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Led by the Frontline Health Workers Coalition and partners, World Health Worker Week (WHWW) brings together advocates, health workers, leaders, and communities calling for more resources to support health workers.

Directed primarily at policymakers and global leaders, the goal of this week is to urge decisionmakers to follow through on global commitments and to invest in, protect, and support the health workforce, especially women.  The 2024 theme is Safe and Supported: Invest in Health Workers.

The case for investing in community health workers is clear and proven, with immense health, social, and economic returns. Though the financial return on investment for the primary health care workforce has been demonstrated to be as high as 10:1, the current funding gap for community health programs is estimated to be $5.4 billion annually.

Across the African continent, there are many contexts in which leaders and decisionmakers have made policy commitments related to investing in health, but have not yet implemented them.  In 2001, African Union countries set a target of allocating at least 15% of their annual national budgets to their health sectors, known as the Abuja Declaration. But achieving this goal has remained elusive. In Mali, before COVID-19 and the latest governance transitions, Mali’s spending on its health sector was around 4%.

How much longer will it take for more countries to be able to reach the Abuja Declaration targets?

While increasing spending on primary healthcare is necessary, investing in health workers cannot simply be a matter of increasing national spending, or increasing international donor funding.

Whatever the cause, it is clear that greater domestic and international investments in health systems and health workers have not been forthcoming. In the Sahel, even with willing policymakers and treasuries, armed conflict and transitional military governments are a growing obstacle to increased national investment in health. Furthermore, in decentralized health systems, increased national investment may not even necessarily reach primary care systems, as community health systems are not principally financed by the national government.

If not policymakers and leaders, who can do the investing in health workers that so many communities desperately need? Are there other strategies and possible investors? Especially in decentralized health systems?

Communities are being overlooked as essential partners for investing in community health programs.

The calls for increased health financing and investment usually end at the national level. Even the terms “local financing” and “domestic resource mobilization” are mostly used to refer to national budgets. But if we end our advocacy there, we neglect possible health financing that is more localized including district, community, household, and even individual health financing. 

Let us also not forget the Bamako Imitative of 1987, whose purpose was to increase the participation of the community not only in the decision making and governance of the primary care health system, but in its financing as well.

For the past several years, Mali Health has been seeking to expand the understanding of who can do the investing and supporting of health workers. In Mali’s decentralized health system, we are seeking to help build community-led solutions for investing in and supporting community health workers.

To be sure, we do not mean to suggest that primary care workers should not be a health policy priority for every national government, as they are in Mali. But as we continue to advocate for greater investment and the fulfillment of the ambitions of the Abuja Declaration, women and children need health workers now, and we can work on local solutions to support health workers now.

For example, there is already a source of health financing that is highly localized, largely due to the Bamako Initiative. In addition to external donor funding and domestic spending, out of pocket payments (OOPs) are a significant source of health financing in most African countries – matching and exceeding other types of spending in many cases. Regrettably, OOPs and user fees are inequitable and burdensome, but they are a critical component to how primary care systems are financed today, especially in decentralized health systems.

But user fees and OOPs represent just one method for community involvement in the financing of health services. As we advocate for replacements to OOPs and user fees, we have an opportunity to reallocate them and other community resources into more equitable, affordable and sustainable strategies that could channel local, community-led resources to invest in the health workforce. Rwanda provides an excellent example for how community-based health insurance can mobilize community and local resources for more equitable access to quality healthcare, alongside national and donor investments.

To improve health equity, meet urgent health needs, and overcome the expected health workforce shortage, we cannot depend alone on increased national budgets or increased donor funding. While part of a solution, they are not the whole solution. As we work with policymakers and leaders, let us also not forget those with proximity to these challenges, and who work hard to support health workers in their community every day. They have valuable perspectives and insights, not simply as the recipients of health worker services, but as investors in them.

Let us begin to think about investment so that all health workers can be safe and supported, not just from the top down, but also from the bottom up.