Cost-Effectiveness Assessment of Community Health Workers in Non-Communicable Disease Management An Implementation Science Perspective in Low- and Middle-Income Countries

Abstract

Background: Low- and middle-income countries (LMICs) face severe shortages of professional health workers, limiting non-communicable disease (NCD) management. Community health workers (CHWs) offer a scalable solution, yet evidence on their cost-effectiveness remains heterogeneous. This systematic review and data re-analysis updates and extends the 2025 scoping review by O'Donovan et al., synthesizing cost-effectiveness evidence for CHW-led NCD interventions in LMICs (2015–2024) from an implementation science lens. Methods: Following PRISMA guidelines, we systematically searched PubMed, Embase, Scopus, and Web of Science for economic evaluations of CHW programs targeting NCDs in LMICs. We included 20 studies (52 scenarios) from the core 2025 review, supplemented by comparative data from horizontal integrated CHW programs. Costs were re-analyzed from societal and health-system perspectives; incremental cost-effectiveness ratios (ICERs) were pooled narratively and subgrouped by program type (vertical NCD-focused vs. horizontal integrated), disease area, and equity dimensions where reported. Markov-style long-term projections and sensitivity considerations were derived from study-level modeling. Results: CHW interventions were cost-effective in 35/44 (80%) scenarios, with ICERs ranging from dominated (cost-saving) to US$4,080 per DALY averted. For cardiovascular disease (CVD)/hypertension (22 scenarios), ICERs spanned US$411–US$4,080 per DALY; diabetes (12 scenarios) showed similar variability, with per-capita costs of US$0.23–US$1.33. Vertical (NCD-only) programs exhibited higher upfront costs but comparable long-term value to horizontal integrated models. Equity-weighted analyses in select studies indicated greater relative benefits for the poorest quintiles. Probabilistic sensitivity analysis across studies confirmed robustness in >70% of simulations. Conclusion: CHW-led NCD management is highly cost-effective and aligns with universal health coverage (UHC) goals. Implementation science highlights the need to differentiate vertical vs. horizontal models and prioritize equity. We propose a practical “CHW-NCD Investment Return Toolkit” for policymakers.