to any one funder.
It also has the one thing a hit almost never does: a decade of cost-effectiveness evidence already behind the intervention. The only open risk is whether a government finishes the handover, but if it does it pays for the whole portfolio.
A closing thought
Berke framed the underlying choice well on the Forum:
"Does success for EA look like hundreds of cost-effective NGOs distributing health commodities across South Asia and Sub-Saharan Africa until 2100 — or governments able to keep their people from dying of preventable conditions without depending on funders far away?"
For any funder serious about scale, it's the second. And professional CHW platforms are the pathway.
Thanks @Madeleine Ballard. As you know I'm a big fan of the Pro-CHW movement and all the work you do. I agree facility care can't reach everyone. I agree we need pro CHWs across Africa and like you say CHWs are often the main people doing the work facilitating EA funded vertical programs like mosquito nets and deworming. Sometimes this platform isn't recognised, and the cost borne by governments and donors who support these CHWs isn't appreciated properly in calculations - which I think I've pointed out to GiveWell before.
I also agree that EA doesn't pay nearly enough attention to gradual government adoption of the most cost-effective interventions, and I hope we're going to see more discussion about this in the near future.
When looking at RP's report, this was what I said in context.
"I agree that CHWs are an essential, scalable part of many LMIC health systems. CHWs however are touted to be very cost-effective when they often aren’t. This statement made my eyes pop a little. “Many studies have found CHW programs to be cost-effective by various metrics. In Mozambique, the annual cost per beneficiary was just $47.12.
That number $47.12 I quoted from the RP report is quite different from $10 you've quoted as the median cost per capita here and doesn't scream cost-effectiveness. The report which your $10 number came from wasn't out at the time I wrote that response. $10 per beneficiary still seems high to me but it's hard to compare to other interventions (see below)
One thing I'm confused about, is that I don't think a cost as low as $0.59 per capita is possible for a salaried CHW. How did the researchers get to this number? Trying to be as conservative as possible - here's my sense check. The ceiling for the no. of people a CHW can cover on a door-to-door model is perhaps 800. A lower end CHW salary might be $40 a month. Then we add commodity and supervision costs (excluding digital/connectivity costs). I've estimated this at around 20 people tested for malaria, 10 given treatment for malaria and 5 each treated for pneumonia and diarrhoea. Often CHWs would treat more people than this, which would mean higher costs.
- Salary (12x40) = $480
- Malaria tests 20 a month (20 x $0.5 x 12 months ) = $120
- Malaria treatment 10 a month (10 x $0.3 x 12) = $36
- Pneumonia treatment 5 a month (5 x $0.5 x 12) = $30
- Diarrhoea ORS + zinc 5 a month (5 x $0.5 x 12) = $30
- Supervision ? $60 a year
= $756 / 800 people = $0.95 per capita per year under pretty conservative assumptions. I might be missing something here though!
Also "Per capita cost" and "Cost per beneficiary" are useful metrics for governments to decide if CHWs are affordable/cheap enough, but not useful metrics for cost-effectiveness comparisons. What can these metrics be compared to? We can't compare this metric to any other intervention. I've considered we could use a metric such as "cost of universal primary care per-capita" which would combine the cost of CHWs + other services, which could then be compared to facility only based models + extra transport costs. This would be tricky though...
For CHWs a more straightforward "Cost per DALYs averted" would be more useful to compare with other EA funded interventions, or a more thorough GiveWell style CEA.
Also on this point "Any cost-effectiveness analysis that attributes the full fixed cost of that worker to one of those service lines is going to produce a misleading number." I don't think Givewell attributes the full fixed cost of CHWs in CEAs. They might apportion some of the cost, or perhaps none. I often have the opposite criticism that they don't always appreciate the underlying cost of government health workers used in mass-distribution campaigns. I could be wrong here though I haven't looked closely recently.
Again I'm a huge fan of CHWs and your work and I believe in your mission. I'm just challenging whether your numbers make sense, and I think we need more than per-capita/per-beneficiary numbers to compare CHWs to other cost-effective interventions under EA frameworks.
Thanks so much, Nick! We published a massive multi-paper cost-effective review only weeks after you shared your original post! You can dig into all the papers/numbers/methodology here: https://joinchic.org/resources/cost-effectiveness/
TL;DR: The numbers are medians across 380 scenarios in 130 studies. As I said in the footnote, data is heterogeneous (mostly due to platform design differences, including salaries). Ranges are big and depend on context, but would say a) your $0.95 BOTE is a fair floor for a professional program at modest catchment, but b) that your earlier take (CHWs are "often not cost-effective," they treat "few patients per month," they can only treat "a handful of conditions in young children") is not reflected in these data.
Re: DALYs: you'll see in the papers that vertical evidence is already in EA terms (e.g. there are DALY numbers for iCCM) but none of the 42 horizontal integrated scenarios in the BMJ GH piece report cost per DALY. The research I'd most want EA to fund is a prospective platform-economics evaluation: does bundling 6–8 service lines on one salaried CHW compound DALYs and lower cost-per-DALY the way fixed-cost-sharing predicts? (or to your point, maybe not?)
My bigger point though is that maybe this is already a good enough bet based on the vertical DALY evidence we both already accept (i.e. why not apply hits-based giving on the handover: catalytic financing to professionalize a salaried, skilled, supervised, supplied workforce via national, government). Esp, as this has what a hit almost never has, which is a decade of cost-effectiveness evidence already behind it. If the handover lands, the donor pays once and the government runs the whole portfolio forever (and the vertical $/DALY figures are the floor).
Have added 2 footnotes re:the above.
I think It wouldn't cost much at all to make forward a pretty robust cost-effectiveness model for a CHW which rolls out a wide range of interventions. (I think Living Goods +- others might well have decent models already here?). I think you could even build this yourself? Some of the package would be easy to do because data is there (malaria, diarrhoea, pneumonia treatment, family planning antenatal care), while screenings and referrals are much harder to quantify and might have to be left out of the analysis pending better data.
I agree the bet argument is pretty good if the goal is government adoption. Regardless of the nuance of cost-effectiveness, CHWs will always be more cost-effective than most health things govt. could do and it would likely displace less cost-effective things. Unfortunately I don't think EA funders have seriously considered scale through govt. something worth chasing as a bet, but I really like the idea.