Cost-Effectiveness of Alternative Models of Community Health Workers for Promotion of Maternal, Newborn and Child Health in Northern Nigeria

Background: Community health workers (CHWs) have proven to be successful in mobilizing rural populations to utilize primary health services where they can be supported by skilled health workers. This study assessed the cost-effectiveness of three CHW models implemented in northern Nigeria. Method: Using a quasi-experimental design, we compare the costs and health outcomes for communities where CHW models were implemented versus those where no CHW models were implemented. The three CHW models were Community Volunteer (CV), Nigeria Subsidy Reinvestment and Empowerment Programme for Maternal and Child Health Village Health Worker (VHW), and the Junior Community Health Extension Worker providing community based service delivery (JCHEW-CBSD). The unit costs, consultation patterns, benefit-cost ratios, and cost-effectiveness ratios were calculated for the three CHW models. Results: Compared to the CVs, the VHWs and the JCHEW-CBSDs had the highest levels of interactions in the community, each helping to educate 120-130 pregnant women each year. JCHEW-CBSDs made the most referrals for antenatal care (220) and facility births (122); however, women who interacted with the VHWs increased their antenatal care visits the most, with 92% of the women having made at least one and 70% having made 4+ ANC visits. The unit cost of the CVs was lowest, compared to the other two models, at $127 versus $3176 for the VHW model and $4443 for the JCHEWCBSD model. The outcomes per unit cost ratios were highest for the VHW model. For every $1000 invested in the VHW, there were 54 ANC 4+ visits and 95.9 deliveries attended by a skilled birth attendant. The Incremental Cost-Effectiveness Ratios for the VHW model were also lower than for the JCHEW-CBSD model, ranging from a low of an additional $25 per incremental ANC visits to $152 for increments in attended deliveries, the latter amount three times lower than for the JCHEW-CBSD model. Conclusion: This cost-effectiveness study of CHW models in Northern Nigeria shows that the SURE-P VHW model was most cost-effective. The VHW model, an enhanced volunteer model, promises the greatest return on investment if scaled up in northern Nigeria and settings with similar health care delivery contexts.