HOW DO WE DETERMINE WHETHER COMMUNITY HEALTH WORKERS ARE COST-EFFECTIVE? SOME CORE METHODOLOGICAL ISSUES Damian G. Walker, MSc; Stephen Jan, PhD ABSTRACT: Since the Alma-Ata Conference in 1978 reiterated the goal of ‘‘Health for All by the Year 2000’’, health service delivery programs promoting the primary health care approach using community health workers (CHWs) have been established in many developing countries. These programs are expected to improve the cost-effectiveness of health care systems by reaching large numbers of previously under- served people with high-impact basic services at low cost. However, there is a dearth of data on the cost-effectiveness of CHW programs to confirm these views. This may be because conventional approaches to economic evaluation, particularly cost-effectiveness, tend not to capture the institutional features of CHW programs. Therefore, this paper aims to examine the means by which economic methods can be extended to provide evidence regarding the cost-effectiveness of CHWs in develop- ing countries. KEY WORDS: community health workers; cost-effectiveness; review. INTRODUCTION Since the Alma-Ata Conference in 1978 reiterated the goal of ‘‘Health for All by the Year 2000’’, health service delivery programs pro- moting the primary health care approach using community health work- ers (CHWs) have been established in many developing countries. 1 Services provided by these workers are seen to be more appropriate to the health needs of populations than those of clinic-based services, to be less expensive and to foster self-reliance and local participation. Furthermore, because CHWs are more accessible and acceptable to Damian Walker is a Research Fellow in Health Economics, and Stephen Jan is a Lecturer in Health Economics, both at the London School of Hygiene and Tropical Medicine. The authors are members of the Health Economics and Financing Program (HEFP), which is supported by program funds from the Department for International Development, UK (DFID). Requests for reprints should be addressed to Damian Walker, M.Sc, Health Economics and Financing Program, Health Policy Unit, Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK; e-mail: dami- an.walker@lshtm.ac.uk Journal of Community Health, Vol. 30, No. 3, June 2005 (Ó 2005) DOI: 10.1007/s10900-004-1960-4 221 0094-5145/05/0600-0221/0 Ó 2005 Springer ScienceþBusiness Media, Inc.