Development assistance for community health workers in 114 low- and middle-income countries, 2007-2017.

OBJECTIVE: To estimate the level and trend of development assistance for community health worker-related projects in low- and middle-income countries between 2007 and 2017. METHODS: We extracted data from the Organisation for Economic Co-operation and Development's creditor reporting system on aid funding for projects to support community health workers (CHWs) in 114 countries over 2007-2017. We produced estimates for projects specifically described by relevant keywords and for projects which could include components on CHWs. We analysed the pattern of development assistance by purpose, donors, recipient regions and countries, and trends over time. FINDINGS: Between 2007 and 2017, total development assistance targeting CHW projects was around United States dollars (US$) 5 298.02 million, accounting for 2.5% of the US$ 209 277.99 million total development assistance for health. The top three donors (Global Fund to Fight AIDS, Tuberculosis and Malaria, the government of Canada and the government of the United States of America) provided a total of US$ 4 350.08 million (82.1%) of development assistance for these projects. Sub-Saharan Africa received a total US$ 3 717.93 million, the largest per capita assistance over 11 years (US$ 0.39; total population: 9 426.25 million). Development assistance to projects that focused on infectious diseases and child and maternal health received most funds during the study period. CONCLUSION: The share of development assistance invested in the CHW projects was small, unstable and decreasing in recent years. More research is needed on tracking government investments in CHW-related projects and assessing the impact of investments on programme effectiveness.

Increasing utilisation of perinatal services: estimating the impact of community health worker program in Neno, Malawi.

BACKGROUND: By 2015, Malawi had not achieved Millennium Development Goal 4, reducing maternal mortality by about 35% from 675 to 439 deaths per 100,000 livebirths. Hypothesised reasons included low uptake of antenatal care (ANC), intrapartum care, and postnatal care. Involving community health workers (CHWs) in identification of pregnant women and linking them to perinatal services is a key strategy to reinforce uptake of perinatal care in Neno, Malawi. We evaluated changes in uptake after deployment of CHWs between March 2014 and June 2016. METHODS: A CHW intervention was implemented in Neno District, Malawi in a designated catchment area of about 3100 women of childbearing age. The pre-intervention period was March 2014 to February 2015, and the post-intervention period was March 2015 to June 2016. A 5-day maternal health training package was delivered to 211 paid and supervised CHWs. CHWs were deployed to identify pregnant women and escort them to perinatal care visits. A synthetic control method, in which a "counterfactual site" was created from six available control facilities in Neno District, was used to evaluate the intervention. Outcomes of interest included uptake of first-time ANC, ANC within the first trimester, four or more ANC visits, intrapartum care, and postnatal care follow-up. RESULTS: Women enrolled in ANC increased by 18% (95% Credible Interval (CrI): 8, 29%) from an average of 83 to 98 per month, the proportion of pregnant women starting ANC in the first trimester increased by 200% (95% CrI: 162, 234%) from 10 to 29% per month, the proportion of women completing four or more ANC visits increased by 37% (95% CrI: 31, 43%) from 28 to 39%, and monthly utilisation of intrapartum care increased by 20% (95% CrI: 13, 28%) from 85 to 102 women per month. There was little evidence that the CHW intervention changed utilisation of postnatal care (- 37, 95% CrI: - 224, 170%). CONCLUSIONS: In a rural district in Malawi, uptake of ANC and intrapartum care increased considerably following an intervention using CHWs to identify pregnant women and link them to care.

A qualitative study of social connectedness and its relationship to community health programs in rural Chiapas, Mexico.

BACKGROUND: Social connectedness is an important predictor of health outcomes and plays a large role in the physical and mental health of an individual and a community. The presence of a functioning health clinic with a community health worker program may indirectly improve health outcomes by increasing the social connectedness of the community in addition to providing direct patient care. This study examines the social connectedness of the inhabitants of three Mexican towns within the catchment area of a healthcare Non-Government Organization (NGO) through a qualitative analysis. METHODS: Willing participants were videotaped answering open-ended questions about their community and use of healthcare resources. Interviews were then coded for relevant themes and analyzed for content relating to social connectedness, social isolation, and health. RESULTS: Respondents reported that having a functioning community clinic had improved their lives significantly through direct provision of care and by reducing the financial burden of travel to seek medical care elsewhere. Respondents from each town differed slightly in their primary means of social support. One town relied more heavily on organized groups (i.e., religious groups) for their support system. Social isolation was reported most frequently by housewives who felt isolated in the home and by respondents that had to deal with personal illness. Respondents that self-identified as Community Health Workers (CHWs) in their respective communities acknowledged that their roles bestowed physical and psychological health benefits upon themselves and their families. CONCLUSIONS: Overall, a long-term health intervention may directly impact the relative social isolation and social connectedness of a community's inhabitants. The social connectedness of the community is an important quality that must be considered when evaluating and planning health interventions.

Validity and Utility of the Patient Health Questionnaire (PHQ)-2 and PHQ-9 for Screening and Diagnosis of Depression in Rural Chiapas, Mexico: A Cross-Sectional Study.

BACKGROUND: Depressive disorders are frequently under diagnosed in resource-limited settings because of lack of access to mental health care or the inability of healthcare providers to recognize them. The Patient Health Questionnaire (PHQ)-2 and the PHQ-9 have been widely used for screening and diagnosis of depression in primary care settings; however, the validity of their use in rural, Spanish-speaking populations is unknown. METHOD: We used a cross-sectional design to assess the psychometric properties of the PHQ-9 for depression diagnosis and estimated the sensitivity and specificity of the PHQ-2 for depression screening. Data were collected from 223 adults in a rural community of Chiapas, Mexico, using the PHQ-2, the PHQ-9, and the World Health Organization Quality of Life BREF Scale (WHOQOL- BREF). RESULTS: Confirmatory factor analysis suggested that the 1-factor structure fit reasonably well. The internal consistency of the PHQ-9 was good (Cronbach's alpha > = 0.8) overall and for subgroups defined by gender, literacy, and age. The PHQ-9 demonstrated good predictive validity: Participants with a PHQ-9 diagnosis of depression had lower quality of life scores on the overall WHOQOL-BREF Scale and each of its domains. Using the PHQ-9 results as a gold standard, the optimal PHQ-2 cutoff score for screening of depression was 3 (sensitivity 80.00%, specificity 86.88%, area under receiver operating characteristic curve = 0.89; 95% confidence interval [0.84, 0.94]). CONCLUSION: The PHQ-2 and PHQ-9 demonstrated good psychometric properties, suggesting their potential benefit as tools for depression screening and diagnosis in rural, Spanish-speaking populations.

Navigating and circumventing a fragmented health system: the patient's pathway in the Sierra Madre Region of Chiapas, Mexico.

Mexico has implemented several important reforms in how health care for its poorest is financed and delivered. Seguro Popular, in particular, a recently implemented social insurance program, aims to provide new funds for a previously underfunded state-based safety net system. Through in-depth ethnographic structured interviews with impoverished farmers in the state of Chiapas, this article presents an analysis of Seguro Popular from the perspective of a highly underserved beneficiary group. Specific points of tension among the various stakeholders--the government system (including public clinics, hospitals, and vertical programs), community members, private doctors, and pharmacies--are highlighted and discussed. Ethnographic data presented in this article expose distinct gaps between national health policy rhetoric and the reality of access to health services at the community level in a highly marginalized municipality in one of Mexico's poorest states. These insights have important implications for the structure and implementation of on-going reforms.

Evaluation of a novel approach to community health care delivery in Ifanadiana District, Madagascar.

Despite widespread adoption of community health (CH) systems, there are evidence gaps to support global best practice in remote settings where access to health care is limited and community health workers (CHWs) may be the only available providers. The nongovernmental health organization Pivot partnered with the Ministry of Public Health (MoPH) to pilot a new enhanced community health (ECH) model in rural Madagascar, where one CHW provided care at a stationary CH site while additional CHWs provided care via proactive household visits. The program included professionalization of the CHW workforce (i.e., targeted recruitment, extended training, financial compensation) and twice monthly supervision of CHWs. For the first eighteen months of implementation (October 2019-March 2021), we compared utilization and proxy measures of quality of care in the intervention commune (local administrative unit) and five comparison communes with strengthened community health programs under a different model. This allowed for a quasi-experimental study design of the impact of ECH on health outcomes using routinely collected programmatic data. Despite the substantial support provided to other CHWs, the results show statistically significant improvements in nearly every indicator. Sick child visits increased by more than 269.0% in the intervention following ECH implementation. Average per capita monthly under-five visits were 0.25 in the intervention commune and 0.19 in the comparison communes (p<0.01). In the intervention commune, 40.3% of visits were completed at the household via proactive care. CHWs completed all steps of the iCCM protocol in 85.4% of observed visits in the intervention commune (vs 57.7% in the comparison communes, p-value<0.01). This evaluation demonstrates that ECH can improve care access and the quality of service delivery in a rural health district. Further research is needed to assess the generalizability of results and the feasibility of national scale-up as the MoPH continues to define the national community health program.

Integrating multi-national teams: over a decade of lessons learned in Chiapas with Partners in Health-Mexico.

In a globalized world where pathology and risk can flow freely across borders, the discipline of global health equity has proposed to meet this challenge with an equal exchange of solutions, and people working toward those solutions. Considering the history of colonialism, ongoing economic exploitation, and gaping inequities across and within countries, these efforts must be taken with care. The Partners In Health program in Chiapas, Mexico was founded in 2011 by a team of leaders from both the United States and Mexico to strengthen the public health and care delivery systems serving impoverished rural populations. Key to the strategy has been to marshal funding, knowledge, and expertise from elite institutions in both the United States and Mexico for the benefit of an area that previously had rarely seen such inputs, but always in close partnership with local leaders and community processes. With now over a decade of experience, several key lessons have emerged in both what was done well and what continues to present ongoing challenges. Top successes include: effective recruitment and retention strategies for attracting talented Mexican clinicians to perform their social service year in previously unappealing rural placements; using effective fund-raising strategies from multinational sources to ensure the health care delivered can be exemplary; and effectively integrating volunteer clinicians from high-income contexts in a way that benefits the local staff, the foreign visitors, and their home institutions. A few chief ongoing challenges remain: how to work with local communities to receive foreign visitors; how to hire, develop, and appropriately pay a diverse workforce that comes with differing expectations for their professional development; and how to embed research in non-extractive ways. Our community case study suggests that multinational global health teams can be successful if they share the goal of achieving mutual benefit through an equity lens, and are able to apply creativity and humility to form deep partnerships.

National Prevalence of Diabetes and Barriers to Care Among U.S. Farmworkers and Association With Migrant Worker Status.

OBJECTIVE: To quantify the prevalence of diabetes and barriers to care among U.S. migrant farmworkers (i.e., those who travel from their permanent residence for seasonal farmwork). RESEARCH DESIGN AND METHODS: Age-adjusted prevalence of self-reported diabetes and barriers to care were calculated among adult U.S. farmworkers from 2008 to 2017 National Agricultural Workers Surveys. RESULTS: Among 16,913 farmworkers, 30.7% reported one or more barriers to care, most often due to cost. Age-adjusted self-reported prevalence of diabetes was 13.51% (95% CI 10.0-17.1) among migrant farmworkers and 10.8% (95% CI 9.0-12.6) among nonmigrant farmworkers with access to health care. Migrant farmworkers without recent health care had 83% lower odds of reporting known diabetes (adjusted odds ratio 0.17; 95% CI 0.06-0.54) compared with nonmigrant farmworkers, likely because of poor health care access and/or a healthy worker effect. CONCLUSIONS: Many migrant farmworkers face barriers to care, which may lead to significant underdiagnosis of diabetes in this vulnerable population.

Characteristics of Global Health Careers among Graduates of a Global Health Equity Residency Training Program in the United States.

Background: The number of global health (GH) physician training programs in the United States has increased in the past decade. Few studies have explored the demographics of individuals in these programs, the impact of global health training on career development, and specific factors associated with whether graduates achieve a career in global health. Objectives: We aimed to describe characteristics of program graduates and quantify which previously identified factors were associated with achieving a self-defined career in GH among a cohort of graduates from one GH post-graduate training program in a highly resourced academic medical center in the United States between 2003 and 2018. Methods: We conducted a cross-sectional survey and analyzed differences between participants who self-identified as having a career in GH compared to those who did not. Findings: Among 59 individuals invited to participate, 53 (89.9%) responded to the survey. Having a GH mentor was associated with having a career in GH (OR 10.3; p = 0.004). Those who had a GH career were more likely to have a clearly-defined career path (p = 0.03), have institutional support in their current job (p = 0.00006), be able to manage the split between their GH and non-GH work (p = 0.0001), find funding to achieve their objectives in GH (p = 0.01), invest in their personal and family life (p = 0.05), and split work abroad and domestically with few challenges (p = 0.01). Conclusions: We present sociodemographic and career characteristics for graduates from a GH training program in a highly resourced academic medical center in the United States. Mentorship, institutional support, funding, ability to balance GH with non-GH work, and time spent domestically or abroad are key factors associated with successful careers in GH. If institutional funding is allocated to strengthen these aspects of GH training, we anticipate more sustained GH career development.

Breaking the silence on gendered harassment and assault of community health workers: an analysis of ethnographic studies.

INTRODUCTION: Across a variety of settings, women in tenuous financial circumstances are drawn to community health work as a way to advance themselves in the context of limited employment options. Female Community Health Workers (CHWs) are often preferred because they can more easily access mothers and children; at the same time, gender norms are at the heart of many of the challenges and inequities that these workers encounter. Here, we explore how these gender roles and a lack of formal worker protections leave CHWs vulnerable to violence and sexual harassment, common occurrences that are frequently downplayed or silenced. METHODS: We are a group of researchers who work on CHW programmes in a variety of contexts globally. The examples here are drawn from our ethnographic research (participant observation and in-depth interviews). RESULTS: CHW work creates job opportunities for women in contexts where such opportunities are extremely rare. These jobs can be a lifeline for women with few other options. Yet the threat of violence can be very real: women may face violence from the community, and some experience harassment from supervisors within health programmes. CONCLUSION: Taking gendered harassment and violence seriously in CHW programmes is critical for research and practice. Fulfilling CHWs' vision of health programmes that value them, support them and give them opportunities may be a way for CHW programmes to lead the way in gender-transformative labour practices.

Adoption of mHealth Technologies by Community Health Workers to Improve the Use of Maternal Health Services in Sub-Saharan Africa: Protocol for a Mixed Method Systematic Review.

BACKGROUND: Studies have shown that mobile health technologies (mHealth) enhance the use of maternal health services. However, there is limited evidence of the impact of mHealth use by community health workers (CHWs) on the use of maternal health services in sub-Saharan Africa. OBJECTIVE: This mixed method systematic review will explore the impact of mHealth use by CHWs on the use of the maternal health continuum of care (antenatal care, intrapartum care, and postnatal care [PNC]), as well as barriers and facilitators of mHealth use by CHWs when supporting maternal health services. METHODS: We will include studies that report the impact of mHealth by CHWs on the use of antenatal care, facility-based births, and PNC visits in sub-Saharan Africa. We will search 6 databases (MEDLINE, CINAHL, Web of Science, Embase, Scopus, and Africa Index Medicus), with additional articles identified from Google Scholar and manual screening of references of the included studies. The included studies will not be limited by language or year of publication. After study selection, 2 independent reviewers will perform title and abstract screening, followed by full-text screening to identify the final papers to be included. Data extraction and risk-of-bias assessment will be performed using Covidence software by 2 independent reviewers. We will use a Mixed Methods Appraisal Tool to perform risk-of-bias assessments on all included studies. Finally, we will perform a narrative synthesis of the outcomes, integrating information about the effect of mHealth on maternal health use and barriers and facilitators of mHealth use. This protocol follows the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) guidelines. RESULTS: In September 2022, we conducted an initial search in the eligible databases. After removing duplicates, we identified 1111 studies that were eligible for the title and abstract screening. We will finalize the full-text assessment for eligibility, data extraction, assessment of methodological quality, and narrative synthesis by June 2023. CONCLUSIONS: This systematic review will present new and up-to-date evidence on the use of mHealth by CHWs along the pregnancy, childbirth, and PNC continuum of care. We anticipate the results will inform program implementation and policy by highlighting the potential impacts of mHealth and presenting contextual factors that should be addressed to ensure the success of the programs. TRIAL REGISTRATION: PROSPERO CRD42022346364; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=346364. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/44066.

COVID-19 Pandemic Response in a Migrant Farmworker Community: Excess Mortality, Testing Access and Contact Tracing in Immokalee, Florida.

Background: Migrant and seasonal farmworkers face enormous barriers to health and have been a particularly vulnerable population during the COVID-19 pandemic, but their pandemic experiences and potential inequities have not been well studied. Objectives: We aimed to assess the impact of COVID-19 in Immokalee, Florida, a community with a significant population of migrant and seasonal farmworkers. We evaluated for differences in pandemic experience by language, a known barrier to healthcare, to inform and strengthen future public health efforts. Methods: First, to estimate the burden of COVID in the area, we conducted a descriptive analysis of data on COVID-19 deaths for Collier County from May-August 2020. We then surveyed a cross-sectional, randomized representative sample of 318 adults living in Immokalee from March-November 2020 to assess socio-demographics, workplace conditions, sources of information, ability to follow guidelines, and experiences with testing and contact tracing programs. Results were compared across language groups. Findings: Average excess mortality in Collier County was 108%. The majority surveyed in Immokalee had socio-demographic factors associated with higher COVID risk. Non-English speakers had higher workplace risk due to less ability to work from home. Haitian Creole speakers were less likely to be tested, though all participants were willing to get symptomatic testing and quarantine. Those participants who tested positive or had COVID-19 exposures had low engagement with the contact tracing program, and Spanish-speakers reported lower quality of contact tracing than English speakers. Conclusions: The community of Immokalee, FL is a vulnerable population that suffered disproportionate deaths from COVID-19. This study reveals language inequities in COVID testing and contact tracing that should be targeted in future pandemic response in Immokalee and other migrant farmworker communities.

Continuity of community-based healthcare provision during COVID-19: a multicountry interrupted time series analysis.

BACKGROUND: Pandemics often precipitate declines in essential health service utilisation, which can ultimately kill more people than the disease outbreak itself. There is some evidence, however, that the presence of adequately supported community health workers (CHWs), that is, financially remunerated, trained, supplied and supervised in line with WHO guidelines, may blunt the impact of health system shocks. Yet, adequate support for CHWs is often missing or uneven across countries. This study assesses whether adequately supported CHWs can maintain the continuity of essential community-based health service provision during the COVID-19 pandemic. METHODS: Interrupted time series analysis. Monthly routine data from 27 districts across four countries in sub-Saharan Africa were extracted from CHW and facility reports for the period January 2018-June 2021. Descriptive analysis, null hypothesis testing, and segmented regression analysis were used to assess the presence and magnitude of a possible disruption in care utilisation after the earliest reported cases of COVID-19. RESULTS: CHWs across all sites were supported in line with the WHO Guideline and received COVID-19 adapted protocols, training and personal protective equipment within 45 days after the first case in each country. We found no disruptions to the coverage of proactive household visits or integrated community case management (iCCM) assessments provided by these prepared and protected CHWs, as well as no disruptions to the speed with which iCCM was received, pregnancies were registered or postnatal care received. CONCLUSION: CHWs who were equipped and prepared for the pandemic were able to maintain speed and coverage of community-delivered care during the pandemic period. Given that the majority of CHWs globally remain unpaid and largely unsupported, this paper suggests that the opportunity cost of not professionalising CHWs may be larger than previously estimated, particularly in light of the inevitability of future pandemics.

The Immokalee Community Health Coalition: Operationalizing Trust.

The COVID-19 pandemic disproportionately affected migrant farmworker communities in the United States in case rates and deaths. In rural Immokalee, Florida, human rights, health care, and social support organizations with different strengths joined together to form a coalition that provided health information, tests, vaccines, and social supports. This report offers practical advice on how similar coalitions can overcome barriers to care, improve outcomes, and overall increase trust in the health system.

Lessons from an eight-country community health data harmonization collaborative.

BACKGROUND: Community health workers (CHWs) are individuals who are trained and equipped to provide essential health services to their neighbors and have increased access to healthcare in communities worldwide for more than a century. However, the World Health Organization (WHO) Guideline on Health Policy and System Support to Optimize Community Health Worker Programmes reveals important gaps in the evidentiary certainty about which health system design practices lead to quality care. Routine data collection across countries represents an important, yet often untapped, opportunity for exploratory data analysis and comparative implementation science. However, epidemiological indicators must be harmonized and data pooled to better leverage and learn from routine data collection. METHODS: This article describes a data harmonization and pooling Collaborative led by the organizations of the Community Health Impact Coalition, a network of health practitioners delivering community-based healthcare in dozens of countries across four WHO regions. OBJECTIVES: The goals of the Collaborative project are to; (i) enable new opportunities for cross-site learning; (ii) use positive and negative outlier analysis to identify, test, and (if helpful) propagate design practices that lead to quality care; and (iii) create a multi-country 'brain trust' to reinforce data and health information systems across sites. RESULTS: This article outlines the rationale and methods used to establish a data harmonization and pooling Collaborative, early findings, lessons learned, and directions for future research.

Early Lessons From Launching an Innovative Community Health Household Model Across 3 Country Contexts.

Community health workers (CHWs) are integrated into health systems through a variety of designs. Partners In Health (PIH), a nongovernmental organization with more than 30 years of experience in over 10 countries, initially followed a vertical approach by assigning CHWs to individual patients with specific conditions, such as HIV, multidrug resistant-TB, diabetes, and other noncommunicable diseases, to provide one-on-one psychosocial and treatment support. Starting in 2015, PIH-Malawi redesigned their CHW assignments to focus on entire households, thereby offering the opportunity to address a wider variety of conditions in any age group, all with a focus on working toward effective universal health coverage. Inspired by this example, PIH-Liberia and then PIH-Mexico engaged in a robust cross-site dialogue on how to adapt these plans for their unique nongovernmental organization-led CHW programs. We describe the structure of this "household model," how these structures were changed to adapt to different country contexts, and early impressions on the effects of these adaptations. Overall, the household model is proving to be a feasible and functional method for organizing CHW programs so that they can contribute toward achieving universal health coverage, but there is no "one-size-fits-all" approach. Other countries planning on adopting this model should plan to analyze and adapt as needed.

Epidemiologic Impacts in Acute Infectious Disease Associated with Catastrophic Climate Events Related to Global Warming in the Northeast of Mexico.

Rising global temperatures and seawater temperatures have led to an increase in extreme weather patterns leading to droughts and floods. These natural phenomena, in turn, affect the supply of drinking water in some communities, which causes an increase in the prevalence of diseases related to the supply of drinking water. The objective of this work is to demonstrate the effects of global warming on human health in the population of Monterrey, Mexico after Hurricane Alex. We interpolated data using statistical downscaling of climate projection data for 2050 and 2080 and correlated it with disease occurrence. We found a remarkable rise in the incidence of transmissible infectious disease symptoms. Gastrointestinal symptoms predominated and were associated with drinking of contaminated water like tap water or water from communal mobile water tanks, probably because of the contamination of clean water, the disruption of water sanitation, and the inability to maintain home hygiene practices.

Compensation models for community health workers: Comparison of legal frameworks across five countries.

BACKGROUND: Despite the life-saving work they perform, community health workers (CHWs) have long been subject to global debate about their remuneration. There is now, however, an emerging consensus that CHWs should be paid. As the discussion evolves from whether to financially remunerate CHWs to how to do so, there is an urgent need to better understand the types of CHW payment models and their implications. METHODS: This study examines the legal framework on CHW compensation in five countries: Brazil, Ghana, Nigeria, Rwanda, and South Africa. In order to map the characteristics of each approach, a review of the regulatory framework governing CHW compensation in each country was undertaken. Law firms in each of the five countries were engaged to support the identification and interpretation of relevant legal documents. To guide the search and aid in the creation of uniform country profiles, a standardized set of questions was developed, covering: (i) legal requirements for CHW compensation, (ii) CHW compensation mechanisms, and (iii) CHW legal protections and benefits. RESULTS: The five countries profiled represent possible archetypes for CHW compensation: Brazil (public), Ghana (volunteer-based), Nigeria (private), Rwanda (cooperatives with performance based incentives) and South Africa (hybrid public/private). Advantages and disadvantages of each model with respect to (i) CHWs, in terms of financial protection, and (ii) the health system, in terms of ease of implementation, are outlined. CONCLUSIONS: While a strong legal framework does not necessarily translate into high-quality implementation of compensation practices, it is the first necessary step. Certain approaches to CHW compensation - particularly public-sector or models with public sector wage floors - best institutionalize recommended CHW protections. Political will and long-term financing often remain challenges; removing ecosystem barriers - such as multilateral and bilateral restrictions on the payment of salaries - can help governments institutionalize CHW payment.

Economic evaluation of a novel community-based diabetes care model in rural Mexico: a cost and cost-effectiveness study.

OBJECTIVES: Diabetes is the leading cause of disability-adjusted life years in Mexico, and cost-effective care models are needed to address the epidemic. We sought to evaluate the cost and cost-effectiveness of a novel community-based model of diabetes care in rural Mexico, compared with usual care. DESIGN: We performed time-driven activity-based costing to estimate annualised costs associated with typical diabetes care in Chiapas, Mexico, as well as a novel diabetes care model known as Compañeros En Salud Programa de Enfermedades Crónicas (CESPEC). We conducted Markov chain analysis to estimate the cost-effectiveness of CESPEC compared with usual care from a societal perspective. We used patient outcomes from CESPEC in 2016, as well as secondary data from existing literature. SETTING: Rural primary care clinics in Chiapas, Mexico. PARTICIPANTS: Adults with diabetes. INTERVENTIONS: CESPEC is a novel, comprehensive, diabetes care model that integrates community health workers, provider education, supply chain management and active case finding. OUTCOME MEASURE: The primary outcome was the incremental cost-effectiveness of CESPEC compared with care as usual, per quality-adjusted life year (QALY) gained, expressed in 2016 US dollars. RESULTS: The economic cost of the CESPEC diabetes model was US$144 per patient per year, compared with US$125 for diabetes care as usual. However, CESPEC care was associated with 0.13 additional years of health-adjusted life expectancy compared with usual care and 0.02 additional years in the first 5 years of treatment. This translated to an incremental cost-effectiveness ratio (ICER) of US$2981 per QALY gained over a patient's lifetime and an ICER of US$10 444 over the first 5 years. Findings were robust to multiple sensitivity analyses. CONCLUSIONS: CESPEC is a cost-effective, community-based model of diabetes care for patients in rural Mexico. Given the high prevalence and significant morbidity associated with diabetes in Mexico and other countries in Central America, this model should be considered for broader scale up and evaluation.