Donors paid for Africa's community health workers, mostly one disease at a time

Community health workers are the delivery layer for most of what primary health care actually does in sub-Saharan Africa — the person who reaches a household that a clinic does not. A new analysis in BMJ Global Health asks a question that has been oddly hard to answer: who pays for them, how much, and what kind of work does the money buy [s1].

The answers are unflattering in a specific way. The financing is overwhelmingly external, overwhelmingly tied to individual diseases, and — despite a sixfold surge during the COVID-19 years — still leaves a gap of well over $4 billion a year against published cost benchmarks [s1].

How the estimate was built

The authors did a secondary analysis of publicly available data rather than a survey [s1]. Donor financing came from the OECD Creditor Reporting System, covering projects from 2002 to 2022, which were screened and then classified as vertical (single-disease) or horizontal (broader-focus) using standard definitions and manual review [s1]. Government financing was estimated for 37 sub-Saharan African countries from the WHO Global Health Expenditure Database for 2016–2022, by applying maturity-based allocation percentages to the preventive and outpatient curative spending categories [s1].

That second step is an estimate rather than a measurement, and it is the analysis's main methodological limit. National accounts do not generally break out community health worker spending as its own line, so the government figure is derived by apportionment. The authors are explicit that stronger expenditure tracking is one of the things their findings argue for [s1].

What the money looks like

Between 2002 and 2022, global external assistance for community health worker programmes totalled US$14.4 billion, of which sub-Saharan Africa received 76%, or US$11.0 billion [s1].

The split within that is the striking finding. Of donor funds flowing to sub-Saharan Africa, 76.4% supported vertical, single-disease programmes — even though vertical projects made up fewer than 20% of projects by count [s1]. Horizontal, broader-focus programmes received just 14.7% [s1]. In other words, a small number of large disease-specific grants absorbed most of the money, while the many smaller projects aimed at general community health shared a sliver.

The trend line over the last part of the period is steep. Annual external assistance rose from roughly US$0.28 billion in 2016–2019 to roughly US$1.83 billion in 2020–2022, with over 90% of that directed to vertical or COVID-19-related efforts [s1]. The pandemic, in other words, brought a large amount of new money into community health worker programmes and channelled almost all of it into a single emergency purpose.

Government spending across the 37 countries totalled roughly US$1.4 billion over 2016–2022 [s1]. That is less than 20% of total community health worker funding [s1] — but it is allocated differently, with 54.6% going to horizontal services [s1]. Domestic budgets, small as they are, are the part of the system paying for general community health rather than for one disease.

The gap that did not move

Measured against published cost benchmarks, the annual financing gap stayed between US$4.7 billion and US$4.3 billion [s1]. The narrowing is marginal. A surge in donor spending that increased annual external assistance more than sixfold did not meaningfully close it, because the surge was purpose-restricted and temporary.

That is the structural point the paper makes: community health worker financing in sub-Saharan Africa is donor-dominant and vertically oriented, while domestic allocations are limited but relatively more horizontal [s1].

Why the vertical–horizontal split matters operationally

A community health worker paid from a malaria grant is contractually a malaria worker. A household visit that turns up a hypertensive grandmother, a child with untreated pneumonia, or a woman who has missed antenatal care sits outside what that grant funds and, often, outside what its reporting system counts. Multiply that across a workforce financed 76.4% from single-disease sources [s1] and the result is a delivery layer that is broad in physical reach and narrow in mandate.

It also creates a fragility that has nothing to do with the quality of the work. Vertical financing follows donor disease priorities, and when those priorities shift, the worker's salary shifts with them. The 2020–2022 COVID-19 surge [s1] is the clearest recent demonstration of how quickly the composition of this funding can change.

What the authors conclude

The paper's recommendation is not that donors should stop funding vertical programmes. It is that closing the gap will require larger and more predictable government budgets for community health workers, better-aligned partner support, and stronger expenditure tracking, in order to sustain primary health care and advance universal health coverage [s1].

Each of those three is a different kind of ask. Larger domestic budgets are a fiscal and political question. Better-aligned partner support is a coordination question that has been raised for decades. Expenditure tracking is the most immediately actionable of the three, and the least discussed — this analysis had to estimate government spending by apportionment precisely because the data to measure it directly do not exist in most national accounts [s1].

What to watch

The dataset ends in 2022, which means it predates the recent contraction in development assistance for health. The composition documented here — three-quarters donor-funded, three-quarters of that disease-specific — describes the system as it stood before that contraction began, and is therefore useful mainly as a baseline. The question the next few years will answer is whether domestic budgets expand into the space donors vacate, or whether the workforce simply contracts with the funding that built it.

Sources

• Trends in government and donor funding for vertical and horizontal community health worker programmes in sub-Saharan Africa, BMJ Global Health, 24 March 2026