Application of the UPG model to the study findings
In this section of the paper, we present data based on the six stages of the UPG model.
1.
Transfer of productive assets
Asset transfer is ideal for those CHVs who desire to run their own business. This is what the CHVs in this study preferred could be offered in the form of cash or in-kind.
“Apart from giving us money there are things that we can benefit from… If he [benefactor] gives us dairy cattle individually, that gives me milk…. that will benefit me…” (R3, FGD 6, Kaloleni).
The KIIs likewise agreed, with one stating that the benefit would serve the community as a whole.
“…I can also think of…a boda-boda [motor bike]… used for referrals to the facility…that will boost health…if they have their own they will maybe charge less” (KII 02).
CHVs would appreciate some asset transference in the form of a tangible asset as capital, e.g. a motor bike to ferry passengers for a fee or in the form of poultry or livestock from which they could increase their earnings. Although this is the most capital intensive aspect of the programme, previous studies showed that an increase in the total asset-value index led to a positive impact on poverty alleviation [
35]. The sustainability of this core component of the UPG model over time has, however, been criticised [
36]. Seen through the lens of risk and vulnerability, the provision of tangible productive and household assets is considered sustainable when firstly, a minimum acceptable level of consumption is provided, secondly, protecting those considered vulnerable are protected from shocks and adverse events that would require them to sell their assets and thirdly, this vulnerability is prevented in the long-term [
37]. The policy implication includes determining the threshold for “acceptable” consumption level vis-à-vis how sustainable this is.
2.
Weekly stipends/consumption support
Food security is a key concern and may hinder CHVs from taking risks on long-term livelihood activities. Providing a safety net that meets the basic needs of the CHVs such as a monetary compensation for the time they provide their services will allow them to engage better in programme activities as well as enable them to focus on building self-sustaining livelihoods. The CHVs in this study requested for allowances and other support to conduct their duties. This was echoed by the KIIs.
“..[As] has been said….is that token… be increased….they should look at what they will give the CHVs so that they can be well motivated.” (R3, FGD 5 Kaloleni).
“…if there could be some arrangement that they get some payment… I would support that…at least something that can make someone to feel that at the end of the month… he can move on.” (KII 01).
“….what can give us the morale is they think about us at least every month…someone will know even if I lose that way [lost opportunity to earn while volunteering], when a certain day reaches I will get something.” (R4, FGD 3, Kaloleni).
The need for financial incentives was reiterated repeatedly. For the CHVs in this study, it appeared that a fallback plan provided regularly such as a wage/salary would cushion them on the days they forfeited personal businesses to conduct their CHV-related activities. The aim of consumption support through weekly stipends in the UPG model is to ensure stabilisation of consumption and deter the risk of sale of productive assets for immediate consumption needs [
27]
28. It is thus provided until the asset begins to yield an income [
27]. It is a relatively simple process and less labour intensive, however, concern arises when the stipend amounts are standardised rather than customised based on household needs creating an issue with equity [
26]. Estimating consumption needs and justifying distribution based on these needs are among the policy implication aspects of this incentive.
3.
Intensive hands-on training
The CHVs requested technical and vocational training to equip them with skills required for self-employment. Training is tailored to their unique needs and structured to link to a specific livelihood activity. The CHVs in this study requested for enhanced training in the informal sector, in entrepreneurship and best practice in agricultural farming and livestock rearing.
“…We need…training about rearing [livestock] so, that we can know how to keep chicken…and also those drugs that are used when chicken have been affected by any disease and the feeds.” (R7, FGD 9 Kaloleni).
“… Projects…require good management…if it would be possible to help us in bringing leadership training so that we… [are] able to manage those projects that we are even given without difficulty so that we can succeed.” (R1, FGD 2 Rabai).
The KIIs participants also felt that training was important. They suggested that it should accompany the health education training provided for the CHVs to perform their community health activities.
“…if they are taught about health, they should also have trainings teaching how to start their own businesses.” (KII 04).
Additionally, some businesses were not productive because basic training on running core businesses was lacking.
“..Of their dairy cattle… but they are not producing simply because they haven't been held their hands and told this and that should be done.” (KII 03).
Responses from the CHVs pointed to technical or entrepreneurship enhancement that most felt would enable them improve their financial capacity and in this way empower them economically. The hands-on training within the UPG model is designed to provide transferable skills that will enable users to maximise the income-generating asset they are provided [
27]. Provided before and after provision of the assets, beneficiaries are usually able to outpace their peers in per-capita income based on the training they receive [
26]. Additionally, they also benefit from increased access to new labour markets and unlocking access to new job opportunities [
35]. Hands-on training, however, requires significant human resource, more supervision, is time-intensive and requires adaptability to the local context [
26]
36. In resource-poor settings, this can be a huge limitation.
Learning to save one’s income and resources is an integral tool and doing so consistently helps instil a saving culture while expanding ones’ assets. The CHVs in this study expressed desire to save, including a need for education on how to save. The KIIs participants also shared these sentiments.
“…Help us…. save money that can be capital…….so [we] can do something and return with interest…that money can sustain…and the group continues.” (R8, FGD 10 Kaloleni).
“…Give them [CHVs] some allowance….then out of this allowance they will be able to save something and….appreciate…and [be encouraged].” (KII 08).
Building up their savings pool was seen as a way of enhancing economic freedom. The cash would subsequently be ploughed into their businesses to grow their investments. Saving groups were the preferred option as they promote wealth accumulation and boost household resilience [
36]. Additionally, when pooled, the savings may be used for joint business developmental projects just as proposed by the CHVs in this study. Over time however, from the studies that have used the UPG model, this has had negative results with participants saving less towards the end of the intervention [
26]. The likely reason for this is the elastic relationship between increasing income and savings, whereby, possibly as a result of business expansion, borrowing and the need to save decreases [
27].
CHVs are community champions of health yet they had limited access to healthcare services. The financial burden of meeting their own healthcare needs was also enormous. They expressed desire for direct access to healthcare services including tokens for themselves and their family members, thereby enabling them to focus on the healthcare needs of their fellow community members.
“My request is for our hospital, XXX, they should stock the drugs for us because there are those who can go to the chemist and there are those who cannot….Our people suffer… She was taken there… told there is no medicine she has to go and buy, she returned and stayed at home with her illness.” (R4, FGD 2 Rabai).
The CHVs believed that they at the very least deserve access to basic/essential medical services at no additional cost. They were sometimes unable to afford even cheap medications. Some left medical facilities unattended to due to lack of finances. The UPG model recognises health support through two strategies, the first being education and information dissemination, the second being healthcare provision [
27]. However, sustainability is a concern. Physical infrastructure such as water and sanitation facilities, and healthcare infrastructure and resource where limited, impede sustained progress at the household levels particularly where UPG intervention beneficiaries remain vulnerable to macro-level and ecological shocks [
26].
The CHVs in this study emphasised a consistent thread of a need for community engagement, acceptability and identity. CHVs are the social link between communities and the healthcare system. A lack of recognition by and integration into the community is a major challenge at meeting their programme-related duties. The CHVs in this study requested that they get some form of recognition provided by the government or CHV programmes within the community. They also asked for formal introduction to the community leaders and consideration for engagement or inclusion during governance meetings that concern the communities they serve.
“…If we…can be recognized…we can get a badge, t-shirt so when we get in the community they know these are the CHVs,….there are places [where] we are despised,…we go just with our clothes…if you tell them to dig a toilet they tell you go tell the doctor who sent you to come and dig that toilet…but if we have the apparels…they will give us the respect and even our work will continue on well”. (R5, FGD 2 Rabai).
“We would like to have uniform…bags…, then people will respect us, they will say these women are working at the hospital.” (R7, FGD 6, Kaloleni).
On social integration, the KIIs had this to say:
“…If we gave them space in our facility… [then] they can have a central place where they can come and discuss their things with us.” (KII 06).
In this way, they are suggesting some shared space and partnership with the CHVs in form of community embeddedness. This is the final stage of the UPG model by which time, through the model the social capital, social wealth and developments of beneficiaries is believed to have grown through the intervention [
27]. This creates a sense of social prestige [
26]. In our study, the desire for community embeddedness was similar to other studies where CHVs reported that recognition by their communities built social capital for them, strengthening their motivation to continue working and increased their accountability to the communities they served [
3]
38. In addition, self-worth is cultivated among individuals due to improved visibility and empowerment within their communities, providing a sense of control over their livelihoods. Interventions such as the UPG model in this regard has social and economic policy inclusivity implications whereby the economic empowerment it provides gives the poor an opportunity to voice their needs and reduces discrimination [
35].