Background
Community health workers (CHWs) have been defined as lay persons who have received some training to deliver healthcare services but are not professionals [
1]. Broadly, CHWs can be viewed as individuals whose primary role is to extend the reach of the existing mainstream health system [
2] or playing a broader role by serving as cultural mediators or change agents by facilitating grass-roots community engagement to improve health outcomes [
2-
4]. They have been proposed as a means of bridging the gap in the current health systems in many low- and middle-income countries (LMIC) but have also shown promise, particularly with chronic disease management in high-income countries [
5,
6]. Recent studies have shown that when CHWs are well trained and supervised they can positively impact outcomes in maternal and child health:
“CHW’s are most effective when supported by a clinically skilled health workforce, particularly for maternal health, and deployed within the context of an appropriately financed primary health care system. However, CHW’s have also notably proven crucial in settings where the overall primary health care system is weak, particularly in improving child and neonatal health. They also represent a strategic solution to address the growing realization that the shortages of highly skilled health workers will not meet the growing demand of the rural population. As a result, the need to systematically and professionally train lay community members to be part of the health workforce has emerged not simply as a stop-gap measure, but as a core component of primary health care systems in low-resource settings.” [
7].
In the 1970s and 1980s, there was concern about CHW effectiveness due to high-attrition rates, particularly when smaller programmes attempted to go to scale [
7]; however, some long-standing and more recently initiated large-scale programmes have shown promise [
7-
10]. Political will and commitment have been evident in these successful larger scale programmes, each of which has taken a somewhat different approach to training, supervising and remunerating CHWs [
11-
14]. Based on the experiences of some of these countries, it is increasingly being suggested that CHWs be paid and fully integrated into health systems [
7]. Integration suggests clearly delineated responsibilities within the health system, fair remuneration and, in some cases, the possibility of a career path [
7].
Debate on remuneration
While CHW programmes worldwide have taken a variety of approaches to payment, many have operated with relatively low budgets and engaged volunteers. Lack of remuneration has been an often-stated cause of poor retention of CHWs [
3,
8]. While this may be a contributing factor, the desire to give of one’s time is determined by a number of issues. Volunteers in wealthier countries generally have other incomes, such as pensions, spousal income or part-time employment, and find it a meaningful way to occupy their time or make a contribution to society. In lower socio-economic environments – despite low-education levels – building capacity to be able to contribute to one’s community is an important consideration. A recent study in Uganda showed that CHWs while wishing to be remunerated felt that issues such as community recognition and development of new skills and knowledge [
15] outweighed the disadvantage of a lack of funding. Religious beliefs and spirituality seem important in all contexts [
16]. The time one has to volunteer is, however, generally determined by one’s income source. A female farmer in Africa, for example, will have limited time to volunteer compared to a pensioner in a higher income country.
Cherrington et al. [
17] note that there are those who feel that CHWs deserve to be paid and those who argue that receiving a wage is contrary to the very nature of lay advising but that there are legitimate arguments for utilizing both the paid and volunteer models, depending on the context, community needs and programme goals. To avoid the loss of the important characteristics that volunteers bring, it may be necessary to redefine what a “CHW” is, as some take on higher levels of training and a greatly expanded role in existing health systems.
Behavioural economics and remuneration of CHWs
Behavioural economics, which has gained attention in the past decade among economists, psychologists and social scientists, may provide some insights into CHW remuneration, focus and motivation. While not completely rejecting neoclassical economics, behavioural economics does challenge the assumptions on which it is built. Pink [
18] and Dawney and Shah [
19] delineate a number of motivators that may be important and are responsive to “more complex aspects of human nature” than are addressed by neoclassical economics. These include autonomy, mastery, purpose and connectedness (see Table
1). Additionally, research emerging from the Harvard Business School [
20] suggests that behavioural economics, and particularly “altruistic capital”, may have an important role in understanding the motivation of CHWs. Altruistic capital, as defined by this group, means that every individual, in varying degrees, has within them an intrinsic desire to serve others.
Table 1
Motivators: according to behavioural economics theory
Autonomy: acting with choice, does not exclude interdependence with others. The opposite of autonomy is control. Control leads to compliance while autonomy leads to engagement. | Monetary markets: when payments were given in the form of cash, effort seemed to stem from reciprocation and was sensitive to the magnitude of the payment. |
Mastery: the desire to be better and better at something that matters. | Social markets and gifts: when payments were given in the form of gifts or when payments were not mentioned, effort seemed to stem from altruistic motives and was largely insensitive to the magnitude of the payment. |
Purpose and connectedness: those who work in service for a greater purpose than themselves can achieve more than those that do not. | Mixed markets: the mere mention of monetary payment was sufficient to switch the perceived relationship from a social-market relationship to a money-market relationship. |
Heyman and Ariely [
11] draw attention to a distinction between monetary markets and social markets (see Table
1), hypothesizing that “monetary markets are highly sensitive to the magnitude of compensation, whereas social markets are not”. This perspective sheds light on the well-established observation that people sometimes expend more effort in exchange for no payment (a social market) than they expend when they receive payment (a monetary market). They conclude that, “mixed markets (markets that include aspects of both social and monetary markets) more closely resemble monetary than social markets”.
Incentives for health workers have also been proposed as a means of improving health outcomes and have been utilized in a number of settings, with varying degrees of success. When discussing incentives for different cadres of health professionals, Hongoro and McPake [
21] acknowledge the difficulties in designing incentives for health workers that are financially based in that they may undermine the “ethos” of public service that motivates them. Gifts and community recognition are considered to be within the domain of social markets and appear to be important particularly for the motivation of both employed individuals and volunteers, as they are considered to reinforce rather than undermine efforts [
11].
At a time when considerable attention is being paid to how CHWs can be best utilized and integrated into the health system, it seems necessary to try to distinguish between approaches and motivators. The objective of this review is to identify and examine different remuneration models of CHWs that have been utilized in large-scale sustained programmes to gain insight into the effect that remuneration has on the motivation and focus of the CHWs. Five models of CHW remuneration will be considered as described in the “
Methods” section below.
Case descriptions
Methods
In order to classify and examine different remuneration models of CHWs, a MEDLINE search using Ovid SP was conducted between September 2013 and May 2014 and citation searches were also carried out. Search terms included CHWs, remuneration, volunteers, behavioural economics and health, motivation, payment and altruistic capital. An initial 18 review and related articles, books and theses were also identified, and the case studies selected. A further 34 research articles (minimum of 5 per programme) and descriptions of the specific CHW programmes were also identified by citation snowballing from the original journal articles. Selection criteria for including programmes as case studies were those that had been sustained for at least 5 years and had a retention rate of 85% or more – this was taken as an indicator of the sustainability of the programme. A multiple case study approach [
22] was selected rather than a systematic review because of the lack of uniformity in CHW programmes worldwide. All of the programmes selected had broad experience, having trained at least 30 000 CHWs each. Programmes included had a minimum of five relevant publications available for review. A programme was not included if it trained fewer than 30 000 CHWs or was not sustained.
This proposed inquiry aimed to identify all relevant literature pertaining to the remuneration issues of selected CHW programmes. The authors believed that a combination of qualitative, quantitative and mixed methods studies presented more enhanced insights and addressed the research question. Hence, a mixed studies review (MSR) was conducted that allowed a search strategy including diverse designs.
The case studies provided a variety of documented approaches to remuneration including (a) part-time volunteers, working limited hours without regular financial incentives: the Female Community Health Volunteer (FCHV) programme from Nepal; (b) volunteers that sell health merchandise: Bangladesh Rural Advancement Committee (BRAC) Community Health Volunteer (CHV) programme in Bangladesh; (c) volunteers with financial incentives: the Accredited Social Health Activist (ASHA) programme in India; (d) paid full-time CHWs: the CHWs (Behvarzs) in Iran; and (e) both full-time and volunteer CHWs working together: Health Extension Programs (HEPs) in Ethiopia. Not all large-scale CHW programmes have been included due to space limitations. For example, the Brazilian government’s Community Health Agent programme and Pakistan’s Lady Health Worker programme [
10] are examples of well-known and documented paid full-time CHW programmes [
7]. The programme in Iran was selected because it has not received as wide an exposure despite its success. The others that were included are well known but have very distinct approaches to remuneration, which lent themselves to a useful contrast. Similarly, the multiple approaches taken in the developed world/United States context, while of interest, is beyond the scope of this paper [
5,
6].
Each of the case studies addressed three central questions – (a) What is the history and description of the programme? (b) What has been the impact of the programme? and (c) What have been the reported effects of the remuneration model? An initial case study was prepared and compared with the set of questions that were to be answered. Further literature searches were undertaken until the questions were answered or it was evident that the answers had not been published.
Table
2 summarizes the five CHW case studies considered in this paper.
Table 2
Summary of CHW programmes in the case studies
Behavioural Economics Model | Monetary market: paid for full-time work | Monetary market: paid for full-time work | Mixed market: incentives | Mixed market: selling of health commodities | Social market: volunteers |
Working hours | Full time | Full time | Part time | Part time 15–20 h | Part-time 5–10 h per week |
Current number | 31 000 | 38 000 | 820 000 | 80 000 | 48 000 |
Minimum education level | Completed high school | Grade 10 | Grade 8 | Some years of school | Literate if possible |
Ratio | 1:1500 | 1:2500 | 1:1000 | 1:1500 | 1:400 |
Training and supervision | 2 years full time, refresher courses and monthly meetings | 1 year full time | 23 days then attend weekly meeting | Initial 21 days then supervised 2–3 times a month | Initial 15 days then refresher once a month |
Impact | Reduced IMR, MMR, increased life expectancy | Decreased MMR, IMR, increased family planning, clean water, HIV tests | Increased facility-based deliveries, decreased MMR and neonatal mortality | NA | Decreased IMR under-5 mortality and morbidity |
Retention | Required to work for 4 years in government service | 93.5–99% over a 1- to 6-year period | NA | 84–89% | 85% over 5 years |
Advantages | High-retention rates, high-quality service in rural areas | High coverage, allows for extension of health services and community engagement | Increased coverage for specific health interventions | Marginalized women have a chance to earn small incomes and to engage in health | High levels of community good will and support |
Disadvantages | High cost, long training period before starting to work | High cost, long training period before starting to work | Focus on incentivized health interventions | Focus on selling health commodities could distract from health issues | Other commitments may create less time for the field work |
Case studies
Part-time volunteer CHWs without financial incentives: Female Community Health Volunteer programme in Nepal
Volunteers that sell health merchandise: Community Health Volunteer programme in Bangladesh
Volunteers with financial incentives: the Accredited Social Health Activist (ASHA) programme in India
Paid full-time CHWs – Behvarz programme in Iran
Both full-time and part-time volunteer CHWs – Health Extension Worker programme in Ethiopia
Discussion and evaluation
The purpose of this review is to understand broadly five remuneration models utilized by large-scale, well-established CHW training programmes in different parts of the world and to gain insight into their effect on the motivation and focus of the CHWs and how this might impact on government planning of CHW programmes.
Motivation and focus
From the information available in the literature, it appears that – according to behavioural economics theory – CHWs work best within a social or monetary market rather than a mixed market [
11,
18,
20]. A social market is one where volunteering one’s time for the common good, social status and community appreciation are the most important motivators whereas the monetary market is one in which the CHWs are trained and work full time and are remunerated for the hours expected of them. Because of the nature of the work, both groups benefit from a strong sense of service to their community or altruistic capital [
20]. Both full-time and volunteer CHWs can become demotivated if they do not have access to adequate training, quality supervision, community acceptance or appreciation or if they are expected to work longer hours than they can realistically manage while fulfilling their other commitments. Full-time paid CHWs can further lose motivation if their allowances are not provided in a timely fashion.
The use of incentives or low remuneration, which falls into the category of a mixed market according to behavioural economics, such as in the ASHA programme in India, appears to create an environment where intrinsic motivation can be lost, focus is placed on incentives and discontent can occur. Time-consuming means to raise funds such as the sale of commodities can prevent part-time CHWs, who have many other responsibilities, from focusing on health issues. The use of gifts and community appreciation seems to be of value to all CHWs.
Remuneration models can also affect the health problems on which the CHW focuses, which is also important for planners to take into consideration. These case studies showed that the programmes that utilized volunteers or full-time paid CHWs or a combination of the two, successfully achieved community engagement with communities taking ownership for change. When planners are looking for health extenders [
2] to fulfil existing government goals, incentives were effective. For example, when children needed to be mobilized for immunization or mothers escorted to health centres for antenatal visits or delivery, an incentive can be provided to a trained CHW who will help fulfil these goals. If, however, the goal is mixed – community engagement and incentivized health work – the focus of these CHWs is predominantly on areas where incentives exist with little or no time given to community empowerment. Financial incentives can also lend themselves to falsification, and the CHWs can become demotivated and discontent if they feel the funds are inadequate or there is a delay in them reaching the CHW.
Categories
Categories of CHW remuneration differ according to the purpose of the CHW programme, the context in which it operates, commitment by the government and the funds available. Throughout the course of the case studies, it became increasingly evident that defining CHWs as “lay persons who have received some training to deliver healthcare services but are not professionals” [
1] may no longer be adequate to encompass the range of roles being undertaken by this cadre of individuals. All of the programmes had high-retention rates and contributed, albeit in different ways, to improving health outcomes in the communities they were working. However, comparing the work of a Behvarz in Iran who has received 2 years of university-based training and is employed full-time in government service with a FCHV in Nepal who receives 15 days of training and works with the community 5 h per week does not seem useful. Despite the higher level of mastery that the Behvarzs achieved, the role of the FCHVs might be seen as equally important as they demonstrated high levels of community trust that government workers, at least in the Nepalese setting, may have failed to do. Having two broader categories – (1) CHWs that are trained to be part of the formal work force and paid according and (2) CHWs that receive minimal training and offer limited hours according to the context – may be more useful.
Role of the government
Countries that have successfully managed to begin the long process of addressing their rural health needs have done so with high levels of government commitment and through a process of ongoing action, reflection and rethinking at every level. This is particularly evident in Ethiopia and Iran but is also seen in Nepal [
1,
12-
14,
48,
49]. Whether paid or voluntary, the role of being a rural-based CHW is a demanding one, and selecting the right candidate who is community minded, resilient, can withstand challenges in the field and able to solve problems innovatively will be important whether paid or not. Presenting the programme in a way that builds the individual’s altruistic capital may be important for planners to consider. Equally, having a regular flow of funds to the CHWs if remunerated is important to avoid demotivation.
Limitations
It was decided to include only one case study for each type in order to achieve some depth of understanding. This resulted in the loss of what could have been learned if we were able to include more examples. Comparison is difficult due to the diverse nature of the case studies. Even for sustained programmes, it was often difficult to find quality direct impact data on the effectiveness of the CHWs but rather showed improvement in overall health in that country. The challenges in defining a “CHW” have been discussed elsewhere in the paper.
Conclusion
The case studies examined in this paper show that a number of different approaches to CHW training and remuneration can be successful. According to the type of outcomes intended for the CHW, and the context, planners might choose one type of remuneration over another. While the case studies focused on the developing world context, it can equally be applied in wealthier countries. Categorizing according to (1) CHWs that are trained to be part of the formal work force and paid accordingly and (2) CHWs that receive minimal training and offer limited hours according to the context, provides a means by which selection criteria, expectations, remuneration, training, roles and expectations can more easily be delineated without losing the benefits of either approach.
The case studies show that the issue of payment is more complex than might initially appear and can undermine the programme if not thought through well. If payment or incentives are perceived as inadequate or do not flow in a timely fashion, then this can be demotivating to the CHW. Part-time models should not place unrealistic expectations on the CHW’s time or capacity. Maximizing community appreciation and altruistic capital within the programme is also important for planners. Other models will no doubt emerge, and quality research is needed to understand the relationship between remuneration and motivation. Remuneration does not, however, stand alone, and ongoing research will be needed to understand the complex issues of community engagement, CHW appreciation, meaningful supervision and the relationship and need for paid and unpaid human resources in a system that can empower the communities to improve health. Governments and planners have an opportunity to examine the most cost effective and sustainable models that can increase community engagement and thereby reduce the overall healthcare costs.
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http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
DS, RC, JN, MO and CO conceptualized the study and discussed and prepared the methodology. DS wrote the manuscript. MO contributed to contents on economics. DS, RC, JN, MO and CO reviewed and edited the article. All authors approved the final version of the article prior to review.
1. Dr Debra Singh is a Medical doctor living in Jinja, Uganda, and is the National Research and Collaboration Coordinator for the Kimanya-Ngeyo Foundation for Science and Education in Jinja and is a PhD candidate at University of Sydney.
2. Robert Cumming Professor of Epidemiology, and Geriatric Medicine Public Health, School of Public Health. He studied medicine at UNSW and then trained as an epidemiologist at Columbia University in New York and at the University of Sydney. He has worked at the University of Sydney since 1990. He has also spent time at UCSF, the University of Wisconsin and Makerere University in Uganda. Bob is a Life Member of the Australasian Epidemiological Association.
3. Joel Negin is a Senior Lecturer in International Public Health and Director of Research at the School of Public Health at the University of Sydney. His research focuses on health systems, infectious disease and access to care among marginalized groups in low-resource settings.
4. Michael Otim is a NHMRC postdoctoral fellow and recipient of a Poche Fellowship for 2013. He is a health economist with a research interest in priority setting in Aboriginal health and costing of outreach healthcare to Aboriginal communities.
5. Christopher Orach is an Associate Professor and Deputy at the Makerere University School of Public Health in Uganda. He completed his Ph. D. at the Vrije Universiteit Brussel, Belgium. His main research fields are public health in complex emergencies, refugee health services organization and reproductive health.