High-Impact Growth Podcast – “Financing Community Health Programs with Africa Frontline First”

Podcast: High-Impact Growth
Host: Dimagi (Jonathan Jackson & Amie Vaccaro)
Guest: Nan Chen, Co-Executive Director, Africa Frontline First
Date: August 29, 2024

Episode Overview

This episode explores the critical question of how to finance and institutionalize impactful community health worker (CHW) programs across Africa. Hosts Jonathan Jackson and Amie Vaccaro speak with Nan Chen from Africa Frontline First (AFF) about the evolution of community health programs, the persistent funding gaps, the political and operational challenges to professionalizing CHWs, and innovations in financing, technology, and collective action to make such programs sustainable and high-impact.

Key Discussion Points

1. Nan Chen’s Journey into Community Health (02:00–04:25)

• Nan’s path began in law and policy, moved through impact investing, and settled into global health after observing disconnects in policy implementation and government engagement.
• At Last Mile Health, she worked to scale CHW programs in Liberia, combining policy, practice, and finance to effect real change.
• Her experience underscores the necessity of partnerships and collective action for tackling complex health challenges.

Quote:
“My career path here is marked by curiosity, which drives me, but also conundrums that I’ve run into and I’m hoping that we could find our ways out of.”
—Nan Chen [02:10]

2. Africa Frontline First: Origin, Mission & Scope (04:25–08:37)

• AFF emerged in 2020 amidst the COVID-19 pandemic, inspired by President Ellen Johnson Sirleaf’s call to “make this moment count” after similar lessons from the Ebola crisis.
• AFF’s mission is to shift the financing paradigm for CHWs, ensuring sufficient and effective investment for professionalized, impactful programs.
• Focuses include technical assistance, advocacy, and designing financing solutions that put governments in control.

Quote:
“She [Sirleaf] said, ‘Let’s make this moment count. Give me something big on community health to champion and let’s get it done.’”
—Nan Chen [06:53]

3. The State of Community Health Worker Policy & Financing (08:37–11:34)

• Progress: Over 40 African countries now have CHW strategies; however, only ~10 have government health budgets with CHW line items.
• Challenge: Translating vision into funded, operational programs remains elusive.
• AFF offers hands-on technical assistance in 17 countries, supporting investment cases, resource mapping, and government leadership.

Quote:
“Our goal is to use the tools of better financing to get more money to community health workers and to make the money…flow more effectively.”
—Nan Chen [09:52]

Timestamped Insight:
[10:55] Ministers of health—“Don’t come into my house and tell me what to do…don’t mess up all of my furniture and leave without…giving me a voice in this.”
—A minister (recounted by Nan Chen)

4. From Policy to Practice: Institutionalizing CHW Programs (11:34–20:38)

• The political momentum for CHWs is unprecedented, but the challenge is moving from aspiration (“how”) to operation and routine funding/execution.
• Only a minority of countries have both strategy and budget; building/maintaining a trained and remunerated workforce is complex.
• Countries increasingly use standardized service packages and training; yet, the relational and political work (e.g., keeping CHW on the political agenda, aligning diverse stakeholders) is less codified.

Quote:
“At this point, all countries have a vision for universal health coverage and they know where they’re going—but everybody’s driving a different car and that’s okay.”
—Nan Chen [13:46]

Implementation Challenge:
“Building habit at all system levels is key—how do you move from a pilot or politician’s priority to making it just part of the culture and process?”
—Jonathan Jackson [16:03]

5. Adaptation, Feedback, & Resilience in CHW Programs (20:38–24:43)

• Successful institutionalization means CHW programs become “politics-proof,” resilient to administration changes.
• The process is similar to social habit formation: large, early prompts (e.g., policy launches) gradually give way to routine execution as the “new normal.”
• Local adaptation is crucial: nations can’t simply copy Ethiopia/Rwanda; solutions must fit each country’s unique context, politics, and health system.

Quote:
“Keeping the ideas—even if you lose the policy battle—figuring out the people, the practices, the pilots and the loose coalitions, I think is another way to think about policy change.”
—Nan Chen [22:30]

6. Technical Assistance: A Non-Scalable but Essential Lever (24:28–27:59)

• AFF’s in-country technical assistance (TA) is highly relational and customized, supporting governments to close resourcing and policy gaps—not easily scalable like technology, but indispensable.
• Example: In 2023, through partnership, AFF helped countries reallocate $219m in Global Fund investments to CHW infrastructure, training, and remuneration.
• TA involves data, evidence, and capacity-building, but ultimately hinges on relationships and negotiation among local actors.

7. How Funds Are Used & What’s Changing on the Ground (27:59–32:46)

• Examples:
  • Burkina Faso: Training 17,000 new CHWs, upgrading info systems.
  • Zambia: Creating a new master list of CHWs for better workforce management.
• General trend: Combining funds for salaries, training, and systems strengthening.
• AFF and partners advocate for cost optimization, recognizing that while CHWs are cost-effective, quality services require real investment.

Quote:
“CHWs are cost-effective, but they aren’t cheap—and that’s not a bad thing. Services and quality cost money.”
—Nan Chen [30:32]

8. Technology’s Role in Efficiency, Adaptation, and Payment (32:46–37:42)

• Digital tools are changing the cost structure and reach of CHW programs:
  • Digital/blended learning reduces recurring training costs.
  • Integrated digital systems for service verification and payment improve reliability, speed, and accountability.
  • More adaptable workforce models and digital payments can lower overhead and increase worker motivation and program resilience.

Memorable Story:
“In Indonesia, we were sending sacks of cash out to islands because we couldn’t get the mobile payment system working. The actual cost and risk of delivery is enormous.”
—Nan Chen [35:34]

Quote:
“If you can just get that paper transaction [for CHW payment] digital and do it in real time when they’re owed, that’s a huge benefit."
—Jonathan Jackson [37:18]

9. Trends and the Push for Aligned, Country-Led Financing (38:38–46:36)

• Frustrations: Donors feel their contributions are a drop in the bucket; governments and partners face technical and political barriers to cost/benefit transparency.
• AFF and Africa CDC initiated a “listening tour” to identify pain points (“gridlock,” “fragmentation”) and drafted a “collective financing approach”:
  • Principles: Put government in the driver’s seat, create unified plans/costing/monitoring, ensure transparency, and align short-term impact with long-term sustainability.
  • December 2023: 13 institutions publicly committed to coordinated, collective investment in CHW professionalization.

Quote:
“We conducted what we were calling a listening tour…asking everybody what’s hard about this? What do you need? What is holding you back?”
—Nan Chen [39:15]

10. Making the Investment Case: Cost, Benefits, and Ownership (46:36–48:21)

• The “one plan, one budget, one M&E report” approach helps donors and governments see their contributions in context and fosters collective impact.
• Real progress: Major donors now support CHW salaries, previously off-limits.
• Shift underway towards increased domestic financing and adding CHWs to government payrolls—a hard but essential political decision.

Quote (on donor funding for salaries):
“It is ludicrous that in the first place some of these donors’ policies forbid spending money on CHW salaries.”
—Jonathan Jackson [46:36]

Notable Quotes & Memorable Moments

“Let’s make this moment count. Give me something big on Community Health to champion and let’s get it done.”
—President Ellen Johnson Sirleaf (paraphrased by Nan Chen) [06:53]

“At this point, all countries have a vision for universal health coverage…but everybody’s driving a different car and that’s okay.”
—Nan Chen [13:46]

“We need to stop talking about just the cost. Those who are making decisions, they need to know the benefits.”
—Nan Chen [44:06]

“If you can just get that paper transaction digital and do it in real time when they’re owed, that’s a huge benefit… That isn’t a recipe for building household wealth and for having economic security, which—one of the huge benefits beyond just the health benefit of well-funded CHW programs is you’re creating great jobs.”
—Jonathan Jackson [36:09]

Timestamps for Key Segments

• Introduction & Episode Purpose – [00:00–01:18]
• Nan Chen’s Journey – [02:00–04:25]
• AFF: Origins & Role – [04:25–08:37]
• Policy vs. Reality – [08:37–11:34]
• Politics, Practice, and Implementation – [13:15–20:38]
• Sustaining Change: Institutionalization – [16:34–20:38]
• Adaptation & Local Relevance – [20:38–24:43]
• Technical Assistance in Practice – [24:28–27:59]
• Country Examples: New Funding Impact – [27:59–32:46]
• Digital Tools & Payment Innovation – [32:46–37:42]
• Collective Financing and Ownership Trends – [38:38–46:36]
• Costing, Benefits, and Donor Collaboration – [46:36–48:21]

Closing Takeaways

• The conversation on CHWs has advanced from “Should we have CHW programs?” to “How do we implement, finance, and institutionalize them sustainably?”.
• Technical advances, especially in digital training and payments, are poised to decrease costs and improve accountability.
• The sector is moving towards pluralistic, locally adapted models and more cohesive, government-led financing and management.
• AFF’s core approach is to build government capacity, ensure investment is effective and aligned, and institutionalize CHW programs as standard, routine elements of health systems—not political experiments.
• The collective and country-led financing paradigm, grounded in deep listening and shared commitment, is key to scaling and sustaining high-impact CHW programs across Africa.