Nature of review

An initial wider scoping review was conducted to identify and map the available evidence on economic evaluations of both vertical and integrated horizontal CHW programmes in LMICs published between 2015–2024. The protocol was uploaded to Open Science Framework (OSF) on July 27, 2023 [18]. Due to the large number of studies identified and the heterogeneity between studies, reporting of results has been divided into several publications, by disease area or type of CHW, for clarity and to facilitate comparisons between similar studies [19,20]. This paper focuses exclusively on three infectious diseases: HIV, malaria and TB - three of the leading infectious diseases in LMICs [3]. While other infectious diseases, such as COVID-19 and Ebola, have significant public health impacts, they are not included in this study due to the distinct epidemiological contexts, response mechanisms, and funding priorities these diseases demand, and the limited number of studies identified for these other topics.

A scoping review was chosen given the broad and varied nature of the field, with the goal of identifying updated evidence, mapping research methodologies, and highlighting knowledge gaps. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines [21]. The PRISMA-ScR Checklist is available in the Supplementary Material (S1 Checklist).

Search strategy and study selection criteria

An initial search was conducted covering January 1, 2015 to July 11, 2023 in the following databases: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations and Daily (1946 to July 06, 2023); Ovid Embase Classic+Embase (1947–2023 July 07); Ovid APA PsycInfo (1806 to July Week 1 2023); Ovid Global Health (1910–2023 Week 26); Ovid AMED (Allied and Complementary Medicine) (1985 to June 2023); Cochrane Central Register of Controlled Trials (CENTRAL); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Web of Science Core Collection; Scopus; and Latin American and Caribbean Health Sciences Literature (LILACS). To ensure this review was up-to-date, a second repeat search was conducted to capture relevant literature up to and including July 16, 2024.

Additionally, we searched the following sources to identify any relevant grey literature: Google Scholar, Bielefeld Academic Search Engine (BASE), DART-Europe E-theses Portal; e-theses online service (EThOS), Open Access Theses and Dissertations, and The OAIster database, plus websites of key organisations involved with CHWs (e.g., CHW Central, Community Health Impact Coalition, and Healthcare Information for All (HIFA.org)). Grey literature included (but was not necessarily limited to) theses or dissertations, preprints or unpublished research, and internal reports.

The search strategy included all appropriate controlled vocabulary and keywords for ‘Community Health Workers’, ‘Economic Evaluations’ and ‘LMICs’, which are defined below. Reference lists of included studies were reviewed to identify any additional studies missed by database searches. Full search strategies are available in the Supplementary Material (S1 Table).

CHWs

For the purpose of this review we drew upon previous literature [22–24] to define CHWs as healthcare workers who:

1. (a). are primarily based in the community providing primary healthcare services, both in facilities and in community settings;
2. (b). are part of the health system (i.e., government or non-governmental organization supported CHWs), performing tasks related to health-care delivery, and/or health education, promotion, or care coordination; and
3. (c). have received organised training and/or certification, but do not have a tertiary-level degree such as a nursing or midwifery degree.

Economic evaluations

Both full and partial economic evaluations were included. Full economic evaluations, as defined by Drummond et al., (2015) [25], compare the costs and outcomes of health interventions against alternatives such as the current standard of care or a no-intervention scenario. This may include Cost-Effectiveness Analysis (CEA), Cost-Utility Analysis (CUA), Cost-Benefit Analysis (CBA), Cost-Minimization Analysis (CMA), Cost-Consequence Analysis (CCA), Social Return on Investment (SROI), Multi-Criteria Decision Analysis (MCDA), Budget Impact Analysis (BIA), and Programme Budgeting and Marginal Analysis (PBMA).

Partial economic evaluations, on the other hand, consider costs and/or consequences without necessarily comparing alternatives or linking costs to benefits. They can include outcome descriptions, cost descriptions, cost-outcome descriptions, effectiveness evaluations, or cost analyses.

While full economic evaluations are preferred for guideline and policy development due to their comprehensive nature [26], partial economic evaluations are valuable for initial program development and in contexts where full evaluations are too costly, particularly in LMICs [27].

LMICs

The World Bank classification of economies was used to categorise LMIC countries as either ‘low’, ‘lower-middle’ or ‘upper-middle’ income based on the costing date for each respective study [28].

Inclusion and exclusion criteria

Studies were included if they:

• Primarily evaluated CHW programs, excluding those focused exclusively on other healthcare professionals such as doctors, nurses, or midwives.
• Evaluated vertical CHW programs focused on HIV, malaria or TB (e.g., programmes where CHWs were solely focussed on malaria, for example. For HIV, studies were included where HIV related co-infections, such as cryptococcal meningitis, were reported).
• Provided details of an economic evaluation, including either full or partial evaluations.
• Were published between August 2015 and July 2024, as the previous review on this topic covered literature up to July 2015.
• Evaluated interventions or programs located in LMICs as per the World Bank classification in the year the study was costed.

Studies were excluded if they:

• Were letters to the editor, commentaries, protocols, opinion pieces, policy briefings, or conference abstracts. Although systematic reviews were excluded, their reference lists were searched for potentially eligible studies.
• Assessed the economic impact of digital add-ons to CHW programs (e.g., mobile phone interventions), as the focus of our review was on the economic evaluation of CHW-led interventions themselves, not digital add-ons.

No restrictions were placed on the time frame of the analysis or language of publication. Although the search was conducted in English, full texts were reviewed in any language. Studies were not excluded based on quality due to the high diversity in study types and the interest in exploring the breadth of available evidence. Full eligibility criteria are detailed in the PICO framework in the Supplementary Material (S2 Table).

Study screening process

Following a search of the databases and grey literature by a qualified information search specialist, citations were exported to the Covidence platform [29]. Duplicate results were removed using an automated ‘de-duplicate’ feature within Covidence.

Given the high number of studies identified for screening a team of 18 researchers took part in the initial study screening process. Following training and piloting, each title and abstract was reviewed by two reviewers independently. Any conflicting screening decisions were resolved by a third reviewer who read the study in full and evaluated it against the inclusion and exclusion criteria.

The full texts of the remaining relevant articles were then analysed by two reviewers for final inclusion or exclusion. If a full text was excluded at this stage, a reason was documented. Any conflicts at this stage were flagged within Covidence and resolved by a third reviewer.

Data extraction

Data was extracted by two reviewers into a custom Google Sheets document. Each reviewer performed quality control on the other reviewer’s extractions, and a third reviewer (an economist) was available to resolve any disagreements. The extraction form was tested for user-friendliness and completeness by all extractors independently and discussed during a joint video conference call. Modifications were made based on the feedback. The spreadsheet captured the article meta-data, information about the study site and CHWs involved in the study, methodological and reporting data, as well as outcomes and cost data.

Outcomes were categorised into five categories: (i) Service Provision (e.g., visits, number of medications distributed, number of household visits); (ii) Population Coverage (e.g., households covered); (iii) Mortality(e.g., reduction in mortality, lives saved) and Morbidity (e.g., TB-related hospitalisations) outcomes; (iv) Cost Savings and Cost Recovery outcomes (e.g., amount of money saved); and (v) Societal Outcomes (e.g., economic growth).

In terms of cost data, the documentation included whether costs were reported in the following categories: (i) Cost per CHW; (ii) Cost per Consultation; (iii) Cost per Service; (iv) Cost per Capita; or (v) Cost per Beneficiary. We also extracted other cost reporting which is specific to infectious diseases, such as Cost per Person/Partner Tested. We documented whether cost per outcome was reported in the study (i.e., Cost per Disability-Adjusted Life Year (DALY) Averted or Cost per Quality-Adjusted Life Year (QALY) Gained). All costs were converted to and reported in 2024 US$ to facilitate comparison. For costs reported in US$, we first converted costs to local currency units (LCUs) of the same year using that year’s exchange rate (World Bank, ‘US$ per LCU, period average’). With the costs reported in US$ now in LCUs, and for costs originally reported in LCUs by the resource, we inflated costs to 2024 LCUs using LCU inflation rates reported by the International Monetary Fund (‘inflation, average consumer prices’). With all costs in 2024 LCUs, we converted costs to 2024 US$ using the ‘LCU per US$, period average’ official exchange rate for 2024.

We also report on whether the study authors drew conclusions on the cost-effectiveness and affordability of the CHW program. To determine cost-effectiveness, we looked for comparisons against: (i) thresholds (willingness to pay or gross domestic product (GDP)/capita); or (ii) an alternative service or delivery modality, such as facility-based care. For affordability, we noted whether authors reported how the intervention affects the overall healthcare budget (budget impact analysis), including whether the intervention is affordable within the current budget constraints. That said, we report on cost-effectiveness and affordability based on the authors determination or conclusions from the original study, regardless of whether a threshold was used.

We used Microsoft Excel to organise and analyse extracted data.

Patient and public involvement

Patients and the public were not consulted as part of this scoping review.

Ethics approval

A self-assessment was conducted via the University of Washington Human Subjects Institutional Review Board (IRB) which determined that this study was not human subjects research and did not require IRB review.

Search results

The initial broader literature search (which included HIV, malaria and TB but also other health areas such as non-communicable diseases (NCDs), mental health, neglected tropical diseases (NTDs) and maternal, newborn and child health (MNCH) as well as horizontal, integrated CHW programs) yielded 9,790 articles, which were reduced to 5,663 after the removal of duplicates. 5,345 studies were excluded following abstract screening, and an additional 170 were excluded after full-text review. After coding studies by disease area, this process resulted in 33 HIV, malaria and TB studies being included in this review, representing 106 scenarios. Further details can be found in the PRISMA flow chart (Fig 1).

Download:

• PNG
  larger image
• TIFF
  original image

Fig 1. PRISMA flow diagram.

https://doi.org/10.1371/journal.pgph.0004596.g001

Our findings on horizontal integrated CHW programs and NCD and mental health-focused CHWs are currently under review, while we expect to publish the MNCH and NTD findings in 2025 [19,20].

The following three subsections present cost and cost-effectiveness findings separately for malaria, HIV and TB. Each section describes the CHW programs and alternatives assessed and reports on the relevant cost, cost-effectiveness and affordability findings. For cost-effectiveness, we report the incremental cost-effectiveness ratios (ICERs) converted to 2024 US$. An ICER reports the difference in total costs (incremental cost) of the CHW program and the comparator divided by the difference in the chosen measure of health outcome or effect (incremental effect) to provide a ratio of ‘extra cost per extra unit of health effect’.

Malaria

We identified nine studies focused on malaria, with 51 individual scenarios reported within these studies. These studies were conducted in twelve countries (eight low-income and four lower middle-income countries) across two regions. Six of the nine studies were partial cost effectiveness analyses, and three were full economic evaluations (see Table 1).

Download:

• PNG
  larger image
• TIFF
  original image

Table 1. Details of CHW roles and scenarios in malaria intervention studies.

https://doi.org/10.1371/journal.pgph.0004596.t001

Malaria interventions were heterogeneous in design, with CHW workforces ranging between 822–47,238 (median: 2,440; using the midpoint of the reported range in the study reporting on multiple countries) and CHW-to-population ratios spanning from 1:47 beneficiaries to 1:577. CHWs were involved in a wide range of malaria-related service delivery activities, including distributing bed nets (n = 2) [30,31], conducting indoor residual spraying (IRS) (n = 1) [32], distributing prophylactic medication (n = 3) [33–35], and screening, treatment and referrals (n = 3) [30,36,37]. The majority of studies compared the CHW intervention against usual care, more specifically malaria treatment provided by CHWs vs. at health facilities, or in the case of IRS, against standard spraying [32]. Two studies also compared CHW distribution of bed nets to alternative distribution channels [30,31].

Compensation of CHWs varied. In four studies CHWs received stipends [31,33,35,36] (although the specific amounts were only reported in one study) [36]; in one CHWs were salaried with the salary range across different settings being $41.4–165.63 per month/CHW [38]; and one where CHWs received performance based incentives, though the specific amounts were not provided [37]. Finally, the compensation model was not reported in two studies [30–32], and in one, the CHWs were volunteer (see Table 2 for full details) [34].

Download:

• PNG
  larger image
• TIFF
  original image

Table 2. Summary details of Malaria-focused interventions.

https://doi.org/10.1371/journal.pgph.0004596.t002

The most frequently reported cost metric was cost per beneficiary of the intervention, and costs ranged from $1.20 to $104.80 (n = 6 studies). The type of beneficiary varied due to the nature of the intervention. Four studies reported on cost per service [31,33,34,37]. Other cost outcomes reported included cost per structure sprayed [32], cost per net distributed [31], cost per CHW [36], cost per person protected [32], cost per years of life lost due to premature mortality (YLL) averted [30] and ICERs per YLL [30] and per DALY averted [38].

As assessed by the study authors, five of the interventions were found to be cost-effective [32,34,35,37,38]. This conclusion was drawn without the use of a threshold or other criteria on one study [35], or on the basis of a comparison with an alternative in four studies [32,34,37,38]. In one study the control arm (with no CHWs) was more cost-effective [31], and in one study one of the scenarios was cost-effective (where CHWs were involved and nets were distributed in difficult to access areas), while scenarios led by CHWs and/or distributing nets in other settings of different remoteness levels were not [30]. Two studies did not assess cost effectiveness [33,36].

Only three studies assessed affordability, all concluding the CHW interventions were affordable [33,34,37]. In two cases this conclusion was reached because the CHW-led intervention was cost saving for the health system compared to current spending [33,35]. In one study authors did not use any criteria to reach this conclusion [34].

HIV

We identified 14 studies focussed on HIV, with 31 individual scenarios within these 14 studies. The studies were conducted in a mix of upper-middle (South Africa), lower-middle (Kenya and Zambia) and low income (Tanzania, Uganda and Malawi) countries, all of which were in sub-Saharan Africa. The roles of CHWs within these studies included providing administration and logistics support (e.g., mobilizing community health groups), delivering medications, and contacting sexual partners (n = 5) [39–43]; screening for HIV or co-infections (e.g., cryptococcal meningitis) (n = 7) [39,40,43–46] providing ongoing management (e.g., conducting home visits for adherence support) (n = 6) [42,43,45,47–49]; partner notification and tracing (n = 2) [39,42] and providing referrals (n = 9) [39–41,43–47,50]. All studies involved CHWs offering outreach, education, or training to patients, except for one where CHWs’ roles were not reported [51]. Twelve studies used standard care as a comparator, typically delivered within a facility (n = 8) (see Table 3).

Download:

• PNG
  larger image
• TIFF
  original image

Table 3. Details of CHW roles and scenarios in HIV intervention studies.

https://doi.org/10.1371/journal.pgph.0004596.t003

Table 4 provides further details on included HIV-related studies (see Table 4). The size of the programs in the included studies varied from 6 to 576 CHWs (median: 34) and CHW-to-population ratios spanning from 1 CHW per 12 beneficiaries to 1:41,667 beneficiaries. In four studies, CHWs were salaried, with two reporting the specific monthly salary ($239-$586) [42,45,48,50]. In three studies, CHWs received a stipend, ranging from $10 per patient to a one-off payment of $27 [40,41,49]. Seven studies did not report any details about CHW compensation [39,43,44,46,47,51,52].

Download:

• PNG
  larger image
• TIFF
  original image

Table 4. Summary details of HIV-focused interventions.

https://doi.org/10.1371/journal.pgph.0004596.t004

Methodologies varied, with nine studies conducting full economic evaluations and five utilizing partial economic evaluations. Cost outcomes demonstrated considerable variation, with the cost per beneficiary (n = 12) ranging from $3.9 to $341 and the cost per new diagnosis (n = 4) ranging from $37.49 to $445.33. Studies conducted in Uganda (n = 2) reported the lowest cost outcomes, with a cost per beneficiary of $3.9 and an ICER per DALY averted of $16.95 [40,49]. Other cost outcomes reported included ICER per patient loss averted (n = 1) [47] and cost per LYG (n = 1) [48].

Eight studies concluded that the CHW-led intervention was cost-effective, with four specifically reporting cost-effectiveness when comparing CHW-led community- or home-based care with standard care delivered at a facility [47,48,51,52]. A study conducted in Tanzania found HIV testing and counselling delivered by CHWs to be most cost-effective delivered in a facility vs. at home or within a public venue [44]. This was due to its integration into existing healthcare services, allowing it to leverage infrastructure, reduce setup and travel costs, and test high volumes of patients efficiently. They found combining facility- and community-based approaches was necessary to achieve widespread diagnostic coverage. Both studies evaluating partner notification services (compared to standard care, delivery by nurses, or passive notification) were considered cost-effective by authors [39,42]. Cost-effective studies often targeted specific high-priority populations (e.g., pregnant women, sexual partners of HIV-positive individuals, adolescents).

Four studies found CHW-led interventions to be not cost-effective [40,41,43,49]. These included home-based HIV testing and counseling and group psychotherapy in Uganda (compared against group HIV education classes), as well as HIV self-testing and ART distribution in Malawi. One intervention in South Africa, integrating NCD screening into home-based HIV testing, yielded inconclusive results [46]. Additionally, one study did not assess cost-effectiveness [50].

Two studies assessed affordability. One concluded that working with CHWs instead of nurses would be affordable, citing cost savings of approximately $421,224 for HIV partner notification services, making it an approach within the national health system’s budget [39]. In contrast, the other study determined that home-based HIV counseling and testing exceeded the available public funds for HIV testing in Uganda [40].

Tuberculosis (TB)

We identified 10 studies, with 24 individual scenarios focused on TB (see Table 5). These took place in eight countries (seven lower-middle income, one low income). CHWs in these studies delivered multiple aspects of care including home-to-home educational visits, screening via collection of sputum samples, and administrative delivery of results and medications. The most common roles of the CHWs were in health service provision, including monitoring, management and treatment (n = 8) [53–60]; screening and case finding (n = 8) [53–55,58–62] outreach and education activities (n = 7) [53–55,57,58,60,62] and referrals (n = 5) [54,55,58,59,62]. To a lesser extent, CHWs were involved in administrative duties such as supply chain and logistics (n = 3) [53,61,62]. Comparators were most frequently facility based care (n = 4) [56,57,59,62].

Download:

• PNG
  larger image
• TIFF
  original image

Table 5. Details of CHW roles and scenarios in TB intervention studies.

https://doi.org/10.1371/journal.pgph.0004596.t005

Of the 10 studies concerning CHW-led TB interventions, the majority were partial economic evaluations consisting of cost analysis (n = 5) [53,54,56,58,61] and cost description studies (n = 1) [55]. The remaining four studies were full economic evaluations, including cost-effectiveness analyses (n = 2) [59,60], a cost-consequence analysis (n = 1) [57] and a social return on investment study (n = 1) [62].

The CHW workforce in these studies ranged from 14-796 workers (median: 134). The CHW-to-beneficiary ratios for TB-focused interventions varied widely, ranging from 1:168 in Uganda to 1:12,262 in Myanmar. Instead of individuals targeted, one study reported the population served in terms of households (n = 470) [61]. The ten studies included salaried CHWs (n = 2, though the salary amounts were not documented) [55,61]; stipend CHWs (n = 3) [56,57,62], where the monthly stipend ranged from $54-$126/month (median $77); and CHWs who received various performance-based payments (n = 3) [53–55]. In some studies CHWs were provided other non-financial benefits (e.g., covering travel costs and providing meals) (n = 2) [53,55], or remuneration or benefits were not mentioned (n = 2; n.b. The total does not sum 10 as some studies included CHWs subject to more than one remuneration method) [59,60].

Six of the 10 studies reported the cost per beneficiary, which ranged from $12.57 -$26,556 (median = $8,620). Two studies reported on cost per TB case diagnosed [53,54] ($2 - $6) and three reported cost per patient completing treatment ($30 - $31,999) [53,55,57]. The other studies included cost outcome measures such as cost per contact investigated by CHW [61], cost per patient screened and submitting a sputum sample [53], cost per positive contact diagnosed [54,61], cost per multidrug resistant patient treated [57], and cost per patient re-treated [55]. Only one study, involving two scenarios in Uganda and Cameroon, reported on the incremental cost-effectiveness ratio (ICER) for DALYs averted ($717 and $1,122 respectively) [59]. In half of the studies (n = 5), CHW interventions were reported by authors to be cost-effective when compared against the alternative. In one study, treatment of drug sensitive TB delivered by influential community members was considered cost-effective when compared against a GDP/capita threshold, and the nine-month MDR treatment regimen was found to be more cost-effective than the 20–24 month regimen [60]. The study which looked at delivery by four different iNGOs found the one forming self-help groups that support TB patients by facilitating treatment adherence, providing education, and conducting community mobilization activities to ensure sustainable TB care to be most cost-effective [55]. No studies assessed affordability (see Table 6).

Download:

• PNG
  larger image
• TIFF
  original image

Table 6. Summary details of TB focused interventions.

https://doi.org/10.1371/journal.pgph.0004596.t006

Methodological findings across all studies

In this section we summarise selected methods-related findings across all included studies (n = 33) and scenarios (n = 106).

Across studies in all three disease areas, the most commonly reported outcomes were cost per beneficiary (n = 23) and cost per service (n = 9). Both metrics varied widely, both within and across disease areas: cost per beneficiary ranged from $1.20 to over $26,000 (median: $10.49), while cost per service ranged from $0.46 to $435 (median: $3.65). Only one study reported Cost per CHW, with scenarios ranging from $2,025 to $5,638 (median: $3,258). There was no clear relationship between CHW remuneration and cost per CHW per year.

In 13 studies, representing the majority of scenarios (n = 58), a provider perspective was used and 17 studies employed a one year time horizon, which is helpful for comparability. All studies included some recurrent costs. However, there was variability in reporting on training costs (n = 26), non-training capital items (meaning items used over one year, such as equipment) (n = 25) and indirect costs or overheads (n = 20). A limited number of studies reported out of pocket and opportunity costs (n = 7) and costs averted (n = 7).

The majority (n = 29) considered cost-effectiveness, most frequently comparing some cost measure for the CHW-led scenario against an alternative (n = 22), such as facility-based care without CHWs. Only 5 studies considered whether the intervention would be affordable in the setting [33–35,39,40].

Only one study used the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist [63], despite it being the leading guidance for authors to follow to ensure that health economic evaluations are identifiable, interpretable, and useful for decision making.

Strengths and limitations

This study has several strengths. Firstly, to our knowledge, it is the only study to specifically document costs, cost-effectiveness and affordability of CHWs working on vertical HIV, malaria and TB programs in LMICs. This review also presents comparable results (in 2024 US$) by disease area, thus facilitating synthesis and comparison of findings. Finally, given the size of the evidence base, we are able to draw some conclusions about the cost-effectiveness of CHWs working in these areas compared to other health professionals, and highlight the importance of geographic setting and context for these results.

The main limitation of this review is that we cannot determine why CHW-led implementation may be more cost-effective than care provided by other health professionals. A common hypothesis is that this cost-effectiveness is driven by differences in remuneration, as CHWs are often compensated at significantly lower levels than other health professionals, if they are paid at all. However, most studies included in this review did not provide sufficient information on the remuneration of both CHWs and other health professionals to confirm this hypothesis. Additionally, we did not extract data on whether the included studies described activities integrated into existing CHW roles or represented standalone activities, though this distinction was often not clearly reported. However, this distinction is important for accurately interpreting costs - such as marginal costs versus total program costs. Finally, we did not assess the quality of the included studies, which constrains our ability to determine which studies offer the most reliable conclusions regarding cost-effectiveness and affordability; however this is in keeping with accepted scoping review methodology [83].

We also only considered the three main infectious diseases (HIV, malaria and TB), while not reporting on other important infectious diseases about which more limited evidence exists. Our results cannot, therefore, be considered representative of all infectious diseases, but only those included in the review.

Reflexivity statement

We adhered to the consensus statement on equitable authorship in international research collaborations as outlined by Morton et al., (2021) [84]. The following reflexivity statement is provided in that context. This research was conducted by a multidisciplinary, global team comprising researchers and practitioners from LMICs where CHW programs are implemented, such as Malawi, Rwanda, Uganda, Kenya and Liberia. Team members hold positions in academic institutions, non-governmental organisations, and frontline health services (and included CHWs), enabling us to integrate both theoretical and practical insights into our study. All members who contributed to the study design, implementation, analysis, and writing of this paper have been included as co-authors. We acknowledge that the authorship team does not include LMIC government stakeholders, who are a key audience for this research. While many team members have extensive experience engaging with government health systems, this absence may limit study findings. That said, this study was undertaken by the Community Health Impact Coalition (CHIC), a collective of thousands of CHWs and dozens of global health organisations spanning over 60 countries in five WHO regions. The research questions, data collection methods, and analysis were shaped by CHIC’s commitment to understanding the drivers of impact and quality in CHW-delivered care globally.

Importantly, this work was also shared with CHWs to explore their opinions and solicit their feedback. Their insights were integral to refining our approach and ensuring the relevance of our findings to those most directly impacted by CHW programs. For a detailed reflexivity checklist, please refer to the Supplementary Material (S2 Checklist).

Directions for future research

There are several important points that can be addressed by future research. First, stakeholders have expressed a desire for clear conclusions about the cost-effectiveness and affordability of CHWs. Our experience with this review suggests that although definitive conclusions regarding affordability remain limited, evidence on cost-effectiveness is emerging. However, improving the clarity of study reporting is essential to ensure that those who most need this evidence can effectively interpret and apply the findings. In the absence of a CHW-specific reporting checklist, authors are advised to use the CHEERS checklist [63], as adherence to a reporting checklist has been shown to improve reporting quality [85].

Second, and related to reporting, lack of evidence about CHW remuneration, roles and their importance for cost-effectiveness limits our understanding of why CHWs might be more cost-effective, which can inform how to implement CHW programs in the future for maximum cost-effectiveness. Considering recent discussions on the importance of fair compensation for CHWs [86], this information is crucial to include in any discussion around cost-effectiveness. Additionally, future research should examine how workforce shortages and inconsistent integration into national health systems impact the scalability and sustainability of CHW programmes, despite their demonstrated cost-effectiveness.

Third, we suggest future research aligns with WHO care integration recommendations and considers horizontal, integrated CHWs who work on delivering HIV, malaria and TB care, but also across other health areas as well. For this type of study, an outcome measure like the DALY which encompasses both morbidity and mortality improvements across disease areas becomes increasingly important. Researchers need not limit themselves to a single outcome measure and can continue to report on cost per beneficiary and other such measures that can be useful for programmatic planning. However, if we aim to influence priority-setting and resource allocation decisions at the ministerial level and improve comparability of findings across studies, DALYs are currently the best measure to use.

Given that the majority of current evidence is focused on three countries, which is perhaps a reflection of donor research priorities, funding distribution, or the prevalence of health challenges in these countries, it highlights the need for economic evaluations to be conducted in more geographical contexts, to ensure that findings are applicable across a broader range of settings.

Finally, future research should integrate real-world financing data, including donor contributions, national health expenditures, and cost-sharing models, to ensure cost-effectiveness findings are directly actionable for policymakers and funders. Regional collaborations, such as the Africa CDC’s ongoing economic review of CHW services across the African Union, present opportunities to improve CHW financing research [87]. One avenue for translating research into policy is through organizations such as the Community Health Impact Coalition (CHIC), which leverage collaborative initiatives to inform Ministries of Health on CHW model development.