IN THE BUSINESS OF SAVING LIVES
Entrepreneurial models of community healthcare turn health workers into sales associates, and communities into customers.
These models shift the cost of health programs onto the world’s poorest and most marginalized. And they are significantly less effective than programs that pay community health workers (CHWs) a stable salary.
The “big idea” is that alongside providing basic health education and services, CHWs are paid commission from selling health products door-to-door. Many programs also offer small performance-based cash incentives for certain tasks — such as data collection to satisfy donor-reporting priorities. These perverse incentives warp service delivery by distracting CHWs away from important but less financially rewarding responsibilities, while destabilizing their own financial security.
STEPS TOWARD BETTER CARE MODELS
- Retire sales-based CHW models as a strategy for sustainability. They restrict access and underperform.
- Align with WHO guidelines for CHW remuneration and support.
This means salaries, supervision, training, and integration – not commissions. - Partner with governments early and often. Sustainability comes from domestic financing and national ownership, not unit sales.
- Listen to CHWs. They are experts in their own work. Their feedback helped reveal the weaknesses of the entrepreneurial model–and their insights should shape what comes next.
The entrepreneurial CHW model promises financial sustainability and empowerment. Instead, it creates barriers to care, distorts CHW priorities, and underperforms relative to professional CHW programs. The evidence is now overwhelming: salaried, professional CHW models are more effective, equitable, and aligned with the mission of health for all.
For social innovators committed to health equity, the path forward is not to transform CHWs into micro-entrepreneurs. It is to build and strengthen the systems that allow them to do what communities value most: provide care without conditions.
