By: Gita Ramamurti (Financing Alliance/Yale) and Pernille Hoej and Jennifer Schechter (Hope Through Health)
In the small West African nation of Togo, investing in access to quality healthcare for mothers and their babies can have substantial effects in terms of saving lives, generating employment opportunities, and making the health system more resilient. A recent return on investment (ROI) analysis of a community health program run by Hope Through Health (HTH) in Northern Togo shows an impressive 11:1 return. This analysis will inform future decisions about the scale up and financing for this program.
HTH is an NGO that has partnered with the Togolese government to pilot a community health program in Northern Togo focused on improving maternal and child health. Currently, 1 in 11 children born in Togo will die before their 5th birthday and 360 mothers die for every 100,000 live births. Only 30% of the population has access to basic health services. To address this situation, HTH’s program uses community health workers (CHWs) to engage in proactive case finding and home-based care and also eliminates clinic user fees, provides clinical mentorship, and improves supply chain management. Through this combination of community- and clinic-level activities, the program strives to increase access, timeliness, and quality of care for children under the age of 5 and pregnant and postpartum women.
Early results of the pilot, which launched in August 2015, were positive in terms of increasing both the reach and utilization of health services. Eager to make more informed financing and programmatic decisions going forward, HTH collaborated with the Financing Alliance for Health earlier this spring to perform an ROI analysis for 2016, the program’s first full year of operation. In 2016, the HTH program employed 26 CHWs and served a catchment population of roughly 37,300 people. The ROI analysis was led by Gita Ramamurti, a Yale MBA/MPH student with past experience in consulting and community health, who completed this work as part of a practicum course with the Financing Alliance.
To estimate program cost, HTH used the Community Health Planning & Costing Tool (CHPCT) which was developed by UNICEF and Management Sciences for Health. The CHPCT is unique in its comprehensiveness, capturing costs across the full range of activities that could be included within a community health program. The tool has previously been implemented to cost public-sector community health initiatives, e.g. in Sierra Leone and Malawi. HTH’s use of this tool, however, was one of the first uses of the CHPCT by an NGO to cost a sub-national program.
HTH completed its cost analysis by using a variety of sources including academic literature, government reports, HTH program data, and CHW interviews. In 2016, cost per capita for the population served by the HTH program was $7.74 with approximately $5.07 per capita spent on clinic-level activities and $2.67 per capita spent on community-level activities. At the clinic level, roughly 97% of program costs were for medicines and supplies. At the community level, CHW salaries were the biggest cost bucket, representing 27% of community-level costs, followed by medicines and supplies, representing 23% of community-level costs. The CHPCT also estimated average weekly caseload per CHW across different services as well as the estimated cost for each service. Going forward, this type of costing detail will be extremely helpful to HTH and the Togolese government in informing financing conversations and discussions about program scope and potential expansion.
To estimate the impact of its integrated program, HTH leveraged the Financing Alliance’s investment case methodology which assesses three primary economic benefits of a CHW program:
1. Lives Saved: CHWs save lives by providing treatments for life-threatening diseases and educating catchment populations about important preventative health measures. To quantify this impact, the number of lives saved for the HTH program was estimated using the Lives Saved Tool. To estimate the economic benefit of this healthier population, the number of lives saved by the program was then multiplied by the benefit per life saved, which is based on the average number of productive working years per life saved and projected GDP per capita.
2. Employment: CHW programs are a valuable source of employment in their catchment communities. This employment has positive ripple effects on the local economy.
3. Insurance: CHW programs strengthen health systems especially at the community level. By doing so, CHW programs increase the resilience of health systems against potential public health crises and their high associated costs.
In 2016, each HTH CHW was estimated to have saved 2.7 lives. Looking across all three benefits described above, the estimated impact of the HTH program in 2016 is $86.33 per capita for the population served.
ROI is calculated by dividing total impact by total costs. The estimated ROI of HTH’s pilot program in 2016 is 11:1. That is, for every $1 spent on the HTH program, an estimated $11 in benefit is generated in return. A more conservative ROI calculation that just includes the impact of lives saved due to the program yields an ROI of 10:1. These results are in line with the Financing Alliance’s estimate of the global return on CHW programs which found a 10:1 ROI.
HTH will continue to refine and update its ROI analysis going forward. Ultimately, however, this deeper understanding of the costs and benefits of the maternal and child health program will enable HTH to make more informed financing and program management decisions in the future.