Redesigning national health service delivery: the case for community-based health service providers in Uganda

Generating evidence to guide investments in new service delivery platforms remains a major challenge. We applied a linear constrained optimisation model, ex ante, to estimate the potential health impact and trade-offs of integrating community-based providers (CBPs) into Uganda’s essential healthcare package. Specifically, we compared a facility-only delivery strategy with an integrated strategy that included Village Health Teams (VHTs) and medicine retailers. Outcomes included potential expansion of the optimal service package, additional net disability-adjusted life years averted, average cost-effectiveness, and maximum cost-effective investment per provider. Integrating CBPs could avert an additional 4.7 million net disability-adjusted life years and expand Uganda’s optimal health package by 25 interventions compared to the facility-only strategy. VHTs achieved health gains at 42 per net DALY averted and remained cost-effective at an investment of up to 3,423 per provider; medicine retailers remained cost-effective up to $19,792 per provider. Although current policies restrict CBP utilisation, results indicate substantial potential for health system strengthening. Constrained optimisation provides a systematic approach to quantify the value of new delivery platforms. Our findings provide an evidence-based roadmap for integrating CBPs in Uganda, while the adaptable model itself serves as a replicable tool to inform similar analyses in other settings.