Background
Human resource management and CHWs
Relationship between management actors and CHWs
Methods
Study design
Study setting
Country | Programme | District |
---|---|---|
DRC | Expanded Programme of Immunization | Bunia district; Ituri region, North East |
Ghana | Expanded Programme of Immunization and Home Management of Malaria | Atiwa district, Eastern region |
Senegal | Programme Sante USAID/Sante Communautaire (PSSCII) | Rufisque, Dakar region |
Uganda | Integrated Community Case Management | Masindi district, Western region |
Zimbabwe | Village Health Worker programme | Mutoko district in Mashonaland, East province |
Data collection
Document review
Key informant interviews
Country | KIIs | FGDs |
---|---|---|
DRC | 7 (3 supervisors; 4 community) | 3 (1 male; 1 female; 1 mixed) |
Ghana | 7 (3 managers; 2 supervisors; 2 community) | 2 (1 male; 1 female) |
Senegal | 5 (1 manager; 2 supervisors; 2 community ) | 2 (1 male; 1 female) |
Uganda | 5 (2 managers; 2 supervisors; 1 community) | 2 (1 male; 1 female) |
Zimbabwe | 7 (3 managers; 3 supervisors; 1 community) | 4 (1 male; 3 female) |
Focus group discussions
Data analysis
Ethics
Results
Who is a CHW?
What does a CHW do?
Provision of healthcare services | Health promotion/distribution of health goods | Community organization |
---|---|---|
• Home-based treatment of illnesses such as malaria, diarrhoea, ARI | • Home visits to promote health | • Encouraging community to undertake specific tasks such as setting up ambulance service, addressing specific health issues, collecting water for the health centre and health facility maintenance/repairs |
• Health education on areas such as HIV/AIDS prevention, nutrition, breastfeeding and hygiene | ||
• Follow up of TB/HIV patients | ||
• Assisting in clinics (weighing, record keeping) | • Providing nutrition/cookery classes | |
• Providing health education in health facilities | • Expanded Programme of Immunisation: defaulter tracing, mobilization of communities | |
• Advocating for community ownership of programmes (for example, support to CHO and CHPS programme in Ghana) | ||
• Collecting data: community register and disease surveillance | ||
• Promoting health insurance scheme | ||
• Attending planned and emergency births | ||
• Representing community at meetings (health committee, development committee) | ||
• Distributing and checking use of bed nets | ||
• Providing antenatal and postnatal care services | ||
• Mass drug administration – distribution, house-to-house visits (annual) | • Linking with other volunteers (for example, working with other NGOs) | |
• Family planning education and contraceptive distribution | ||
• Stimulating demand for and raising awareness of formal health services/referrals | ||
• Referrals for complications in pregnancy, illnesses in under 5s, HIV VCT, burns/injuries |
HRM practices: attraction and retention
CHW expectations | HRM practices | Expectations met | HR outcomes |
---|---|---|---|
Skills and knowledge enhancement
| • Initial and refresher training | • Further improvement wanted: frequency and quality of refresher training | • Most CHWs are female |
• CHWs more likely to be older | |||
• Enhancing skills for main role | • Opportunities for further training | ||
• Shortage of CHWs | |||
• Many candidates apply to be CHW in Zimbabwe | |||
• Enhancing health skills to serve families at home | |||
• Average length of service: 8–10 years | |||
Financial benefits
| • Provision of financial incentives | • Irregular/insufficient per diems and transport reimbursements | • Few CHWs leave |
• Per diems for training and other events | • Younger CHWs are more likely to leave; leave for paid jobs; young women leave when they marry | ||
• Free/reduced fees for healthcare for CHWs and families | |||
• Fixed stipends – per time worked or per activity | • Stipends: inadequate amount; delays in receiving stipends | ||
• Incentives from health campaigns, for example, immunization | |||
• No written guidelines on incentives for CHWs | |||
• Lunch and travel allowance for meeting attendance | |||
CHW role fits with other roles
| • Exemption from communal labour; help with farming | • Use of job description varied: job described in training or CHW has job description or no job description | |
• Manageable with other job | |||
• Use of job description | |||
• Manageable with other responsibilities such as farm work, looking after home and family | • Irregular supervision by health centre supervisors | ||
• Supervision: reporting to supervisors; regular meetings with supervisors; supervisory visits to community | |||
• Supervision does not monitor workload | |||
• Community support for farm work often lacking | |||
Social status and prestige
| • Provision of t-shirts, uniforms, badges, etc. to aid recognition as health worker | • CHWs not always valued in community | |
• Seen as a “Doctor” – community status and respect | • CHWs not always supported/respected by health staff | ||
• Recognition as a health worker | • Recognition by the community; official ceremony when CHWs are recruited | • Lack of incentives such as t-shirts, ID badges, equipment for gardening (formerly provided by NGOs) |
“It is the community which supports us. When we arrived in the community, there are children already prepared by the parents to be vaccinated. This is our conclusion.” (CHW, FGD, female, DRC).“When we send a patient to the health centre for medical care and leaves the centre being cured, it is our great joy and honour in the community. We are happy because God has blessed our work.” (CHW, FGD mixed, female, DRC).
“You wait for long to get that $42 dollars which sometimes comes after 7 months. They make us wait for each other till everyone comes. At one time we had to wait for 3 days. We use our money to get transport to and from Mutoko Centre and to buy food.” (CHW, FGD, female, Zimbabwe).“We were told that when you become a CHW you will get an incentive so I thought it would help me and my family.” (CHW, FGD, male, Zimbabwe).
HRM practices: recruitment and selection
“The challenges we sometimes face is that you just do not find someone who knows how to write and to read. But you end up selecting someone committed to help, but having difficulties to read and to write. I think that is the major challenge.” (KII, community member, male, DRC).“There are challenges when recruiting CHWs. Few people are ready to apply for the work. Young people aged 18–22 years are very difficult to be recruited as they look for paid jobs. There is lack of financial motivation.” (KII, community member, female, Senegal).“The other challenge with these things is political and we don’t want the chairmen to select but they were forcing their way in to select their own people. You find a man selecting a wife and a son, and then you are asking the other community members to select, they select different people and this one would annoy the chairpersons and when this annoyance has continued you find the chairpersons unhappy with the CHWs because his people were left out.” (KII, supervisor, male, Uganda).
HRM practices: performance management
HRM practices that appear to support performance | Gaps in supporting performance |
---|---|
Practices reported across many contexts
|
Gaps reported across many contexts
|
• Initial training: length and topics varied, but some dissatisfaction with length and coverage | • Lack of equipment, drugs and supplies |
• Lack of transport or support for travel | |
• Refresher training; ad hoc, related to programmes or linked to meetings; but some dissatisfaction including lack of allowances and frequency | • Skills not kept up to date e.g. insufficient training for multiple roles |
• Lack of support from community members / community’s unrealistic expectations of what CHWs can do | |
• Job description: job described in training; job description given to CHW | |
• Supervision: send reports to supervisors; regular meetings with supervisors; supervisory visits to community |
Gaps reported in one context
|
• Lack of regulation of CHW practice vs training given (Senegal) | |
Practices reported in one context
| • Irregular supervision by health centre supervisors (Uganda) |
• Annual performance awards nominated by community health officers (Ghana) | |
• No job descriptions (Uganda) | |
• Cash reward for identifying a case of guinea worm (Ghana) | • External evaluators observe immunization and report to health centres but not to CHWs (DRC) |
• Community can sack a volunteer, if he/she does not carry out their duties (Ghana) | |
• Some review workshops to check competencies (Zimbabwe) |
“The way we receive training and respect for us from our authorities, it encourages us to work harder and give out our all for the health of the community.” (CHW, FGD, male, Ghana).“They are in the community and are likely to save these people and give report or warning on any symptoms of TB, or guinea worm case or even treatment compliance issues. These occur more in the community than in the hospitals. When daily treatment is given by visiting the nurses daily, many default. But when volunteers are used to supervise the compliance to treatment by the community, it really works. Volunteerism needs to be sustained.” (KII, manager, Ghana).
“The biggest problem is the drugs. If the supplies can be constant, that is one of the motivations of CHWs by the way. When drugs are there, the community is happy. They even call them doctors.” (KII, manager, female, Uganda).“The challenges include: shortage or complete lack of medicines, and equipment to use. Patients come at night and we do not have drugs and even a torch to help us check them.” (CHW, FGD, female, Uganda).