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Community Health Worker

Commu nity Health Worker Incentive s and Dis incentive s: How Th ey Affect Motivation, Retention, and Sustainab ility
Incentives and Disincentives:
How They Affect Motivation, Retention,
and Sustainability

Contributors
BASIC SUPPORT FOR INSTITUTIONALIZING CHILD SURVIVAL
1600 Wilson Blvd., Suite 300, Arlington, VA 22209 • Tel: 703.312.6800 • Fax: 703.312.6900 Karabi Bhattacharyya Peter Winch
E-mail: infoctr@basics.org • Website: http://www.basics.org
Karen LeBan Marie Tien
Community Health Worker
Incentives and Disincentives:
How They Affect Motivation, Retention, and Sustainability

Karabi Bhattacharyya
Peter Winch
Karen LeBan
Marie Tien
Abstract
This paper examines the experience with using various incentives to motivate and retain community
health workers (CHWs) serving primarily as volunteers in child health and nutrition programs in
developing countries. It makes recommendations for more systematic use of multiple incentives based
on an understanding of the functions of different kinds of incentives and emphasizes the importance of
the relationship between a CHW and community. Case studies from Afghanistan, El Salvador, Honduras,
and Madagascar illustrate effective use of different incentives to retain CHWs and sustain CHW
programs.

Recommended Citation
Karabi Bhattacharyya, Peter Winch, Karen LeBan, and Marie Tien. Community Health Worker Incentives
and Disincentives: How They Affect Motivation, Retention, and Sustainability. Published by the Basic
Support for Institutionalizing Child Survival Project (BASICS II) for the United States Agency for
International Development. Arlington, Virginia, October 2001.

Credit
Cover photo: Johns Hopkins Center for Communications Program (JHU/CCP).

BASICS II
BASICS II is a global child survival project funded by the Office of Population, Health, and Nutrition of the
Bureau for Global Programs, Field Support, and Research of the U.S. Agency for International
Development (USAID). BASICS II is conducted by the Partnership for Child Health Care, Inc., under
contract no. HRN-C-00-99-00007-00. Partners are the Academy for Educational Development, John
Snow, Inc., and Management Sciences for Health. Subcontractors include Emory University, The Johns
Hopkins University, The Manoff Group Inc., the Program for Appropriate Technology in Health, Save the
Children Federation, Inc., and TSL.

This document does not represent the views or opinion of USAID. It may be reproduced
if credit is properly given.

1600 Wilson Boulevard, Suite 300 • Arlington, Virginia 22209 USA


Tel: 703-312-6800 • Fax: 703-312-6900
E-mail address: infoctr@basics.org • Website: www.basics.org
Table of Contents
Acknowledgments .............................................................................................................. v

Acronyms .......................................................................................................................... vii

Executive Summary ........................................................................................................... ix

Section 1
CHWs: The Context ......................................................................................................... 1
Background ................................................................................................................ 1
Attrition in CHW Programs ........................................................................................... 2
Definitions of Key Words .............................................................................................. 2
CHWs and Comprehensive Primary Health Care ........................................................... 3
CHWs in the Context of Health Sector Reform .............................................................. 4
CHWs and Community-IMCI ........................................................................................ 5
Policy Environment and Decentralization ...................................................................... 6

Section 2
Methodology ................................................................................................................... 9
Organization of This Review ........................................................................................ 9
Methodology ............................................................................................................... 9

Section 3
Who are CHWs and What Do They Do? ........................................................................... 11
Characteristics of CHWs ........................................................................................... 11
Duties of CHWs ........................................................................................................ 11

Section 4
Monetary Incentives and Disincentives ........................................................................... 15
Money as an Incentive .............................................................................................. 15
Problems with Using Money as an Incentive ............................................................... 16
In-kind Payments as an Effective “Compromise” ......................................................... 17

Section 5
Nonmonetary Incentives and Disincentives ..................................................................... 19
Supervision or Recognition ........................................................................................ 19
Personal Growth and Development Opportunities ........................................................ 21
Training .................................................................................................................... 21
Peer Support and CHW Networks ............................................................................... 24

Section 6
Relationship with the Community .................................................................................... 25
Enhancing the Relationship Between CHWs and Communities ..................................... 25
Selection of CHWs .................................................................................................... 26
TA BL E OF CO NT EN TS

Community Recognition of CHW Work ........................................................................ 27


Community Organizations that Support CHW Work ..................................................... 29

iii
Section 7
Putting It All Together: Multiple Incentives ....................................................................... 31
Behavioral Model ...................................................................................................... 31
Examples of Multiple Incentives ................................................................................ 31

Section 8
Conclusions and Recommendations ............................................................................... 35
Support the CHW’s Relationship with the Community .................................................. 36
Use Multiple Incentives ............................................................................................. 36
Match Incentives with Duties ..................................................................................... 37
Employees or Volunteers? ......................................................................................... 37
Importance of Monitoring ........................................................................................... 37
Topics for Research .................................................................................................. 38

Section 9
References ................................................................................................................... 39

Annexes
Annex 1: Examples of the Use of Multiple Incentives ...................................................... 43
Annex 2: Questionnaire for E-mail and Initial Interviews .................................................. 49
Annex 3: Interview Guide for BASICS Examples ............................................................ 51

Tables
Table 1. Alternative Titles for CHWs ............................................................................... 2
Table 2. Comparison of CHWs with Professional Health Staff ........................................... 3
Table 3. Roles of CHWs in the Implementation of the Three Elements of the
HH/C IMCI Framework ...................................................................................... 7
Table 4. Motivation Model ............................................................................................ 32
Table 5. CHW Incentives and Disincentives Organized by a Systems Approach .............. 33
TA BL E OF CO NT EN TS

iv
Acknowledgments

T
he authors would like to acknowledge the following people who made comments on the
various drafts of the paper: Renata Seidel, Mark Rasmuson, Rene Salgado, Marilyn Rice,
Paul Ickx, Lisa Sherburne, Stephan Solat, Judianne McNulty, William Brieger, Eric
Swedberg, Peter Gottert, and Michael Favin. Adwoa Steel, Marcia Griffiths, Tina Sanghvi, and
Alfonso Contreras were interviewed for some of the examples. Paul Ickx drafted the example from
Afghanistan. The authors also thank Wendy Hammond and Kathleen Shears for editing the paper
and Kathy Strauss for layout and design.

ACK NOWLE DGME NTS

v
Acronyms
ADRA Adventist Development and Relief Agency

AHSSP Afghanistan Health Sector Support Project

AIN Atención Integral a la Niñez

ARI acute respiratory infection

BHT bridge to health team

BHW barangay health worker (Philippines) or basic health worker (Afghanistan)

CARE Cooperative for Assistance and Relief Everywhere

CHA community health agent

CHC community health center

CHP community health promoter

CHVW community health volunteer worker

CHW community health worker

CRS Catholic Relief Services

DHO district health office

HA health agent

HAC health action committees

HC health center

HH/C household and community

IMCI Integrated Management of Childhood Illness

MOH Ministry of Health

NGO nongovernmental organization

ORS oral rehydration solution

TBA traditional birth attendant

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

VHC village health committee

VHW village health worker


ACRO NYMS

vii
Executive Summary

O
ver the past couple decades, a on experience. Indeed, the very effectiveness
number of studies have shown that of CHW work usually depends on retention.
community health workers (CHWs) This paper examines experience with
can help reduce morbidity and mortality in various incentives for CHWs and their impact
certain settings. Health programs have on retention of CHWs and the sustainability of
recruited and trained these primarily volunteer CHW programs. It reviews the types of
workers to carry out a variety of health incentives that are needed to motivate
promotion, case management, and service involvement, to retain CHWs once they have
delivery activities at the community level. been trained, and to sustain their performance
CHWs can serve as a bridge between at acceptable levels. Although there are
professional health staff and the community important lessons to learn from other
and help communities identify and address community-based development workers, this
their own health needs. They can provide paper focuses primarily on community-based
information to health system managers that workers who provide some type of health or
may otherwise never reach them and can nutrition service.
encourage those in the health system to
understand and respond to community needs. Organization of the Paper
CHWs can help mobilize community The paper is organized into the following
resources, act as advocates for the sections. Section 1 discusses the context of
community, and build local capacity. CHW programs, including the changes
The overall environment of international brought on by health sector reform and the
public health has changed dramatically with IMCI approach. Section 2 describes the
health sector reform and decentralization. objectives and methodology of the review.
Local governments have greater autonomy Section 3 reviews the typical characteristics
and authority to develop and finance health of CHWs and provides an overview of the
solutions appropriate to their locales. In child wide range of their functions. Section 4 looks
survival programs, the Integrated at the various ways that cash can be both an
Management of Childhood Illness (IMCI) incentive and a disincentive and reviews in-
approach is changing the way sick children kind incentives. Section 5 discusses some of
are managed and health facilities are the other program features that can motivate
organized. As these dramatic changes in the CHWs to continue their work, including their
public health context create new opportunities relationship to other health staff, their sense
for programs that include community health of personal growth and accomplishment,
workers, this is a critical time to review the training opportunities, and peer support.
past experience and draw lessons for the Section 6 examines the critical relationship
future. between CHWs and their communities.
One of the most critical problems for Section 7 reviews how the use of multiple
CHW programs is the high rate of attrition. incentives can contribute to CHW retention,
Attrition rates are reported between 3.2 and Section 8 contains conclusions and
EX EC UT IV E SU MM AR Y

percent and 77 percent. Higher rates are recommendations.


generally associated with volunteers. Such
high attrition rates lead to a lack of continuity Conclusions
in the relationship between a CHW and Perhaps the most important conclusion of this
community, increased costs in selecting and review is that there is no tidy package of three
training CHWs, and lost opportunities to build incentives that will ensure motivated CHWs

ix
who will continue to work for years. Rather, a transportation to go to all the households.
complex set of factors affects CHW Many CHWs are restricted to preventive and
motivation and attrition, and how these factors promotive roles that leave them unable to
play out varies considerably from place to respond to community demands for curative
place. However, program planners can draw care (and usually medicines).
on the extensive experience of the public Monetary incentives can increase
health community with CHW programs. A retention. CHWs are poor people trying to
summary of the main conclusions of the support their families. But monetary
review follows. incentives often bring a host of problems
CHWs do not exist in a vacuum. They because the money may not be enough, may
are part of and are influenced by the larger not be paid regularly, or may stop altogether.
cultural and political environment in which Monetary incentives may also cause
they work. The process of health sector problems among different cadres of
reform, the adoption of the IMCI strategy, development workers who are paid and not
and the progress made by community-based paid. However, there are some success
nutrition programs have generated renewed stories of programs paying CHWs. Many
interest in the potential contribution of CHWs. programs have used in-kind incentives
Health sector reform has changed the effectively.
supervisory structure within health systems Non-monetary incentives are critical to
and given more autonomy to peripheral the success of any CHW program. CHWs
health facilities. It has also decentralized the need to feel that they are a part of the health
control of health funds, allowing greater system through supportive supervision and
flexibility in spending for various types of appropriate training. Relatively small things,
CHW incentives. The IMCI strategy includes such as an identification badge, can provide a
a training curriculum on assessing and sense of pride in their work and increased
treating mild and moderate childhood status in their communities. Appropriate job
illnesses. Such training allows CHWs to play aides such as counseling cards and regular
a curative role, which is usually what replenishment of supplies can help ensure
communities demand. Policies on CHW that CHWs feel competent to do their jobs.
distribution of antimicrobials and Peer support can come in many forms, such
antimalarials can have tremendous effects as working regularly with one or two other
on their relationship with the community. CHWs, frequent refresher training, or even
The motivation and retention of CHWs is CHW associations.
influenced by who they are in the community In the end, the effectiveness of a CHW
context. The inherent characteristics of comes down to his or her relationship with the
CHWs, such as their age, gender, ethnicity, community. Programs must do everything
and even economic status, will affect how they can to strengthen and support this
they are perceived by community members relationship. First, program planners must
and their ability to work effectively. recognize the social complexity of
At the micro level, the specific tasks and communities and that communities are not all
duties of CHWs affect their motivation and alike. Different communities will need
retention. When given too many tasks, CHWs different types of incentives, depending on the
EX EC UT IV E SU MM AR Y

feel overwhelmed with information or may other job opportunities available, prior
spend so much time in training that they experience with CHWs, the economic
rarely practice what they have learned. Often situation of the community, and other factors.
the catchment areas they cover are too large Unfortunately, very little experience or
with too many households, making it difficult guidance is available on how best to
for a CHW to spend the time or find the differentiate communities. It is important to

x
CHW Incentives and Disincentives Organized by a Systems Approach

Incentives Disincentives
Monetary factors ■ Satisfactory remuneration/ ■ Inconsistent remuneration
that motivate Material Incentives/Financial ■ Change in tangible incentives
individual CHWs Incentives ■ Inequitable distribution of
■ Possibility of future paid incentives among different
employment types of community workers

Nonmonetary factors ■ Community recognition and ■ Person not from community


that motivate respect of CHW work ■ Inadequate refresher training
individual CHWs ■ Acquisition of valued skills ■ Inadequate supervision
■ Personal growth and ■ Excessive demands/time
development constraints
■ Accomplishment ■ Lack of respect from health
■ Peer support facility staff
■ CHW associations
■ Identification (badge, shirt)
and job aids
■ Status within community
■ Preferential treatment
■ Flexible and minimal hours
clear role

Community-level ■ Community involvement in ■ Inappropriate selection of


factors that motivate CHW selection CHWs
individual CHWs ■ Community organizations ■ Lack of community
that support CHW work involvement in CHW
■ Community involvement in selection, training,
CHW training and support
■ Community information
systems

Factors that motivate ■ Witnessing visible changes ■ Unclear role and


communities to ■ Contribution to community expectations (preventive
support and sustain empowerment versus curative care)
CHWs ■ CHW associations ■ Inappropriate CHW behavior
■ Successful referrals to ■ Needs of the community not
health facilities taken into account

Factors that motivate ■ Policies/legislation that ■ Inadequate staff and


MOH staff to support support CHWs supplies
and sustain CHWs ■ Witnessing visible changes
■ Funding for supervisory
activities from government
and/or community

involve communities in all aspects of the interactions with all community members and
EX EC UT IV E SU MM AR Y

CHW program but especially in establishing in how to respond to difficult people or


criteria for CHWs and making the final situations. Community-based organizations,
selection. Programs can provide opportunities such as religious groups or youth clubs, can
for quick visible results that will promote provide support to CHWs and significantly
community recognition of CHWs’ work. CHWs lessen their load by taking on health
must be trained in appropriate and respectful education activities.

xi
Many successful programs use multiple systems approach that helps an implementer
incentives over time to keep CHWs consider what can be done to support a CHW
motivated. A systematic effort that plans for at different levels of the system.
multiple incentives over time can build up a
CHW’s continuing sense of satisfaction and Vary the incentives based on CHW duties.
fulfillment. CHWs continue to play an important role in
many international primary health care
Recommendations programs. While continuing their preventive
Support the CHW’s relationship with the and community mobilization tasks, CHWs are
community. increasingly becoming involved in community-
The fact that the effectiveness of the work of based case management of prevalent
the CHW depends almost entirely on his or childhood diseases. The Community-IMCI
her relationship with the community is framework lays out three elements of
surprisingly often overlooked. Many programs implementation and describes different types
focus on clinical training, supervisory of communities where those elements are
checklists, and logistics (all of which are appropriate. The role of CHWs, and
extremely important), to the exclusion of consequently their incentives, will vary among
activities that support the community the elements.
relationship. Effective programs have
(explicitly or implicitly) oriented the whole Are CHWs volunteers or employees?
program to support and strengthen every In general CHWs are not paid salaries
interaction that a CHW has with community because the MOH or donors do not consider
members. Many examples of such efforts are salaries to be sustainable. Yet CHWs are often
given throughout the paper, from public held accountable and supervised as if they
recognition of CHW work by supervisors to job were employees. CHW programs must
aides that support the ongoing dialogue recognize that CHWs are volunteers, even if
between community members and CHWs. they receive small monetary or nonmonetary
Programs must continually ask what can be incentives. They are volunteering their time to
done to promote beneficial interactions. serve the community.

Use multiple incentives. Continue to understand your program.


In most of the programs reviewed, incentives Many programs do not understand why their
were implemented in an ad-hoc manner rather CHWs drop out. Programs would be well
than as part of a systematic program. It would served by monitoring some of the most
be useful to identify the functions of each of important factors that affect a CHW’s
the incentives used to understand which are motivation and desire to stay on the job.
the critical functions and how those might vary Program managers must stay abreast of the
based on the CHW role and type of community. “competition”: what other jobs and
Intrinsic incentives work to promote a sense opportunities are available for the CHWs?
that the work is worthwhile, while extrinsic When new tasks or functions are added,
incentives include salary and increased status programs should assess how CHWs are
within the community and with colleagues. It is managing the increased workload. How do
EX EC UT IV E SU MM AR Y

clear that both intrinsic and extrinsic incentives community members and the CHW interact?
should be implemented and monitored. The What demands are community members
table on page xi shows a list of CHW making on the CHWs? How do their
incentives, including key disincentives supervisors and other staff in the health
mentioned in the literature and through system treat CHWs? Do the CHWs have the
personal communi-cations, organized into a training and job aides they need to be

xii
effective and feel competent in their jobs? realistic attrition rates? What is the most
What monetary or nonmonetary incentives efficient way to monitor CHW programs? What
would increase their motivation and support are successful ways of reducing attrition and
their work? increasing retention of CHWs? What are some
financing strategies to pay CHWs in a regular
More research is needed. and sustainable manner? What are the critical
The question of how to sustain a long-term functions that are achieved by different
CHW program and to retain workers requires incentives? What are the most important
additional investigation. It is unfortunate that differences among communities that affect
despite the vast experience with CHWs, CHW programs, and what is the best way to
relatively little scientific evidence is available assess these differences? How can planners
to answer some of the basic questions: What efficiently tailor their programs to meet local
are the current attrition rates? What are needs?

EX EC UT IV E SU MM AR Y

xiii
Section 1

CHWs: The Context

C ommunity health workers (CHWs) are not a new concept. Health


programs have recruited and trained CHWs to carry out a variety
of health promotion, case management, and service delivery activities
at the community level for several decades. CHWs can serve as a
bridge between professional health staff and the community and help
communities identify and address their own health needs. They can
provide health system managers with information that may otherwise
never reach them and can encourage those in the health system to
understand and respond to community needs. CHWs can help
mobilize community resources, act as advocates for the community,
and build local capacity (Center for Policy Alternatives 1998).

Background paradigm shift in the management of sick


Yet for many public health practitioners, children and organization of health facilities.
especially donor agencies, CHWs are a failed And with the advent of the community
concept. Both the effectiveness of CHWs as component of IMCI, CHWs have been sought
change agents and the feasibility of out as effective community agents with a role
implementing and sustaining large-scale CHW to play in the prevention of disease, the
programs have been called into question. promotion of healthy behaviors, and, in some
After being touted earlier as a key component places, the case management of sick
of the strategy of Health for All by the Year children.
2000, CHW programs have frequently failed to These dramatic changes in the public
live up to the expectations of a dynamic health context have created new opportunities
grassroots movement. for CHW programs. Now is a critical time to
Despite this perception, CHW programs review past experience and draw lessons for
are worth reviewing. Over the past two the future. Although there may be important
decades, a number of studies have shown lessons to learn from other community-based
that CHWs can help reduce morbidity and development workers, this paper focuses on
mortality in certain settings. The overall community-based workers who provide some
environment of international public health has type of health or nutrition service.
changed dramatically with health sector CHW programs face many problems,
C HW S: T HE CO NT EX T

reform and decentralization, giving local including poor training, inadequate supervision,
governments greater autonomy and authority lack of supplies, and poor relationships with
to develop and finance health solutions communities. One of the most frustrating
appropriate to their locales. In child survival elements of many CHW programs is their high
programs, the Integrated Management of attrition rate. This paper examines recent
Childhood Illness approach has created a experiences with CHW programs to determine

1
the factors that contribute to high motivation Walt (1998) provides the following
and low attrition of CHWs. Identifying these common definition of CHWs as:
incentives will help program planners develop
sustainable CHW programs. ... generally local inhabitants given a
limited amount of training to provide
Attrition in CHW Programs specific basic health and nutrition
Attrition rates for CHWs of 3.2 percent to 77 services to the mothers of their
percent are reported in the literature, with surrounding communities. They are
higher rates generally associated with expected to remain in their home
volunteers (Walt 1989). One review (Parlato village or neighborhood and usually
and Favin 1982) found attrition rates of 30 only work part-time as health workers.
percent over nine months in Senegal and 50 They may be volunteers or receive a
percent over two years in Nigeria. CHWs who salary. They are generally not,
depend on community financing have twice however, civil servants or professional
the attrition rate as those who receive a employees of Ministry of Health.
government salary. In the Solomon Islands,
attrition was attributed to multiple causes in
addition to inadequate pay, including family
Table 1. Alternative Titles for CHWs
reasons, lack of community support, and
upgrading of health posts (Chevalier 1993). Title Country
High attrition rates cause several
Activista Mozambique
problems. Frequent turnover of CHWs
Anganwadi India
means a lack of continuity in the
Animatrice Haiti
relationships established among a CHW,
Barangay health worker Philippines
community, and health system.
Basic health worker India
Considerable investment is made in each
Brigadista Nicaragua
CHW, and program costs for identifying, Colaborador voluntario Guatemala
screening, selecting, and training the CHW Community health agent Ethiopia
rise with high attrition rates. When CHWs Community
leave their posts, the opportunity is lost to health promoter Zambia
build on their experience and further develop Community
their skills over time through refresher health representative various countries
training. The very effectiveness of CHW Community
work usually depends on retention. health volunteer Malawi
Community
nutrition worker India
Definitions of Key Words
Community
Community Health Workers resource person Uganda
Since the role of the CHW was re-emphasized Female multipurpose
during the Alma Ata conference in 1978, there health worker Nepal
have been several variations and definitions of Health promoter various countries
this term. The specific roles and Kader Indonesia
responsibilities of CHWs vary greatly among Monitora Honduras
C HW S: T HE CO NT EX T

countries, depending on people’s access to Outreach educator various countries


health care and the presence of other cadres of Promotora Honduras
health workers. Table 1 shows the vast array of Rural health motivator Swaziland
titles used for CHWs. In this report the term Sevika Nepal
CHW refers to all of these titles, with the local Village health helper Kenya
titles used to refer to specific examples. Village health worker various countries

2
Section 1

A distinction should be made between Motivation: Desire to serve and perform


CHWs and other professional health staff to effectively as a CHW
explain the unique role and background of
CHWs. Table 2 presents an example from Retention: Length of time that an
Latin America comparing two groups of health individual CHW actively
workers—professional and volunteer. This performs appropriate
comparison applies in most other countries community primary health
and regions. care tasks
Many definitions of CHWs also reflect
expectations of their roles. For example, Sustainability: A continuing system of
“…members of the communities where they recruitment, training, and
work; should be selected by the communities; supervision of a cadre of
should be answerable to the communities for volunteers in a community or
their activities; should be supported by the district that meets its member
health system but not necessarily part of its or group health care needs
organization; and have a shorter training
[period] than professional workers” (Frankel CHWs and Comprehensive
1992). CHWs usually provide services to Primary Health Care
people living in specific catchment areas, During the Alma Ata conference in 1978,
most often the areas where they themselves CHWs were identified as one of the
live. cornerstones of comprehensive primary health
care. CHWs had the potential to deliver
Other Definitions equitable health services to populations living
The following definitions and assumptions for in remote areas and to help fill the unmet
the key concepts of CHW incentives, demand for regular health services in many
motivation, retention, and sustainability are countries. Such workers could solve the
used throughout the paper. problems of poor access to health care and the
high cost of doctors and reduce the social and
Incentives: Positive or negative, intrinsic cultural barriers to health care. While providing
or extrinsic factors simple technical and educational interventions,
influencing CHW motivation CHWs could also serve as an entry point into
and volunteerism (Note: this the larger cultural, environmental, political, and
paper focuses on incentives social factors that affect health. They could be
that can be addressed agents of change stimulating community
programmatically.) participation in efforts to resolve the causal

Table 2. Comparison of CHWs with Professional Health Staff

Auxiliary nurses or health technicians Health promoters or village health


(professional health staff) workers (volunteers from the community)
■ Primary education plus 1–2 years ■ Third grade education plus 1–6
of training months of training
C HW S: T HE CO NT EX T

■ From outside the community ■ From the community


■ Employed full time ■ Employed part time
■ Salary usually paid by the program ■ Supported by farm labor or other
(not by the community) community help
■ May be traditional healers

Source: Walt 1988

3
factors of illness (Frankel 1992). In other homes, compared to a reduction of only 15
words, CHWs were thought to be the magic percent when it was available only through
bullets of primary health care. pharmacists (Parlato and Favin 1982). In Nepal,
After Alma Ata many countries initiated where CHWs were provided with antibiotics and
programs to scale up local CHW initiatives to training in the diagnosis of pneumonia, an
the national level. By the early 1990s, evaluation found that the case management by
however, enthusiasm for CHWs was waning CHWs was correct in 80 percent of cases
among ministries of health and donor (Dawson et al. 2001). A study in Ecuador found
organizations for a variety of reasons. that CHWs were much more cost effective than
hospital-based workers in vaccinating children
■ Countries could not replicate CHW (San Sebastian et al. 2001). Among populations
programs and take them to scale while with limited access to basic health care, CHWs
maintaining the original levels of altruism, can facilitate referrals. There is growing
commitment, and effectiveness. evidence that CHW programs are an appropriate
■ The barefoot doctor movement in China, way to address concerns about equity among
which was for many the model for scaling underserved populations, as well as to increase
up CHW programs, declined in both the effectiveness of programs. Two impact
coverage and effectiveness in the wake studies carried out in Colombia suggest that
of economic reform and conversion of smaller-scale programs (within a neighborhood,
much of the health sector to the fee-for- municipality, district, or ethnic community)
service model. developed through community participation are
■ Attempts to create a global (one-size-fits- more effective in changing health-related
all) approach to CHW programs led to practices than larger programs (Quinones 1999).
inflexible programs and approaches. Along with other community resource people,
■ Use of the mass media and social CHWs can be critical to the promotion of key
marketing seemed to be more cost preventive and treatment behaviors.
effective than CHWs in promoting While CHWs may not be appropriate in all
changes in health-related behaviors at the settings, they cannot be dismissed as a
national level. programmatic option. Mass media and social
■ Attempts were initiated to upgrade the skills marketing approaches cannot by themselves
of existing community-level health care provide the depth of interaction necessary to
providers (pharmacists, private physicians, change complex health behaviors. For example,
traditional healers) rather than to create new the media may promote eating foods rich in
cadres of health workers who might cease vitamin A, but CHWs can work with individual
activities once funds run out. families to develop acceptable recipes and use
■ The use of CHWs as agents for specific locally available foods. Similarly, approaches
vertical programs, such as for diarrhea that rely exclusively on the private sector may
and malaria, diminished the advantages have limited impact where commercial outlets
of the holistic approach and often led to are rare. Healthy behaviors need to be
multiple training with less time on the job. negotiated continually so that families can apply
them to their own situations. CHWs can be a
Despite these limitations, there is evidence practical and effective way to do this in many,
C HW S: T HE CO NT EX T

that CHWs can reduce morbidity and mortality though not all, situations.
under certain conditions and therefore provide
outreach and services that governments may CHWs in the Context of
not otherwise be able to deliver. In Egypt infant Health Sector Reform
mortality was reduced by 40 percent when oral Most countries in Africa and much of the rest
rehydration solution (ORS) was distributed to of the world are undergoing health sector

4
reform that involves the reorganization of the Governments that have devolved local
entire health sector. Health sector reform decision making and authority to districts,
usually includes decentralization, the municipalities, and villages seem to be
introduction of fees for a variety of health successful in applying general government
services, integrated health care packages, guidance flexibly to meet their local health
and donor coordination. needs. Appropriate legislation and policies can
The focus on health sector reform and help CHWs organize and retain members and
decentralization has led to a renewed maintain a CHW system over time. Two
emphasis on ways to extend coverage to examples are discussed on page 6.
underserved areas as well as to increase local
involvement in decision making regarding CHWs and Community IMCI
health service delivery. The problems faced by In 1995 WHO and UNICEF launched the
health systems are illustrated in a recent study Integrated Management of Childhood Illness
of health services in Burkina Faso (Bodart et strategy. IMCI is an integrated approach to the
al. 2001). The study documents a steady assessment, classification, and treatment of
decline in the use of curative services, a sick children that combines aspects of nutrition,
strong urban bias in public spending on health, immunization, disease prevention, and
and high cost of care to patients. Policymakers promotion of growth and development. The
are concerned about how to address these and strategy addresses the illnesses and health
other issues to improve access to health care problems responsible for the majority of deaths
among underserved populations. Health sector among children under five years of age and the
reform, including decentralization of civil and fact that children are often ill from multiple
health systems, provides a new opportunity to causes. IMCI ensures that a child who is
revitalize CHW programs and develop local brought into a health center for diarrhea will also
solutions to CHW incentives. be treated for malaria or pneumonia if needed.
The role and tasks of CHWs vary by Until recently IMCI focused on improving
district and community, and the type of health systems (including drug availability) and
incentives needed to support the CHWs in the skills of health workers to assess, classify,
these tasks need to be locally specific as and treat children accurately. In 1997 the
well. As part of the movement to decentralize household and community (HH/C) component
health services, ministries of health and donor of IMCI was launched (Lambrechts et al. 1999).
organizations are turning increasingly to A framework has been defined for planning and
nongovernmental organizations (NGOs)1 as implementing Community IMCI (Steinwand
natural partners for extending coverage and 2001; Winch et al. 2001) that includes the three
scaling up interventions. CHWs frequently following elements:
play a key role in the operations of NGOs at
the village and district levels. 1. Improving partnerships between health
Because programs funded by facilities and services and the
governments can often change or disappear communities they serve
from one administration to the next, many 2. Increasing appropriate and accessible
large-scale government CHW payment care and information from community-
programs have not been sustained in the long based providers
C HW S: T HE CO NT EX T

term (Frankel 1992). The decentralized 3. Integrating promotion of key family


framework provides new opportunities for the practices critical for child health and
support and motivation of CHWs. nutrition

1. In this document NGO refers to U.S.-based private voluntary organizations and their international and local
nongovernmental partners.

5
The three elements are to be implemen- CHW programs. Two examples of such
ted by working across many sectors (a restructuring are described below.
“multisectoral platform”) in order to address In 1995 the Philippine government enacted
the social, economic, and environmental the Barangay Health Workers Act of 1995,
factors that facilitate or hinder the adoption of which granted benefits and incentives to
key family practices. Each of these elements accredited barangay health workers (BHWs).
addresses a point of influence critical to The act included such provisions as
appropriate child health care. At each point of subsistence allowance, career enrichment
influence, CHWs are often involved in programs, recognition of years of primary health
delivering services and messages and in care, special training programs, and preferential
mobilizing the community (Table 3). access to loans. Experience from a pilot
The role of a CHW varies with the strategy advocacy campaign showed that with adequate
chosen to implement each element that is information and motivation, local government
appropriate for a specific setting. Clearly, units were willing to provide financial and
however, CHWs of some sort are critical to the logistical support, including a transportation
success of Community IMCI. Implementation of allowance and budget for regular upgrade
the community component of IMCI requires a training, as well as formal recognition of the
cadre of workers to deliver needed services to roles of BHWs. BHWs have now organized
peripheral areas, promote child wellness and themselves at the barangay level and in many
good nutritional status, prevent child illness, and areas are federated at the municipal and
link communities with health facilities that may provincial levels and are becoming a significant
be underutilized. Although private practitioners political force for child survival (Paison 1999).
of some kind may be available even in remote A program in Ceara, Brazil, found that a
areas, the fee-for-service approach does not decentralized approach using paid health agents
lend itself to preventive services or to nutrition- (HAs) could improve access to health care. The
related interventions. Organizations such as the HAs had to have lived in the community for the
Pan American Health Organization (PAHO) are previous five years. They also had to be over
therefore promoting CHWs as the entry point for 18, able to work eight hours a day, and
the implementation of Community IMCI. committed to social service. Each HA visits 75
households (225 in urban areas) once a month
Policy Environment and to provide health education and minor curative
Decentralization treatment. Nurses from the nearest clinic
The overall health policy environment can supervise them. The agents earn the equivalent
dramatically affect CHW programs. In Indonesia of US $112 a month (twice the average local
the kader system survived on the tradition of monthly income), which is paid out of tax funds
volunteerism and the support of the PKK, a from the state government to insulate the HAs
national organization of the wives of political from local politics. To ensure local support for
leaders (Favin 2001). In Mozambique the HAs, municipal governments must use
community members who had been happy to some of the newly decentralized funds to
volunteer under socialism are now demanding employ the nurse supervisors before the state
cash incentives with the move toward funds can be released. The results have been a
capitalism (Favin 2001). Policies often determine well-trained cadre of health workers and
C HW S: T HE CO NT EX T

who is eligible to become a CHW and whether dramatic improvements in child health, with an
the CHWs can administer antibiotics or receive infant mortality reduction of 32 percent.
cash incentives. With health sector reform, Unfortunately, attrition rates are not reported
some ministries of health are restructuring their (Svitone et al. 2000).

6
Table 3. Roles of CHWs in the Implementation of the Three Elements of
the HH/C IMCI Framework

Element CHW role


1. Improving partnerships between health ■ Help health facilities conduct community
facilities or services and the communities outreach.
they serve ■ Involve community members in planning and
implementing health programs and services.
■ Raise awareness in the community about
improvements to health services.
■ Educate community members about danger
signs requiring care at health facilities.
■ Participate in data collection for community
health information systems.
2. Increasing appropriate, accessible care and ■ Provide effective basic care (e.g., oral
information from community-based rehydration therapy, antipyretic drugs) for
providers sick children.
■ In some areas, treat sick children with other
first-line drugs, such as chloroquine and
cotrimoxazole, and advocate against harmful
practices, such as injections.
■ Refer sick children to appropriate health
facilities when advanced care is required.
■ Serve as a bridge to other providers (private
sector and traditional healers).
3. Integrating promotion of key family practices ■ Engage communities in selecting behaviors
critical for child health and nutrition to be promoted and identifying actions to be
taken.
■ Promote key family practices for enhanced
physical growth and mental development,
prevention of disease, appropriate home
care, and appropriate care-seeking behavior
through individual counseling and
community meetings.

C HW S: T HE CO NT EX T

7
Section 2

Methodology

T he renewed interest in CHWs described on pages 5-6 is leading


policymakers and program managers to examine critically past
experience with CHW programs. In light of all the problems brought
by high attrition, managers are asking what types of incentives are
needed to motivate involvement of CHWs, retain them once they have
been trained, and sustain their performance at acceptable levels. This
review examines experience with various incentives for CHWs and
their impact on the retention of CHWs and the sustainability of CHW
programs.

Organization of This Review Group in the fall of 1999. BASICS and NGO
Section 3 of this paper reviews the typical staff had observed that minimal tokens of
characteristics of CHWs. Section 4 provides recognition could make a world of difference
an overview of the wide range of their in enhancing community participation and
functions. Section 5 looks at the various ways increasing volunteer retention. By looking
cash can serve as both an incentive and a more closely at incentives, BASICS II hoped
disincentive and reviews the use of in-kind to learn how they affect the motivation,
payments. Section 6 discusses other program retention, and sustainability of CHWs.
features that can motivate CHWs to continue This paper is based on a review of the
their work, including relationships with other literature and interviews with program staff
health staff, sense of personal growth and from many organizations. A literature search
accomplishment, training opportunities, and was conducted using the Internet databases
peer support. Section 7 examines the critical PubMed, Medline, and Popline. The key words
relationship between the CHW and the motivation, incentives, sustainability, CHWs,
community. Finally, Section 8 reviews the volunteers, and developing countries were
contribution of the overall policy environment used in different combinations during the
and the mix of incentives that can contribute search. Several books and articles
to CHW retention. recommended by practitioners working with
CHWs were also used for the paper. Since
Methodology much of the information on CHWs is in the
A review of incentives for CHWs was unpublished (“gray”) literature, this literature
identified as a priority at a meeting between was identified through personal contacts and
the staff of the Basic Support for through a request for information that included
Institutionalizing Child Survival II (BASICS II) a questionnaire sent to the CORE Child
Project and the Child Survival Collaboration Survival Community Group list serve and the
and Resources Group (CORE)2 IMCI Working MSH Community Health list serve. The
MET HODOL OGY

2. A network of more than 35 U.S. NGOs working together to improve primary health care programs for women and children and the
communities in which they live.

9
questionnaire generated over 30 responses. in Annex 1 and focused on specific examples
Some of these responses led to further and experiences from work with CHWs.
interviews with over a dozen practitioners. A draft of this paper was circulated to all
Two broad categories of literature were BASICS II technical field and headquarters
identified and reviewed. The first category staff and through the CORE list serve in
included papers reviewing the history and August 2000 to solicit additional information
experience of CHW programs, and the second and comments. Further interviews were
category included specific examples from conducted with project staff to elicit the
programs working with CHWs. One of the key BASICS experience with CHWs.
documents used in this paper is the 1982 Semistructured interviews were conducted
paper Progress and Problems: An Analysis of with staff in the Ecuador, El Salvador,
52 AID-assisted Projects, by Parlato and Honduras, Madagascar, Nigeria, and Zambia
Favin. Although almost 20 years old, this programs. The interview guide in Annex 2
paper is unique in systematically reviewing covers a wide range of topics, including the
the experience of a wide range of primary selection of CHWs, support from the health
health care programs. The authors provide system, training opportunities, and monetary
important details about the work of CHWs in and nonmonetary incentives. On the basis of
these programs, although they include little these comments and additional experiences,
information about incentives. substantial revisions were undertaken and the
Initial group and private interviews were final paper completed.
conducted with BASICS II staff, NGO staff The literature review and interviews
active in child survival programs, academics, focused primarily on CHWs working in child
and current and former staff from programs health, rather than other types of development
funded by the United States Agency for workers, such as family planning workers,
International Development (USAID). These traditional birth attendants, or agricultural
interviews were based on the interview guide outreach workers.
MET HODOL OGY

10
Section 3

Who Are CHWs and What


Do They Do?

L ong before considering money, t-shirts, or other external


incentives, programs must decide whom to select as CHWs.
The characteristics of the CHWs are usually far more important for
their ability to function effectively than their external incentives.

Characteristics of CHWs CHWs, 23 percent women, and 37 percent


No prescription for the ideal CHW exists, but both men and women. Many programs require
programs must understand the role and that CHWs be literate (primary school
status of the people who work as CHWs in educated) so that they can record health
order to plan appropriate incentives. In many information and use written materials. Other
cultures men cannot visit and talk with programs have developed ways to record
women, and women cannot travel alone to information for nonliterate people, such as
other communities or talk with people in using color-coded cards or pebbles in boxes
unfamiliar households. The ethnic group, (Storms 1979). Literacy requirements often
religion, or language skills of CHWs are often affect the age of the selected CHWs: literate
critical to their ability to work effectively. people tend to be younger. There is some
Most non-Western cultures place greater evidence, on the other hand, that older CHWs
emphasis on ascribed characteristics (those are more respected in their communities
inherent in the person, such as age or (Ofosu-Amaah 1983).
gender) than on achieved characteristics,
such as special training. Thus, in some Duties of CHWs
cultures young unmarried women are not The responsibilities of CHWs, as in any job,
viewed as people with health expertise even are tied to the need and expectation of
when they have received extensive training. various incentives. The specific duties and
Similarly, communities respond differently to functions of CHWs can dramatically
CHWs from inside the community than to influence their effectiveness and motivation

W HO A R E C HW S A ND WH AT DO TH EY DO ?
those from outside. Some community to stay on the job. A CHW may assist the
members may feel that because insiders are health system in improving access to health,
“just like me” they have no special promoting preventive health messages,
knowledge. Others may feel that insiders providing nutritional counseling or curative
understand their situation far better than care, and helping community residents find
outsiders. Such “insider” CHWs “…are armed other health care options through referrals.
with knowledge that no professional can Some CHWs work only in health promotion
match: an intimate knowledge of their own and have no curative functions. All national
culture” (Quinones 1999). health programs operate with financial
Most CHWs are from the communities constraints and limited trained staff. As a
where they work, but their personal result, these programs tend to add tasks and
characteristics vary widely among countries. functions continually to the duties of existing
One review of 38 projects (Parlato and Favin staff, especially CHWs. Although there is no
1982) found that 40 percent enlisted men perfect equation for the combination of CHW

11
duties, recent experience sheds light on scientific evidence of the optimal number and
some of the issues surrounding the role of mix of CHW functions and tasks. Programs
the CHW. must carefully monitor CHWs’ workloads and
their effects on motivation as additional tasks
Single or Multiple Focus are added.
The Alma Ata Declaration enumerated the
following tasks expected of CHWs: “home Mix of Curative and Preventive
visits, environmental sanitation, provision of Services
water supply, first aid and treatment of simple Whether CHWs have a single or multiple
and common ailments, health education, focus, the balance between curative and
nutrition and surveillance, maternal and child preventive care has been identified as an
health and family planning activities, issue. Prevention is extremely hard to sell in
communicable disease control, community all public health programs. When curative care
development activities, referrals, record- is offered, it is generally more welcomed and
keeping, and collection of data on vital events” appreciated by the residents (Frankel 1992;
(Ofosu-Amaah 1983). This long list of Heggenhougen et al. 1987; Walt et al. 1989;
responsibilities would seem unreasonable to Curtale et al. 1995). A report from Tanzania
demand of volunteer workers. Some programs noted that “CHWs have expressed frustration
have trained several people and divided the at not being able to provide the quality of
functions among them. For example, in Nepal services demanded by the community and
the village health worker does the basic therefore want further training in curative
preventive and curative work, while the medicine” (Heggenhougen et al. 1987). With
community health leader motivates the disappointment on the part of the villagers
community to participate in special campaigns and feelings of inadequacy among the CHWs,
(Parlato and Favin 1982). A team of workers the relationship has been “characterized by a
often exacerbates the problem of incentives, lack of support from the community….” The
however, because more people require support. Tanzania report states that “unless the
Many programs have trained CHWs to community’s expectations change, the lack of
work in a single area, such as diarrhea, support for the CHWs will be aggravated if the
malaria, or nutrition. For example, in many preventive role predominates over their
parts of Latin America, volunteer collaborators curative activities….”
conduct treatment and surveillance for “Credibility of CHWs is highly dependent
malaria. They make home visits to people with on the workers’ curative role,” find Parlato and
symptoms of malaria, complete patient Favin (1982). In Nepal community health
reports, take blood smears, and administer volunteers who were able to treat acute
doses of chloroquine (Ruebush et al. 1994). respiratory infection (ARI) greatly increased
The advantage of CHWs with a single focus is their credibility among the village population.
that they can be trained and monitored to (Curtale et al. 1995). A lack of curative skills
perform a manageable set of tasks. The main may be a disincentive for CHWs,
disadvantage is frequent training and compromising their standing in the
retraining in various vertical programs, with no community. (Gilson et al. 1989). Given a
opportunity for integration. Experience in choice between preventive and curative care,
Madagascar suggests that a CHW can community members demand more curative
manage only three or four themes at the most care (Walt et al. 1989), and problems often
(Gottert 2001). arise when CHWs cannot meet community
MET HODOL OGY

Apart from a consensus that no one demands. The relationship between the CHW
person can manage all the activities laid out and the community must be monitored and
in the Alma Ata Declaration, there is little supported to ensure an effective partnership.

12
Drugs with recruiting CHWs from practicing drug
Closely linked to the importance of providing sellers and pharmacists has shown that this
curative care are CHWs’ access to and supply strategy makes drugs available, gives the
of drugs. The kind of medicines CHWs should drug sellers greater prestige, and greatly
be allowed to administer has been the subject reduces attrition (Ishan 2001).
of much debate. Many are concerned that In Nigeria’s Gongola State, village health
treatment with antibiotics and antimalarials, in workers (VHWs) were trained to work in
particular, might lead to overuse and misuse remote villages to treat common diseases
of these medicines and eventual increases in with basic drugs and provide health education.
drug resistance. Those who advocate An operations research study conducted to
inclusion of these drugs in CHW kits argue determine what contributed to the high VHW
that they are readily available from local attrition rate found that one of the main
pharmacists and drug sellers and that trained reasons was villagers’ dissatisfaction with the
CHWs may be able to promote proper usage. VHWs’ limited curative role. The VHWs’ lack
The respect and status of CHWs in their of training or licenses to give injections
communities unquestionably increases when created a discrepancy between what the
they have drugs at their disposal. In their community wanted and what the VHW could
review of 52 projects, Parlato and Favin (1982) provide (Gray and Ciroma 1987).
found that “CHWs’ credibility suffers when
drug supplies are irregular.” Recent experience

MET HODOL OGY

13
Section 4

Monetary Incentives and


Disincentives

B y definition a CHW is not usually a full-time salaried employee of


the ministry of health (MOH) or other organization. The primary
reason is the belief that the MOH cannot afford to pay CHWs over the
long term. Compensation of CHWs for their services, however, is a
recurrent issue in many programs. CHWs often work long hours, even
full time, alongside salaried employees, which inevitably leads to
demands by CHWs for regular compensation for services provided.
While full-time salaried CHWs are relatively rare, many CHWs receive
some type of cash incentive. This section of the paper reviews cash
incentives of all types.

Money as an Incentive month in 1984). Men with lower monthly


There are many advantages to providing incomes worked two years and women with
CHWs with cash incentives. From the program lower incomes worked one year, while men
perspective, paid CHWs can be asked to work with higher pay stayed an average of 3.25
longer hours to achieve specific objectives years and higher paid women stayed 1.5
within a specified time frame. When agents years. Small salaries were mentioned most
are paid, rigorous supervision can be often as the reason VHWs found the work
exercised, programs can be implemented difficult. In a system established in Ethiopia’s
rapidly, work routines can be standardized, Gumer District, each household contributed
and service quality can be maintained one birr (US$0.15) a year to support the

M ON ETAR Y IN CE NT IV ES AN D DI SI NC EN TI VE S
(Phillips 1999). Negative reinforcers such as community health agents (CHAs) and
firing or punishment can be used to encourage traditional birth attendants (TBAs). This
desired performance. Payment is also seen as contribution was enough to cover a modest
helping to build some economic equity in a stipend for all trained CHAs and TBAs, and
minimally literate or economically the attrition rate fell from 85 percent a year to
disadvantaged population. zero (Wubneh 1999).
The main programmatic advantage to From the CHW perspective, appropriate,
cash incentives is the apparently lower respectful, and regular compensation is a sign
attrition rate among paid CHWs. In Gongola of acknowledgment and approval that allows
State, Nigeria, the Rural Health Program of them to earn a living or supplement other
the Christian Reformed Church found that income. Cash incentives may come in several
VHWs left their posts after one to three years forms. CHWs may be part of the civil service
(Gray and Ciroma 1987). The VHWs worked and be paid a salary. They may also be given
one or two hours a day and received a small a small stipend. CHWs are often given per
salary (the equivalent of US$13 to $27 a diem and travel allowances to attend training

15
or make field visits. Cash incentives may also interventions and whose children were fully
be tied to drug sales. immunized and participating in growth
The source of CHW payments can be the monitoring were eligible to receive low-interest
community (contributions from individual loans for income-generating activities. Each
households), the government, an NGO, or group of mothers paid an annual fee for a
even a for-profit company. The source of health card, and the funds were used to
funds may affect the role and allegiance of support the CHW. These funds have been
the CHW. Several NGOs have tried to create matched by a one-time grant from the
community revolving drug funds or other institution sponsoring the CHW program.
types of community-based credit funds Mothers had an economic incentive to learn
specifically for health incentives. When health interventions in order to have access to
associated with profits that are the “incentive” the loans (Augustin and Pipp 1986).
for the CHW, few of these schemes have
been successful or achieved any level of Problems with Using Money as
scale (Edison 2000; Henderson 2000). When an Incentive
compensation is tied to drug sales, CHWs While paying CHWs regularly can solve many
tend to focus on curative care, while CHWs problems, experience in many countries has
with salaries maintain both preventive and shown that such payment can have unforeseen
curative activities (Parlato and Favin 1982). negative consequences, depending on how it is
Fee-for-service schemes often result in an handled. Money can be a divisive factor for
increase of curative over preventive activities CHWs and can undermine their commitment
and the overprescription of medications and the relationships they have with their
(Davis 2000). Some NGOs report misuse of communities. Volunteers often cite lack of
the funds through “borrowing” from the remuneration as a key factor causing their
proceeds of the sales. attrition, but they also cite other critical reasons,
There is some indication that such as lack of community support and lack of
decentralization increases the flexibility of the supervision (Wubneh 1999). Payment is difficult
local government to respond to issues of to disaggregate from other reasons because
CHW remuneration. In the Philippines an they are often interconnected. When using cash
increasing number of honoraria, or travel incentives, program managers should calculate
allowances, have been provided to community how long such a payment scheme can be
volunteer health workers (CVHWs) from both funded. When the government or an NGO offers
municipal governments and village monetary support, special effort is needed to
development councils. The honoraria, which compensate for possible distrust or heightened
M ON ETAR Y IN CE NT IV ES AN D DI SI NC EN TI VE S

range from US$.50 to US$50 a month, are expectations in the community. Some examples
possible because of the devolution of health of the negative consequences of paying CHWs
services from the provincial level to the are described below.
municipality and village levels. At each level
local support for the health programs is The Money Is Never Enough
funded out of the government’s respective The first problem with money is that workers
revenue allocation (Paison 1999). inevitably demand more money, benefits, and
Some countries have experimented with opportunities for promotion. In the Solomon
insurance plans. In Haiti a combination of a Islands 38 percent of nonworking VHWs left
prepaid scheme, existing community groups, because of irregular remuneration. Ninety-two
and revenue-generating activity has been percent of the 66 working VHWs surveyed
used to motivate CHWs to provide preventive thought their allowances were inadequate and
services. Groups of mothers who could wanted them doubled from US$13.67 to
demonstrate their knowledge in child survival US$27 a month (Chevalier 1993). In

16
Swaziland CHW salaries did not change over receive any remuneration (Quinones 1999).
a decade in which the local currency gained Monitoras who work in Honduras along the
400 percent in buying power (Green 1996). If border with El Salvador frequently complain
CHWs do not consider their salaries that their Salvadoran counterparts are paid
adequate, their performance and retention while they are not (Griffiths 2001).
levels may by negatively affected.
Are CHWs Accountable to the
Sustainability of Payments Community or to the Government?
The second problem with monetary CHWs who receive a salary or stipend may
compensation is that payment is often see themselves as employees of the
irregular and may end altogether when government or NGO rather than as servants
project funding runs out. Using other terms of the community. Financial incentives can
for payments, such as “field allowance,” destroy the spirit of volunteerism and work
“transport allowance,” or “per diem,” can against the volunteer philosophy of a sense of
have advantages in some circumstances community (Alonzo and Hurtate 2000). Even a
because they create fewer expectations. tiny allowance can reinforce the community’s
The sustainability of such incentives, perception that the CHWs are government
however, ultimately may depend on their employees and lead to expectations that they
source. give even more freely of their time and
Payments are often linked to specific personal resources (Taylor 2000; Hilton 2000).
training sessions. In Zambia the NGO A community may become less willing to
Adventist Development and Relief Agency support the volunteers in other ways. For
(ADRA) provided small “meal allowances” to example, communities in Mozambique that
CHWs when they brought their monthly thought activistas would receive a monetary
reports to the health centers (Edison 2000). To incentive from an NGO or the MOH withheld
circumvent salary issues, an NGO in Bolivia their in-kind support (Snetro 2000). When
gave very small financial incentives to CHWs people distrust the government, they distrust
for discrete tasks that were easy to measure CHWs who are perceived to be a part of the
and track (Shanklin 2000). Staff had to spend government system.
time evaluating over-reporting and double
reporting among CHWs, however. In-kind Payments as an
Effective “Compromise”
Inequity among Workers Paying CHWs in kind rather than in cash has
Comparison of their salaries with those of other advantages. In-kind payments are less prone

M ON ETAR Y IN CE NT IV ES AN D DI SI NC EN TI VE S
workers may lead CHWs to call for salary to comparison with levels of compensation of
increases or benefits such as pensions and salaried employees because their exact value
health care. Payment is rarely consistent may be difficult to quantify. CHWs can be paid
among cadres of workers such as CHWs and in kind with cooking, food, housing, and help
community-based distributors of contra- with agricultural work and child care. Most
ceptives, who may work side by side and successful in-kind payments are planned and
perform similar duties. Such discrepancies can implemented by the community. Beneficiary
result in jealousy and enmity. If some but not families in Peru have taken turns working for
all CHWs or other community workers are paid, free on the farms of the volunteers in
tension can result between the paid and unpaid recognition of their important contribution
groups. In Colombia CHWs who receive (Buenavente 2000).
financial compensation for their work have Another type of in-kind payment is
generated tension and envy among other material items provided by NGOs. Such
CHWs and community leaders who do not items are often, though not always, related

17
to the CHWs’ job functions. Successful in- Preferential Treatment
kind payments provided by NGOs have Several programs demonstrate appreciation
included bags to carry supplies, agriculture for CHWs’ work through preferential treatment,
tools, raincoats, backpacks, supplies for such as access to credit programs, literacy
home improvement, educational materials, classes, or first-in-line treatment at health
herbal plants, and fruit trees. Alonso and posts. For example, CHWs in Guatemala were
Hurtarte (2000) have found, however, that exempt from military service (Parlato and
incentives given too often or in too many Favin 1982). In India the CHW must show
forms are unsuccessful and demotivating in success with an income-generating activity to
the long term. The Shishu Kabar Hearth gain recognition as a health worker. Rather
nutritional program in Bangladesh gave each than receiving a salary or wage, the Indian
volunteer mother a set of dishes at the end CHW is given access to credit for income-
of the sessions, avoiding a cash payment. generating activities through a bank loan
This incentive helped the volunteers feel (Arole 2000). Other NGO programs give
appreciated and made it easier for trainers CHWs, especially women, priority for
to recruit mothers in new communities inclusion in other development programs,
(Wollinka 1997). In some instances food such as group-guaranteed lending and
supplements have been used as payments, savings programs. In the Ashanti Region of
but CHWs have been reluctant to continue Ghana, members of the village health
working when the food supplements have committees (VHCs) receive identity cards that
ended. ADRA’s experience has shown that allow them to be seen quickly at clinics. When
any kind of financial support or subsidy, there is a death in the family of a VHC
despite its positive short-term impact, is member, a small cash donation is given to the
problematic for long-term sustainability family, and the district health management
(McHenry 2000). Selectively giving payment team (DHMT) is represented at the funeral
or food to some communities and not to (Leonard 2000). In all such cases, preferential
others can generate animosity among treatment of CHWs must be monitored
communities and jealousy among families carefully to ensure that community members
(Shanklin 2000). do not resent special treatment of CHWs.
M ON ETAR Y IN CE NT IV ES AN D DI SI NC EN TI VE S

18
Section 5

Nonmonetary Incentives
and Disincentives

E ven when monetary or in-kind incentives are provided to CHWs,


they are not sufficient to maintain and retain CHWs’ motivation.
Other types of incentives, often intangible, are critical to job
satisfaction and fulfillment. These incentives include a good
relationship with health staff, personal growth and development
opportunities, training, and peer support. Perhaps the most important
nonmonetary incentive, a good relationship with the community, is
discussed in the following section.

Supervision or Recognition as a result (Elder 1992). In Kitwe, Zambia,


CHWs occupy a unique position in the health where the community health promoters
system. They are usually not full-time salaried (CHPs) had no contact with the health
health workers, yet they are the pivotal bridge system, frequent visits by outsiders (donors
between the community and the health and NGOs) helped them maintain their
system. Compared with other health workers, commitment and motivation (Steel 2001).
they tend to have the lowest status because Sometimes the MOH sends letters of
of their low levels of education and poor appreciation to the CHWs and their families,
economic status. To ensure that the CHWs although such expressions of appreciation are
remain “of the community,” ministries of health not the norm.
are usually reluctant to treat them as another Typically, after the initial training a CHW’s
cadre of health worker, while the CHWs are relationship with the rest of the health system

N ON MO NE TA RY I NC EN TI VE S AN D DI SI NC EN TI VE S
often eager to be identified with the prestige of is limited to what is usually called supervision.
the health system. These competing and Supervisors can give the CHW opportunities
contradictory tensions create a host of to discuss problems, exchange information,
problems related to a CHW’s sense of and take advantage of continuing education.
inclusion in and support from the health Supervisory visits help reduce the feelings of
system. isolation that often accompany a CHW’s
The MOH can help CHWs feel supported occupation. To be effective, supervisory visits
and appreciated in many ways. In Indonesia a should be regular and based on a common
radio-based health communication campaign understanding of the purpose of the visit.
motivated the kaders by publicly praising CHWs appreciate good supervision given with
them as “volunteers who work without the honest intention of capacity building and
compensation for our children in our village for mentoring. In Guatemala supervised CHWs
the sake of the future.” After the campaign had attrition rates two to three times lower
mothers and village headmen complimented than those of unsupervised CHWs because
the kaders and attended the health posts their link with outside experts gave them
more often. Retention improved significantly higher status (Parlato and Favin 1982).

19
Weak, inadequate, and inconsistent hospitals felt that their work was undervalued
supervision is cited frequently as a cause of and that they were treated differently from the
low rates of CHW retention (Frankel 1992; other health workers and assistants, even
Ofosu-Amaah 1983; Heggenhougen et al. though they performed the same tasks. This
1987; Walt et al. 1989; Curtale et al. 1995; perception was seen as a major demotivater
Ojofeitimi 1987; Schaefer 1985). Problems and reason for attrition (Quinones 1999).
with supervision range from the logistical When supervision is inconsistent, CHWs
difficulties of reaching remote communities to may not feel supported by the health system.
interactions that are more punitive than Ensuring that supervisors are trained to
supportive. Ofusu-Amaah (1992) summarizes supervise and soliciting the community’s
many of the problems of CHW supervision of involvement in supervision can increase
by health professionals in the following list: retention of CHWs and help ensure their long-
term sustainability in the community. A study
■ heavy clinical and other responsibilities of in Colombia (Robinson and Larsen 1990)
health professionals found that the community had more influence
■ inappropriate training of health on the CHWs than the health system,
professionals in primary health care contrary to widely held assumptions. If the
■ inaccessibility of villages community and not the health system is the
■ multiple uncoordinated supervision visits primary reference group for CHWs, then
by different health personnel working with feedback from the community has a
the CHWs significant influence on motivation and
■ lack of vehicles or petrol performance. This study suggests that the
■ lack of per diem supervisor should ask, “How can my contact
■ general shortage of health personnel with the CHW contribute to further
development of the relationship with the
In Sri Lanka the frequency and duration of community?” These findings indicate that a
supervision was inadequate because of major health facility or NGO supervisor should foster
shortages of supervisory staff at all levels, more positive interactions and dialogue with
and especially at the central MOH level, community members on pertinent issues.
where a third of the positions were vacant
(Ofosu-Amaah 1983). In Tanzania CHWs Identification and Job Aids
received some supervision from the village One of the commonest and easiest ways to
N ON MO NE TA RY I NC EN TI VE S AN D DI SI NC EN TI VE S

leaders and village council but were not strengthen a CHW’s affiliation with the MOH or
familiar with CHW training or job descriptions supporting organization is to provide some form
(Heggenhougen et al. 1987). Poor of identification. Identification cards, badges, or
management can also affect the quality of diplomas can provide security in politically
supervision at all levels of peripheral health volatile situations and are status symbols in the
services and primary level services. Gilson et community. Many NGOs have given CHWs t-
al. (1989) describe this effect as “the shirts, notebooks, caps, ponchos, and bags
reluctance to supervise which comes from with identifying logos that promote group
lack of incentives, lack of confidence in solidarity and facilitate entry into households
supervisory techniques, and lack of during a project (Pearcy 2000; Rubardt 2000).
objectives and targets for which to work.” Some programs provide bicycles or motorcycles
While often beneficial, close contact with for CHWs to use but usually not own. People
health staff can create problems when CHWs who completed the Ghana Red Cross training
compare themselves with professional health program were allowed to purchase and wear the
workers. For example, CHWs in Colombia Red Cross smock or t-shirt. The Red Cross
affiliated with health institutions such as symbol identified them as Red Cross volunteers

20
and provided recognition and respect from their curative services and nutritional interventions
communities and from the MOH (Leonard 2000). rather than from preventive services. In Haiti
Job aids are materials that help a CHW volunteer mothers, or animatrices, are
perform the required tasks. While providing a motivated by seeing their lethargic children
sense of affiliation and enhancing the CHW’s with no appetite become “bright, energetic
authority, appropriate job aids also strengthen children who eat ravenously” (Wollinka et al.
skills and are invaluable in increasing 1997). This dramatic change convince the
confidence. Job aids have included animatrice “that her efforts have had an
medicines, health education materials such impact, which appears to strengthen her
as counseling cards, first aid kits, pots for commitment to the program, the balanced
demonstrating preparation of weaning foods, menu, and the more frequent feeding pattern
pens and pencils, flipcharts, notebooks, and the program recommends.” In Ghana volunteer
boxes to store records. These frequently cited mothers are motivated by the health of their
incentives are important to CHWs’ self- children and their desire to help other mothers
esteem and ability to fulfill their role have healthy children (Leonard 2000).
(Henderson 2000). Mothers’ support groups meet regularly with
the support of health workers to discuss
Personal Growth and breastfeeding and help new breastfeeding
Development Opportunities mothers solve problems. The volunteers often
Personal growth and development is use their own children as examples of healthy,
mentioned consistently in the gray literature exclusively breastfed babies.
as a major incentive for CHWs. Acquisition of CHWs can derive a sense of
knowledge and skills is seen as a stepping accomplishment at a collective level as well as
stone to future employment and a necessary from seeing changes in individual children,
component in meeting community health which is often difficult. CHWs who collect and
needs. Their jobs put CHWs living in rural use health information can monitor and feel
areas with little chance of employment on the proud of their own progress. In Bolivia CHWs,
path of lifelong learning. Ongoing skill health care providers, and community
development (acquisition and promotion of members meet monthly to discuss community-
preventive messages, basic curative collected health data and plan action based on
services, problem analysis, and problem- the data (Howard-Grabman 2000). This process
solving skills) is viewed as important to job has resulted in increased community

N ON MO NE TA RY I NC EN TI VE S AN D DI SI NC EN TI VE S
satisfaction. awareness, more concern for maternal and
CHW posts have been an entry into child health issues, and positive attitudinal
government employment in some situations, but changes in the community and among health
in many other situations the training and job care providers. CHWs are seen as the bridge
duties provided are too minimal to prepare for these empowering meetings between health
CHWs for such employment, where it exists. In care providers and the community. Vaccination,
Solapar District in India, 93 percent of vitamin A usage, and growth monitoring
volunteers were not satisfied with their duties programs increased in the Bolivian
because they believed they would be a stepping communities using this “integrated community
stone to future government jobs that never epidemiological system,” and women in pilot
materialized (Kartikeyan and Chaturvedi 1991). communities were 2.2 times more likely to
breastfeed within one hour postpartum.
Personal Accomplishment
Witnessing positive change is a strong Training
motivator for CHWs. A sense of quick Lack of general and skills-based training is
accomplishment often comes from providing frequently mentioned as a barrier to effective

21
CHW performance (Walt et al. 1989; Gilson et with the communities while enhancing their
al. 1989; Kaseje et al. 1987; Robinson and standing as they try to meet community
Larsen 1990). Most observers of community - needs.
based contraceptive distribution programs Without the ability to provide treatment or
agree that the quality and intensity of agents’ prevention, a CHW can lose standing in the
training is the most important single community. The volunteers in the Sri Lanka
determinant of program quality and impact study state, “Often we have to go to the
(Phillips 1999). Training can provide CHWs public health nurse midwife to get an answer,
with the opportunity to learn skills, receive and then tell the householder. When this
education, interact with higher levels of happens, the community loses faith in us and
professional staff, and obtain other benefits refuses to accept any advice we give them”
that they would not be able to obtain (Walt et al. 1989). Those designing training
otherwise. Learning skills is one of the main should consider the way material is taught,
reasons CHWs volunteer. the place where training is carried out, and
Training is essential if CHWs are to carry relevant skills that strengthen CHWs’ ability to
out their work effectively. Training covers not educate community members (Ofusu-Amaah
only providing preventive, curative, or other 1983; Gilson et al. 1989; Kaseje et al. 1987;
relevant services to the community, but also Robinson and Larsen 1990). Problem-solving
teaching and communicating with community skills are a critical part of the training needed
residents. In Nepal more training allowed the to promote behavior change rather than
community health volunteers (CHVs) to knowledge accumulation.
identify causes and treatment of night
blindness and to recognize fast breathing as a Training Methods Make a Difference
major sign of ARI (Curtale et al. 1995). Their Many training methods are inadequate. The
ability to deliver treatment increased their methods tend to be too theoretical, too
motivation. classroom based, and too complicated
To be effective, training has to be done (Gilson et al. 1989). Such methods can be a
regularly and continuously, with the needs of disincentive to CHWs who are learning
the community in mind (Gilson et al. 1989; unfamiliar information. The following lessons
Kaseje et al. 1987; Robinson and Larsen 1990; learned for participatory training have
Walt et al. 1989). VHWs in Gongola State, emerged through NGO work with CHWs
Nigeria, said in interviews that they felt that (LeBan 1999):
N ON MO NE TA RY I NC EN TI VE S AN D DI SI NC EN TI VE S

further health care training would allow them


to advance to professional health care work ■ CHW functions need to be clearly defined
and receive higher pay (Gray and Ciroma before training.
1987). ■ Curricula, tools, and methods must cover
The right combination of skills can help a each specific CHW task, with ample
CHW become a more qualified worker. Having opportunity for hands-on management of
skills that the community values raises the real cases.
status of a CHW in the community. In ■ Role modeling and one-on-one tutorial
Colombia and Tanzania training strategies training approaches work extremely well.
were based on community surveys completed ■ Adult participatory learning methodologies
by CHW candidates before training began and problem-solving approaches help
(Robinson and Larsen 1990). The skills the CHWs assume the role of change agent
CHWs learned were directly related to the at the community level.
health issues in the communities. Robinson
and others further explain how this training The training venue is also important to
orientation solidifies the CHWs’ connection the CHW’s ability to learn. Training is more

22
effective in a setting that matches CHWs’ frustrated as they became more proficient in
places of residence, whether urban or rural. identifying disabilities. They realized that they
Robinson reports that most training should needed additional education to handle more
take place in the community. Time spent in complex rehabilitation problems (Lysack and
hands-on activities increases visibility and Frefting 1993). In Kenya continuous training
reinforces the relationship with the community provided enough motivation for the village
(Robinson and Larsen 1990). Trainers and health helpers to continue working even
CHWs should go together to the rural or urban without financial support (Kaseje 1987). In
setting to work and assess skills in real Mozambique monthly refresher training
situations (Gilson et al. 1989). CHWs should featured a specific health theme, which
be trained in the closest health facility by allowed activistas to emphasize that theme
health facility staff trainers to better link the during the following months’ health education
formal health care system with the community (Koepsell et al. 1999).
(LeBan 1999). After training, the awarding of Sometimes training alone is enough to
certificates to CHWs or a community keep motivated workers going. La Leche
celebration or recognition ceremony can be League mothers in Guatemala continued to
invaluable in recognizing the CHWs’ provide counseling and referrals four years
accomplishments (Hilton 2000; Henderson after the end of the project grant (Rasmuson
2000; Edison 2000; Pearcy 2000). et al. 1998). Their motivation was attributed to
Using other CHWs to assist with the a combination of refresher training, annual
training can help ensure that it is relevant to workshops, peer support, and visible change.
the local situation. In an adaptation of the Training, however, has a negative side.
training-of-trainers approach in Mozambique, CHWs, especially effective ones, tend to be
lead activistas (the strongest CHWs) were targeted by a variety of vertical health
excellent auxiliary trainers, and their programs (such as tuberculosis, malaria, and
assistance reduced the time and costs of onchocerciasis) and taken frequently for
training (Koepsell et al. 1999). training in these topics. Usually the CHWs
enjoy the additional perks of training (a
Refresher Training chance to leave the community, travel
Continuous training has been cited as “an allowances, interaction with peers, learning
essential prerequisite for an effective CHW new skills), but the communities are left
program” (Frankel 1992) and an important without CHWs during the training. In El

N ON MO NE TA RY I NC EN TI VE S AN D DI SI NC EN TI VE S
factor in retaining the motivation of workers, in Salvador CHWs were found to spend more
light of the short training periods available and time in training than on the job (Contreras
the low levels of education of most CHWs 2001).
(Ofosu-Amaah 1983). Refresher training Training is clearly a critical and ongoing
allows the CHWs to learn new skills, take on part of any CHW program. The NGO CARE
new challenges, and interact with peers, (2000) describes a comprehensive training
keeping the job interesting and promoting strategy in Nyanza, Kenya, that has the
personal development. Little information is involvement of both the MOH and the
available on best practices associated with community. CARE combined a training and
the periodicity of refresher training or the supervision strategy for CHWs using NGO,
sequencing of messages and skill MOH, and community trainers and
development. In most situations refresher supervisors. Community health committees
training depends on budgets and is often cut (CHCs) recruited CHWs to serve 20 families
when resources are scarce. each. The district health office (DHO) provided
Experienced community-based health facilities for training, quarterly in-
rehabilitation kader in Indonesia became service training, and referral. Practical training

23
took place at the hospital. CARE and MOH support, and allowed for local exchange of
staff provided additional incremental training information (Marsh et al. 1999).
for three months following the initial training. Group meetings can provide motivation
The DHO and the CHCs assumed overall for CHWs through peer support. Findings from
supervisory responsibility for the performance Colombia, Mozambique, Nepal, and Uganda
of the CHWs. Within two years, 319 CHWs show that peer support is as important to
were managing sick children at the CHW performance as supervisory feedback
community level. The clinical proficiency of (Snetro 2000; Robinson and Larsen 1990;
the CHWs was equal to or better than that of Taylor 2000; Oriokot 2000). Successful
the MOH clinicians in that setting (LeBan programs have brought CHWs together in
1999; Steinwand 2001). The motivation of the monthly meetings and used these meetings to
CHWs, which had been high early in the promote CHW bonding, as well as provide in-
project, began to subside after a few years. service training and supervision (Robinson
The community elders, already engaged in and Larsen 1990). In the Shishu Kabar Hearth
supervision, promised to take a more nutritional program in Bangladesh, trainers
aggressive role in solving the problems of had the freedom to be creative and make
CHW incentives in their areas. suggestions to improve the program. Their
ideas were incorporated into the program to
Peer Support and CHW give them a sense of ownership and
Networks involvement in decision making. Their
Interaction with other CHWs can be a critical contributions were recognized at weekly
motivator for people who often work with little meetings. The trainers were encouraged to
supervision or tangible evidence of their discuss successes and solve problems
effectiveness. Peer support comes in several among themselves to exchange information
forms. Several NGO programs have and create a supportive environment
successfully paired CHWs so that they can (Wollinka 1997).
work together and support each other. In the Examples of supporting groups of CHWs
Atención Integral a la Niñez (AIN) program in in forming CHW associations exist in many
Honduras, for example, monitoras worked in countries. In Peru CARE has effectively
groups of three. Working in teams allows mobilized community volunteers into local
CHWs to divide their work and reduces the committees that cover specific geographic
sense of isolation and complete areas. Representatives of these committees
N ON MO NE TA RY I NC EN TI VE S AN D DI SI NC EN TI VE S

responsibility for a geographic area. In Liben organize themselves into district associations.
District, Ethiopia, Save the Children The committees meet monthly to discuss
mobilized communities to form “bridge to experiences and mutually reinforce
health” teams (BHTs). Each BHT included a commitment. They raise funds to cover their
wisewoman, a wiseman, and a young own activities, organize training events, and
traditional apprentice. Two-thirds of the BHT advocate for health with government and the
members were influential, respected TBAs, MOH. This arrangement has resulted in
bone setters, herbalists, or circumcisers. dedicated, well trained, and active CHWs who
Most traditional healers in the district were have strong ties to the MOH but are not
elected as BHTs. The teams decreased the dependent on it (McNulty 2000).
isolation of the BHTs, provided mutual

24
Section 6

Relationship with the Community

W orking with the community gives health workers a platform from


which to strengthen their relationship with the community and
receive community feedback, as well as a structure for regular
interaction with health facility staff. Community participation is an
integral part of CHWs’ motivation. Without involvement, communities
lack interest and expectations, leaving CHWs without a support system.

Enhancing Relationships complexity. Communities are not homogenous


between CHWs and groups of people who always work well
Communities together. Like all communities, those in
In many programs the potential of the CHW developing countries are made up of various
has not been realized because of a poor groups of people based on such criteria as
relationship with the community. In the religion, ethnicity, and economic status. With
Solomon Islands, 32 percent of the notable exceptions, the most marginalized and
nonworking village health workers surveyed powerless groups—women and the very poor—
left their posts because of a lack of need CHW services the most, yet rarely have
community support (Chevalier 1993). real involvement in CHW programs. Programs
Programs and organizations that do not that do not recognize the complexity of local
engage communities actively in CHW communities or ensure that the marginalized
programs from their inception generally are given a voice may find that their CHWs are
experience low morale among their CHWs. pawns of the local elites. One way to guard
This lack of shared ownership generally against this is to work through existing
triggers a separation and distance from active community groups and to increase the total
community participation in the CHW program, number of CHWs in a community.
resulting in high attrition. All poor communities are not alike. If
If CHWs are to serve as the bridge programs make any distinction among
between the health system and the communities, it is the distinction between
community, the relationship with the rural and urban communities. Planning tends

R EL AT IO N SH IP W IT H T HE C O MM UN IT Y
community must receive great attention. Yet to be inflexible in responding to the diversity
this relationship is often given plenty of among communities. Of course, communities
rhetoric but few if any financial or technical differ considerably. Some have more
resources. Two misconceptions of the resources than others. Some have access to
community have been common: a naive health facilities, markets, and cash crops,
concept of community and an assumption while others are on the verge of famine, with
that all communities are alike. Much current little food or other resources. The more
understanding of the complexity of stressed communities cannot and should not
communities comes from the work of social be expected to provide labor, money, or other
scientists and the field experiences of NGOs. resources to support CHWs. Communities
Programs have tended to oversimplify the with access to better job markets may have a
“community” and underestimate its social hard time recruiting volunteers, as Catholic

25
Relief Services found in El Salvador (see p. at all times of the day, even when they were
32). Communities may also have different busy” (Ruebush 1994). Candidates should also
epidemiological profiles, as in Ethiopia, where be selected on the basis of their demon-
malaria is a problem only in some altitudes. strated involvement in and commitment to the
Clearly, the relationship between a CHW and community (Robinson and Larsen 1990).
community varies with the characteristics of Community members are often much more
the community. Little has been documented aware of the characteristics that will ensure
on approaches to differentiating communities. CHW retention.

Selection of CHWs Process of Selection


Ideally, a community should be involved in all Once criteria for selection are established, the
aspects of a CHW program, including “community” is usually asked to nominate
selection, training, and supervision, but candidates. Because this process is often a
community members may not have the time black box to outsiders who know little if
and resources to invest in all these areas. anything about the internal social dynamics of
Community involvement in selecting CHWs, the community, many problems can occur at
as well as in using their services and this stage. Communities may not be
contributing in-kind payments, appears to be organized to choose CHWs representative of
critical to CHW programs. the majority of residents, or they may not fully
understand the functions of the CHWs.
Criteria for Selection Communities that do not understand the role
Selecting a CHW involves many steps. of the CHWs are less likely to give the CHWs
Criteria must be established, candidates the necessary support and may not
identified, and a final selection made, perhaps understand their own role in improving their
after a trial period. Although the community health. In Saradidi, Kenya, the responsibilities
could have a role in each step, usually it is of the village health helper were discussed in
involved only in proposing candidates who open community meetings and formal and
meet criteria established by program staff. As informal exchanges (Kaseje 1987). In many
discussed in Section 4, the personal cases, however, selection of CHWs is
characteristics of CHWs play an important completed well before the community has a
role in their relationships with the community clear understanding of what they do. CHWs’
and their continued motivation. ability to carry out their tasks effectively can
When given the opportunity, communities be enhanced when communities are invested
are often able to develop criteria that ensure in trying to improve their own health.
CHWs stay on the job. In trying to revive the Communities understanding of their own
Community Health Agent (CHA) program, the role in changing their health status can help
R EL AT IO N SH IP W IT H T HE C O MM UN IT Y

MOH in Ethiopia established literacy as the sustain the CHWs’ activities. Community
only criterion for recruitment. When asked members should be informed of the job
what criteria they would use to select CHAs, description, capabilities, and commitment of
however, local communities listed 16 CHWs (Frankel 1992; Ofosu-Amaah 1983;
characteristics, including selection by the Heggenhougen et al. 1987; Walt et al. 1989). If
community, married status (so the CHWs the communities understand what the CHWs
would not leave the community), and no are trained to do, there is less chance that
addiction to chat, an herbal stimulant residents’ expectations of a CHW will go
(Bhattacharyya et al. 1997). In Guatemala unmet. Community understanding will also
local residents thought the volunteer reduce inappropriate demands and frustrations
collaborators should be “responsible (Heggenhougen 1987).
individuals” and “able to take care of patients Ideally, a CHW should be chosen with the

26
input of the community so that residents’ the MOH is able to respond with additional
health needs are considered and they respect training and support. This is the ultimate goal
and feel comfortable interacting with the CHW of many CHW programs. In Mozambique,
for their health services. In some cases, where activistas have worked for many years,
however, CHWs have been selected by village their roles seem to have matured, and
leaders who choose relatives or friends or by communities seem to accept their work to a
village committees that disregard community high degree. Community members now
input. A survey-style CHW evaluation by approach activistas for family planning
UNICEF in 1989 reported that 45 percent of services and other types of support (Snetro
the CHWs surveyed were related to the local 2000). When sevikas in Nepal were asked why
chief or subchief. The percentage would have they continued their volunteer work, they said,
been higher if other kinship ties and filial “Our neighbors won’t let us resign; they insist
connections with members of the chiefs’ we continue because their children’s health
councils had been included (Green 1996). A depends on us” (Taylor 2000).
brief evaluation in Swaziland found that Several programs have mentioned the
nepotism and self-interest determined the support of the community as an incentive for
choice of the CHW by the local chief and his CHWs. Trust, prestige, mobility, and social
council, with no consideration of the interaction are other factors that are favorably
candidates’ interest in or qualifications for the mentioned (Walt et al.; Kaseje 1987; Lysack
job (Green 1996). and Krefting 1993; Ruebush 1994). Many
Extensive field experience and long CHWs volunteer because they enjoy serving
association with specific communities have the community.
helped many NGOs find ways to ensure that
the CHW selection process is fair and Visible Benefits
representative of marginalized groups. For Communities that have directly and visibly
example, CHVs in Senegal were chosen during benefited from CHW programs are the most
community meetings by community leaders willing to support the continued presence of
who did not include women or representatives CHWs. The community’s interest in sustaining
of all community groups. Although the chosen a CHW program is based in large part on
CHVs were motivated in the beginning, 60 evidence of positive changes in health status
percent had abandoned their jobs after two because of the CHW or on benefits such as
years, and many of those who remained were effective referrals to health facilities. Visible
no longer motivated to carry out community change is limited by the predominance of
health activities. During the following phase of preventive health in a CHW’s work. With the
the project, volunteers were chosen instead exception of nutritional rehabilitation or the
through in-depth discussion with community use of ORS for dehydrated children, few

R EL AT IO N SH IP W IT H T HE C O MM UN IT Y
members and village health committees dramatic changes in health are visible to
established by World Vision. Five years later community members.
few CHVs had left their posts, an achievement One way CHWs and communities can
attributed to official community recognition of create visible change is to monitor simple
their roles and to moral encouragement from health indicators over time. In Kitwe,
their communities (Aubel et al. 1999). Zambia, communities monitor the number of
children who gain weight in the past month
Community Recognition of as an overall indicator of child health (Steel
CHW Work 2001). In Eastern Province, Zambia,
Community recognition and appreciation of communities use risk maps to monitor
the work of CHWs can have a snowball effect indicators such as immunization status and
as communities demand more services and availability of latrines. Risk maps identify

27
households using color codes to mark Status
indicators, such as green for fully Being identified as a CHW and affiliated with
immunized children and red for those not the health system is usually, though not
fully immunized (Bhattacharyya and Murray always, a status symbol that generates power
1997). The collection and analysis of health and respect within the community. CHWs in
information to chart changes in behavior (for Colombia ranked “having influence in the
example, more use of health services) or community” as the most important extrinsic
health status (for example, fewer cases of reward affecting their performance. Informal
dehydration) allows CHWs to show the observations indicated that this influence
communities the results of their work. made the CHWs opinion leaders on a variety
Encouraging communication and of issues of concern to the community. The
interactions between CHWs and community fact that influence in the community is highly
members is critical to building an valued by community-based workers adds a
understanding of the CHWs’ role and support dimension to their role that few other health
for their work. There are a number of workers, particularly those based in
examples of community supervision of CHWs. institutions, can share (Robinson and Larsen
While community health committees cannot 1990). Identification badges, uniforms, and
be expected to do clinical supervision, they relationships with “outsiders,” as in the Kitwe
can monitor CHW performance at the example, can increase the status of a CHW in
community level. For example, the barefoot a community.
doctors in China were accountable to the Praise and respect from community
villages and were given technical supervision residents and peers can motivate CHWs
by the health centers (Frankel 1992). positively and increase their length of service.
The appreciation of the people they serve is a
Individual Interactions strong incentive that is often cited as impor-
Negative CHW behavior has a negative effect tant to CHWs’ job satisfaction. Minnesota
on community support of CHWs and the International Health Volunteers has trained
messages they promote. Health workers in about 2,000 community volunteers in Uganda
Niger did not treat mothers respectfully or for a variety of tasks. Community recognition
patiently and did not counsel them on has proved to be a valuable tool in motivating
possible side effects of the vaccinations and retaining community volunteers by
given to their children. The mothers reported increasing their status in the community.
that this negative behavior was a major barrier About 70 percent of them have been elected
to their using the CHWs’ health services to various positions on their local councils
(Boyd and Shaw 1995). since becoming volunteers (Mullins 2000).
To be effective change agents, CHWs Especially for women, public recognition
R EL AT IO N SH IP W IT H T HE C O MM UN IT Y

need to demonstrate the positive effects of outside the family can generate self-respect
new practices in their own homes. In and empowerment to act in the community.
Mozambique CHWs who had pit latrines in Poor women in Dhaka, Bangladesh, who
their homes stimulated community interest in served as CHWs for ten years were seen as
their messages promoting the use of such valuable members of their communities
latrines, while those who did not discouraged (Silimperi 2000). The activistas in Mozambique
such interest (Snetro 2000). In Honduras, repeatedly emphasized the importance of
Save the Children and the MOH posted the community value and support, demonstrated
photos and names of CHWs on the health by their neighbors’ increased respect,
post wall, bringing public recognition to the reciprocal gestures of help, and acceptance of
CHWs and increasing their visibility and health behavior change messages; community
retention (Amendola 1999). leaders’ understanding of and support for their

28
role; frequent visits by NGO staff; and emphasis behaviors and community
opportunities to learn (Snetro 2000). mobilization. Health action committees
(HACs) of ten to 12 elected members were
Community Organizations that trained to support the four to six BHTs in
Support CHW Work each kebele (village) and to support TBAs in
In addition to community recognition, the safe delivery and danger sign recognition.
formation of community organizations or village Mothers and primary health caregivers
development committees has been cited as believed that BHT health messages came
useful in supporting and sustaining the role of from traditionally respected sources. BHT
CHWs. Some form of viable community members were motivated by training,
organization is necessary to establish an effectiveness in the community, and support
operational relationship between the from local leadership in the HACs (Marsh et
community and the government. In Gongola al. 1999).
State, Nigeria, the support and encouragement When support from community groups is
of the village health committee emerged as an missing, CHWs face an uphill battle in gaining
important factor in VHW job satisfaction. The the respect of the community. CHWs from
average length of service for 13 former VHWs Cochabamba, Bolivia, felt that the community
who had met monthly with their local was unsupportive and unaware of their
committees was three years, while that of 14 activities. They saw themselves as divorced
others who had never met with their local from important decision-making organizations.
committees or met with them rarely was 1.3 They also felt that institutional support from
years (Gray and Ciroma 1987). highly visible community leaders would
In another example, Save the Children increase their motivation and their credibility
and the MOH trained BHTs in Ethiopia in with the villagers (Gonzalez 1987).

R EL AT IO N SH IP W IT H T HE C O MM UN IT Y

29
Section 7

Putting It All Together:


Multiple Incentives

S uccessful CHW programs depend on a framework of incentives


at the individual, community, and health system levels that
together can motivate people to become CHWs and continue in this
capacity for a few to several years, as well as motivate communities
or ministry health offices to maintain and support CHWs and replace
them over several years. Successful projects generally use multiple
incentives simultaneously to motivate CHWs. Understanding the
functions of various incentives can help programs combine these
incentives effectively.

Behavioral Model to support CHWs at different levels of the


Several models in the behavioral science system (Table 5).
literature apply to motivation in a workplace
setting. A model by Pareek (1986) identifies Examples of Multiple Incentives
six primary needs or motivators relevant to As the rest of this paper shows, appropriate
understanding the behavior of people in incentives depend on the social status of
organizations. This model identifies key CHWs, their duties, and other opportunities in
motives that contribute to employee the community. This section reviews several
satisfaction and fulfillment (Table 4). It examples of programs that have used multiple
suggests that incentives that positively affect incentives. More detail about each program

P UT TI N G IT AL L T OG ET H ER : M ULT IP LE IN CE N TI VE S
and reinforce each of these motives would can be found in Annex 1.
contribute to higher motivation and retention
of CHWs, and that incentives that exacerbate Catholic Relief Services, El Salvador
“fears” would likely lead to higher attrition. Catholic Relief Services (CRS) has used the
The third column in Table 4 categorizes Pareek behavioral model to plan and
the incentives that have been reviewed in this implement multiple incentives for CHWs in El
paper according to the motivation model. This Salvador. This is the only example found of an
type of categorization can help program organization using an explicit behavioral
planners choose several incentives that model to plan CHW incentives and tracking
reinforce positive aspects of all six motives attrition rates to evaluate the effects of the
simultaneously. incentives. The El Salvador experience yields
The same list of CHW incentives, several lessons. First, the use of multiple
including the key disincentives mentioned in incentives based on the model was critical not
the literature and in personal communications, only in reducing attrition but also in involving
can be organized into a systems approach the community (Rosales et al. 2000). Second,
that shows an implementer what can be done attrition rates fell by 18 percent over all three

31
Table 4. Motivation Model

Motive Definition CHW incentives


Achievement Concern for excellence; setting of ■ Possibility of future employment
challenging goals ■ Personal growth and
development
■ Acquisition of skills

Affiliation Concern for establishing and ■ Peer support


maintaining close, personal ■ CHW associations and
relationships networks
■ Community involvement
■ Identification (badges, shirts,
etc.)

Extension Concern for others; urge to be ■ Community recognition of and


relevant and useful to larger respect for CHW work
groups ■ Successful referrals

Influence Concern with making an impact ■ Status in the community


on others; desire to change ■ Accomplishment
matters and develop others ■ Visible changes

Control Concern for orderliness; desire to ■ Clear role


be and stay informed; urge to ■ Job aids
monitor and take corrective action ■ Feedback to the MOH and
when needed community
■ Support from the health system
■ Policies or legislation that
support CHWs

Dependency Desire for the help of others in ■ Satisfactory remuneration


one’s own self-development; urge (monetary and nonmonetary)
to maintain an “approval” ■ Training and refresher training
relationship ■ Supervision
■ Preferential treatment
P UT TI N G IT AL L T OG ET H ER : M ULT IP LE IN CE N TI VE S

Source: Pareek 1996

communities studied and by 54 percent in two the BASICS Project since 1995. The AIN
of the communities. Third, as discussed program has a very strong group of monitoras
above, not all communities are alike. The who weigh children under two years old each
establishment of garment factories in one of month and counsel mothers whose children
the communities led to very high attrition of have not gained weight adequately. Several
CHWs who took jobs in the factories. The factors appear to be critical to the monitoras’
main lesson of the CRS experience may be success. First, they work in groups of three
that creating a cadre of volunteer workers and are free to divide their tasks any way they
may not be the best approach to establishing like. Second, the monitoras, health center
CHWs in areas with growing opportunities for nurses, and program staff all focus on the
paid employment. same indicator: adequate child growth in the
previous month. Because of this unified goal,
Atención Integral a la Niñez, Honduras every actor in the program knows which
The MOH of Honduras has implemented the children are not growing adequately and why,
AIN program with technical assistance from as well as what actions have been taken to

32
Table 5. CHW Incentives and Disincentives Organized by a Systems Approach

Motivating factors Incentives Disincentives


Monetary factors that ■ Satisfactory remuneration; ■ Inconsistent remuneration
motivate CHWs material incentives; financial ■ Change in tangible incentives
incentives ■ Inequitable distribution of
■ Possibility of future paid incentives among different
employment community workers

Nonmonetary factors ■ Community recognition and ■ CHWs from outside community


that motivate CHWs respect ■ Inadequate refresher training
■ Acquisition of valued skills ■ Inadequate supervision
■ Personal growth and ■ Excessive demands or time
development constraints
■ Accomplishment ■ Lack of respect from health
■ Peer support facility staff
■ CHW associations
■ Identification (badge, shirt) and
job aids
■ Community status
■ Preferential treatment
■ Flexible and minimal hours
■ Clear role

Community factors that ■ Community involvement in ■ Inappropriate selection of


motivate CHWs CHW selection CHWs
■ Community organizations that ■ Lack of community involvement
support CHW work in CHW selection, training, and
■ Community involvement in support
CHW training
■ Community information systems

Factors that motivate ■ Visible change ■ Unclear role and expectations


communities to support ■ Contribution to community (preventive versus curative
and sustain CHWs empowerment care)
■ CHW associations ■ Inappropriate CHW behavior

P UT TI N G IT AL L T OG ET H ER : M ULT IP LE IN CE N TI VE S
■ Successful referrals to health ■ Failure to take community
facilities needs into account

Factors that motivate ■ Policies or legislation that ■ Inadequate staff and supplies
MOH staff to support support CHWs
and sustain CHWs ■ Visible change
■ Government or community
funding for supervisory
activities

improve the children’s growth. Third, the Isika project, which implements community-
program has used a variety of small based IMCI and community-based nutrition
incentives to encourage and support the interventions using an integrated
monitoras. communication strategy. The Madagascar
approach to using community volunteers, or
Jereo Salama Isika, Madagascar animateurs, is unique in several respects. The
In Madagascar BASICS has provided program expects that 50 percent of the
technical assistance to the Jereo Salama animateurs will drop out after 12 to 18 months.

33
After the animateurs leave the program, project trained over 2000 basic health workers
however, they are still viewed by the (BHWs) to provide preventive and curative
community as important sources of health care. While the project faces the unique
information. For this reason, the program challenges of war, cross-border traffic, and
celebrates its graduates rather than worrying large numbers of refugees, it shares with
about its dropouts. The program’s goal is to other CHW projects the issues of selecting
train as many people as possible (at least 1 BHWs and providing them with incentives.
percent of the population) in a two-day training The BHWs were selected carefully to
workshop. The technical focus of the program ensure that they were committed to improving
is on promoting “small, doable actions” that health services in Afghanistan and to serving
are illustrated on counseling cards (for the resistance movement. Their work was
example, taking a child to be immunized). All monitored by checking administrative records,
NGOs and donors in the country use the reviewing reports of border crossings, and
same illustrations in a wide range of making annual (in some cases triannual)
materials, resulting in consistency and visits. After their training the BHWs received
continuity to health communication. diplomas, which were considered prestigious.
The Jereo Salama Isika program also The project decided to pay the BHWs to give
highlights the importance of considering the them an incentive to stay in Afghanistan
interaction of the role of the volunteers (in rather then move to Pakistan, as many people
Madagascar they are health promoters only, were doing. AHSSP demonstrated tight
with no curative functions) and their accountability by cross-matching three data
incentives. Finally, the word supervision is not sources, an approach that the BHWs
used to describe the relationship between appreciated because they felt the project was
health staff and volunteers. Instead, able to identify “cheaters.” The BHWs also
communities and health staff celebrate the valued their contact with foreign agencies. The
achievements each year in a health festival. attrition rates were fairly low, with an average
of 5 percent, and the average time of
Afghanistan Health Sector Support participation was just over two years. These
Project (AHSSP) statistics did not change much even when
The Afghanistan Health Sector Support salaries were cut by 50 percent. The BHWs
Project (HSSP) began in 1986 to provide who served in areas that bordered Pakistan
P UT TI N G IT AL L T OG ET H ER : M ULT IP LE IN CE N TI VE S

basic health care to the rural Afghan had much higher dropout rates, probably
population scattered among small villages because of family connections and better
separated by natural barriers or war. The opportunities in Pakistan.

34
Section 8

Conclusions and Recommendations

T he experiences with CHW programs reviewed in the previous


section show that no one CHW program will work for all
communities in all countries. Nevertheless, because program planners
find it easier to develop one program and apply it globally, they are
tempted to move in that direction. If a global CHW program is
impracticable, how should programs be tailored and adapted to
specific situations? What issues should be considered? How should
decisions about incentives be made?

Perhaps the most important conclusion of this demands. Policies on CHW distribution of
review is already known: there is no tidy antimicrobials and antimalarials can have
package of three incentives that will ensure tremendous effects on their relationship with
motivated CHWs who continue to work for the community.
years. Instead, a complex set of factors affect At a micro level, the position of CHWs in
CHW motivation and attrition, and the way their communities influences their motivation
these factors play out varies considerably and retention. The inherent characteristics of
from place to place. Program planners do not CHWs, such as their age, gender, ethnicity,
need to start from scratch, however: they can and even economic status, affect the way
draw on the public health community’s they are perceived by community members
extensive experience with CHW programs. and their ability to work effectively.
In summary, CHWs do not exist in a The specific tasks and duties of CHWs
vacuum. They are part of and are influenced affect their motivation and retention. Given too
by the larger cultural and political environment many tasks, CHWs may feel overwhelmed
in which they work. The process of health with information or spend so much time in
sector reform, the IMCI strategy, and the training that they rarely practice what they
achievements of community-based nutrition have learned. Often the catchment areas are

CO NC LU SIO NS A ND RE CO MM END AT IO NS
programs have generated renewed interest in too large, making it difficult for CHWs to find
the potential contribution of CHWs. Health the time or transportation to visit all the
sector reform has changed the supervisory households. Many CHWs are restricted to
structure within health systems and given preventive and promotive roles that leave
more autonomy to peripheral health facilities. them unable to respond to community
Reform has also decentralized the control of demands for curative care (and usually
health funds, allowing greater flexibility in medicines).
spending for various types of CHW incentives. Monetary incentives can increase
The IMCI strategy includes a training retention. CHWs are poor people trying to
curriculum for the assessment and treatment support their families. But monetary
of mild and moderate child illnesses. This incentives often bring a host of problems: the
strategy allows CHWs to play a curative role, money may not be enough, may not be paid
which is usually what the community regularly, or may stop altogether. Monetary

35
incentives may also cause problems among incentives over time to keep CHWs
different cadres of development workers, motivated. A systematic effort that plans for
some of whom are not paid. Nevertheless, multiple incentives over time can build a
some programs have paid CHWs success- CHW’s continuing sense of satisfaction and
fully, and many have used in-kind incentives fulfillment. Identifying the functions of each of
effectively. the incentives would be useful to clarify the
Nonmonetary incentives are critical to the critical functions and how those might vary
success of any CHW program. CHWs need to based on the CHW role and type of
feel through supportive supervision and community.
appropriate training that they are part of the
health system. Relatively small tokens, such as Support the CHW’s Relationship
identification badges, can give CHWs a sense with the Community
of pride in their work and increased status in Surprisingly, the fact that the effectiveness of
their communities. Appropriate job aids, such as the work of CHWs depends almost entirely on
counseling cards and regular replenishment of their relationship with the community is often
supplies, can ensure that CHWs feel competent overlooked. Many programs end up focusing
to do their jobs. Peer support can come in many on clinical training, supervisory checklists,
forms, such as working regularly with one or two and logistics (all of which are extremely
other CHWs, receiving frequent refresher important) to the exclusion of activities that
training, or joining CHW associations. support the community relationship.
In the end a CHW’s effectiveness depends Effective programs have (explicitly or
on his or her relationship with the community. implicitly) oriented the whole program to
Programs must do everything possible to support and strengthen every interaction of
strengthen and support this relationship. First, CHWs with community members. The paper
program planners must recognize the social includes many examples of such orientation,
complexity and diversity of communities. from public recognition of CHW work by
Different communities need different types of supervisors to job aids that support the
incentives, depending on other local job ongoing dialogue between community
opportunities, prior experience with CHWs, the members and CHWs. Programs must ask
economic situation, and other factors. continually what they can do to promote
Unfortunately, little experience or beneficial CHW-community interactions.
guidance on differentiating communities is
available. Programs should involve Use Multiple Incentives
communities in all aspects of the CHW In most of the programs reviewed in this paper,
program, but especially in establishing criteria incentives were implemented ad hoc rather
CO NC LU SIO NS A ND RE CO MM END AT IO NS

for CHWs and making the final selection. than as part of a systematic program. While
Programs can provide opportunities for quick, multiple incentives are used in successful
visible results that promote community programs, new incentives are often proposed in
recognition of CHWs’ work. CHWs must be reaction to a crisis of low morale rather than as
trained in appropriate and respectful part of an overall program effort to maintain
interactions with all community members and high morale. Programs should consider a
in appropriate responses to difficult people or systematic effort to plan for multiple incentives
situations. Community-based organizations over time to build CHWs’ continuing sense of
such as religious groups or youth clubs can satisfaction and fulfillment.
provide support to CHWs and lessen their Programs might find it useful to identify
load significantly by taking on health the functions of each of the incentives using
education activities. Pareek’s model or some other model to
Many successful programs use multiple understand the critical functions and how

36
those might vary based on the CHW role and community-based workers’ ability to provide
type of community. Intrinsic incentives work preventive services and some curative
to promote a sense that the work is treatment of childhood illnesses. For this
worthwhile, while extrinsic incentives include element CHWs will use IMCI concepts and
salary, increased status in the community, tools to classify and treat illnesses and also
and the support of colleagues. Both intrinsic to provide health education. In this
and extrinsic incentives clearly should be arrangement, which is similar to that in the
implemented and monitored. An incentives examples from El Salvador and Honduras
plan could address the multiple motives of described on pages 31-33, the main problem
achievement, affiliation, extension, influence, with high attrition is the training costs.
control, and dependency, as presented by Programs therefore should plan incentives
Pareek. Alternatively, the plan could combine and develop realistic expectations of the
incentives targeted at different parts of the length of service.
systems—monetary or nonmonetary factors The third element of the Community IMCI
that affect the individual CHW, community framework involves promoting the key family
factors that encourage and support CHWs, practices critical for health and nutrition. When
and health system factors that support CHWs work as health promoters, as in the
CHWs. Ideally, an incentive plan would Madagascar example on pages 33-34,
include a combination of both approaches. programs should consider maximizing the
number of training graduates so that healthy
Match Incentives with Duties behaviors are spread widely.
CHWs continue to play an important role in
many international primary health care Employees or Volunteers?
programs. While continuing their preventive In general CHWs are not paid salaries
and community mobilization tasks, CHWs are because the MOH or donors do not consider
increasingly becoming involved in community- salaries to be sustainable. Yet CHWs are often
based case management of prevalent held accountable and supervised as if they
childhood diseases. While CHWs’ success were employees. CHW programs must
rate is often lauded in the early stages of a recognize that CHWs are volunteers, even if
new and exciting project, their motivation they receive small monetary or nonmonetary
diminishes over time unless frequent steps incentives. They are volunteering their time to
are taken to maintain their enthusiasm for serve the community. Too often CHWs are
their essential but voluntary role. treated as inferior employees instead of
The Community IMCI framework lays out helpful volunteers.
three elements of implementation and Perhaps high attrition is not a problem,

CO NC LU SIO NS A ND RE CO MM END AT IO NS
describes the types of communities in which but an opportunity to involve more community
those elements are appropriate. The role of members in promoting good health and
CHWs, and consequently their incentives, will nutrition. The example from Madagascar
vary among the elements. The first element shows ways to change the way people think
emphasizes building strong partnerships of CHWs: to celebrate graduates rather than
between health facilities and communities, worry about dropouts, plan for high turnover,
which depend to a great extent on the CHWs’ and hold shorter, more frequent training
acting as bridges. In such situations, where sessions.
personal relationships are critical, incentive
packages should be developed to avoid Importance of Monitoring
frequent turnover. Many programs do not understand why their
The second element of the Community CHWs drop out. Such programs would be well-
IMCI framework focuses on improving served by monitoring some of the most

37
important factors that affect CHWs’ motiva- Topics for Research
tion and desire to stay on the job. Such Unfortunately, despite the vast experience
monitoring need not be complex or with CHWs, relatively little scientific evidence
quantitative. Much could be done qualitatively, is available to answer some of the basic
through interviews with and observations of questions: What are current attrition rates?
CHWs and community members during What attrition rates are realistic? What is the
routine field visits. most efficient way to monitor CHW programs?
Perhaps the most important issue that How can CHW attrition be reduced
should be monitored by CHW programs is successfully and retention increased? What
whether the programs are able to stay abreast financing strategies can be used to ensure
of the “competition” for CHWs; that is, other that CHWs are paid regularly and sustainably?
jobs and opportunities. Another issue for What critical functions are achieved by
monitoring is how CHWs manage the increased different incentives? What important
workload when new tasks or functions are differences among communities affect CHW
added. Yet another is the interaction of programs, and what is the best way to assess
community members and CHWs. What these differences? How can planners
demands do community members make on the efficiently tailor their programs to meet local
CHWs? How are CHWs treated by their needs?
supervisors and other staff in the health These issues, touched on in this paper,
system? Do the CHWs have the training and require further investigation. Much research is
job aids they need to be effective and feel still needed to determine the best ways to
competent in their jobs? What monetary or sustain long-term CHW programs and retain
nonmonetary incentives would increase their volunteer health workers.
motivation and support their work?
CO NC LU SIO NS A ND RE CO MM END AT IO NS

38
Section 9

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(BASICS II), 2001: 45. Survival Collaboration and Resources (CORE)
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42
Annexes

Annex 1
Examples of the Use of Multiple Incentives

Catholic Relief Services, disaggregated by community, two of the


El Salvador communities had lower rates (Santiago de
The Catholic Relief Services/CARITAS child Maria fell from 85 percent to 15 percent and
survival project began in El Salvador in 1995. San Vicente from 67 percent to 33 percent),
Community health committees, health while the third community, Zacatecoluca,
promoters, and health collaborators were increased its attrition rate from 40 percent to
elected during community meetings. The role 60 percent. The project found that garment
of the health committees was to maintain a factories recently opened in Zacatecoluca had
link with health facilities and promote drawn the volunteers away for paid
intersectoral collaboration. The health employment (Rosales 2000).
promoters collected local health information
and supervised the health collaborators. The Atención Integral a la Niñez,
health collaborators were responsible for Honduras
holding monthly meetings and making home The Atención Integral a la Niñez project is
visits to mothers to discuss breastfeeding, found in about three-fourths of the health
vaccination, and diarrhea management. areas in Honduras. It is implemented by the
The midterm evaluation of the project MOH with technical assistance from BASICS.
found a high attrition rate among the All health centers (HCs) in those areas
collaborators. The project used the Pareek participate and are phasing in the number of
motivational model to plan multiple incentives communities served, for a total of about 1500
for the volunteers. The achievement motive communities. While the numbers vary
was addressed by using participatory training considerably, three monitoras cover 25 to 35
that reflected community needs, included the households with children under two years old.
development of community organizing skills, HC nurses select communities with the
and took place in the community. Forming lowest health indicators on the basis of a
women’s support groups and health health needs assessment. Communities are
committees, providing ID badges, and asked whether they would like to participate in
promoting volunteer networks addressed the the program. Two communities have refused.
affiliation motive. The extension and influence The nurses hold community meetings in which
motives were achieved when the community community members are asked to nominate
and MOH recognized and expressed support two to five people to be trained as monitoras.
for the volunteers through “achievement days” The only criterion for selection is that one of
every six months. The dependency motive the nominees must be highly literate. About a
was attained by periodic supervision by health third of the volunteers have previous
staff and preferential treatment of volunteers experience as midwives or health promoters.
at health facilities. The control motive was Most are women with children of all ages.
achieved through the use of the health Literate people are often younger and without
information system. children. Many are among the better off in the
The final evaluation showed that the community, and all tend to be extroverts and
attrition rate had dropped from 59 percent to have a “presence” in the community.
41 percent (a difference of 18 percent) among The monitoras’ duties include the
A NN E X 1

three communities. When the data were following:

43
■ Weigh all children under two each month and commitment to volunteer work, of which
and provide individual nutritional there is a long history in Honduras. Their
counseling based on the child’s weight work is celebrated in a yearly party, which
gain in the previous month. usually includes several hours of training.
■ Identify and seek out all children under Initially, the program laid out a year’s worth
two who do not attend the weighing of incentives, including a letter to the
session and keep the lists of children up monitoras’ families from the MOH thanking
to date. them for allowing the monitoras to work,
■ Keep track of children who are not gaining certificates of achievement, identification
weight. badges, and t-shirts.
■ Make follow-up home visits to children Anecdotal evidence shows a fairly low
who were sick or did not gain weight in dropout rate among the monitoras. Those who
the previous month. do drop out tend to be younger, literate people
■ Hold community meetings three times a who find paying jobs. Some of the monitoras
year to report the results of the monthly who work on the border with El Salvador
weighing sessions. border often ask for payment because their
■ Be available at set times to treat sick Salvadoran equivalents are paid a salary.
children under five using a modified IMCI Monitoras were very upset when their
algorithm and, if needed, provide oral reimbursement for travel costs for training
rehydration solution or antibiotics. (The was delayed.
monitoras do not make follow-up Monitoras report monthly on the results of
household visits for this component, the weighing sessions. Sometimes the HC
which was added recently and is being nurses attend the weighing sessions to
phased in). vaccinate children. Increasingly, the nurses
recognize the critical role played by the
The monitoras spend about a day or half monitoras in decreasing their workload.
a day a month conducting the weighing Sometimes monitoras help at the HC during
sessions and perhaps another two days national immunization days and other health
making home visits. Three monitoras usually events. Attempts are being made to make the
work in each community. Working as a group municipalities more responsive to community
is critical to their success. The groups can needs, such as improved water supply
decide how to divide their work. All seem to (Griffiths 2000; Griffiths and De Alvarado
work well together. The program has not heard 1999).
of any problems within the groups.
The initial training lasts five days, after Jereo Salama Isika, Madagascar
which the monitoras are given three days of The Jereo Salam Isika program began in two
training for disease treatment. For this training pilot districts in 1997 and is now going to
they receive a minimal travel allowance. The scale in 20 districts, with a total population of
frequency of refresher training and review 4.5 million people. When the decision was
meetings varies greatly, usually depending on made to go to scale, a number of changes
the interest and initiative of the health center were made in the pilot program, including
nurse. About 60 percent of monitoras receive expanding the topics to include family
some type of refresher training, primarily planning, dropping one cadre of health
focused on counseling. volunteers (the amis de santé), and deciding
The monitoras receive no financial to use only existing community groups rather
compensation for their work. Their main than create new ones.
incentives seem to be their recognition by The current program has two levels of
A NN E X 1

the community and their sense of altruism community volunteers: encadreurs and

44
animateurs. The encadreurs are selected by of village animation committees proved to be
the MOH from existing community leaders. a labor-intensive process. The current program
The animateurs are volunteers who are works only with existing community groups.
nominated by the community. The only criteria The program also uses mass media,
for selection are that they want to serve as broadcasting 45-second radio spots and short
animateurs and are nominated by the rural radio programs frequently over ten
community. The program is so popular that stations. Volunteers are not supervised, but
people knock on the doors of the encadreurs are supported and celebrated through health
asking to become animateurs. In each festivals (Sanghvi 2001; Gottert et al. 2000).
community served, ten encadreurs support 30
animateurs. The main tasks of the animateurs Afghanistan Health Sector
are organizing village theatre 20 to 30 times a Support Project (AHSSP)
year, using the counseling cards with groups In October 1986 a cooperative agreement was
of people, and planning health festivals. signed in Peshawar, Pakistan, between
Sometimes the animateurs go to the health Management Sciences for Health and USAID
center to help organize people when crowds to begin the Afghanistan Health Sector
gather for occasions such as immunization Support Project (AHSSP). Very early on the
days. The animateurs are trained in groups of project developed an accelerated strategy to
20 in two-day workshops, where they learn the train a high volume of community or primary
use of counseling cards and village theatre health care workers, called basic health
techniques. workers. The BHWs would provide preventive,
Most of the animateurs are women with promotive, and simple curative services and
young children with a range of literacy, would be expected to enroll in ongoing 12-day
although some are men. When asked why refresher courses when they went to replenish
they want to be animateurs, most say they their supplies.
want to improve the health of their own The BHWs were selected according to the
families and increase their respect in the following criteria:
community. The program expects that 50
percent of the animateurs will stop working 1. ability to read and write
after 12 to 18 months. The animateurs give 2. equivalent sixth class education
two reasons for stopping their work: 1) their 3. age of at least 16, preferably 20 to 30
child is seven years old, and there is nothing 4. residence in the assigned work location
more to learn and 2) they can have jobs and 5. immediate family inside Afghanistan
still be seen as resources in the community. 6. no employment in Pakistan
A number of principles and lessons 7. willingness to participate in the resistance
learned from the pilot program have benefited movement inside Afghanistan after
the current program (see Gottert et al. 2000 completion of the course
for the complete description). “Small, doable 8. Muslim religion and previous participation
actions” rather than increasing knowledge, are in the resistance movement
the focal points of the overall strategy. These
actions were agreed on by all MOH and NGO The first three criteria established the
partners, ensuring complementary and candidates’ capacity to complete training
consistent collaboration. Counseling cards successfully. The next three were aimed at
were developed to show each of the small, selecting candidates with a personal interest
doable actions, and the same images were in seeing improved health services inside
used in a variety of other materials. The two- Afghanistan. The seventh criterion reinforced
day workshops allow many more people to be the expectation that the BHW would work
A NN E X 1

trained. During the pilot program, the creation inside Afghanistan: serving the resisting

45
population was part of the resistance the life of the project lost their lives while
movement. The last criterion tried to eliminate traveling. The BHWs were not reimbursed for
candidates who had not yet served their their travel to Pakistan for the initial training,
regular term as mujahideen and consequently but they were often sponsored by the
might be called to serve in the armed forces community inside Afghanistan. Travel from
of the resistance. Pakistan to the locality of assignment and
From 1987 to 1993, 2,242 BHWs were transport of medical supplies were advanced
trained and 2,190 served for some period. at going rates.
With very few exceptions, all BHWs trained Cross matching of three data sources, as
were male because of the travel requirements. well as having monitoring reports
Every BHW’s location inside Afghanistan was countersigned by local community leaders,
visited at least once a year, and many up to gave the BHWs a sense of being treated
three times a year. Visiting project monitors fairly. Particularly those who stayed in the
took pictures, obtained signed statements of project for several years appreciated the
military and civil authorities on the BHWs’ project’s ability to pick up and single out
performance, and recorded structured “cheaters.” In many communities the BHWs
interviews with patients. Quality control was received recognition as “doctors” because no
the most difficult aspect of the project: few other source of Western medical care was
highly skilled health workers, such as available. Many BHWs expressed their
physicians and nurses, were willing to risk satisfaction with being able to converse
traveling around the country for technical directly with the agency implementing the
supervision visits. program rather than depending on Afghan
BHWs were given several incentives. authorities, who were often perceived as
Upon graduation from the initial training and partisan and corrupt. The BHWs—even those
completion of each refresher course, each excluded from the program for their poor
BHW received a written document confirming performance—expressed appreciation for
his new skills. This document was valued getting a “fair deal.”
highly for the prestige it gave the BHW and The average time of active participation
the accountability it ensured to community of all the BHWs who dropped out of the
leaders for the time spent in Pakistan. project was 25 months, with a minimum of
Although aware of the possible negative long- less than a month and a maximum of 67
term effects of providing salaries, the AHSSP months. The average (and median) attrition
decided to pay the BHWs because salaries rate was 5 percent of the total BHWs enrolled
were seen as “cash for work” and gave Afghan a quarter, with a minimum of 1 percent and a
families still living in rural Afghanistan an maximum of 8 percent a quarter between
incentive to stay there. The amount was set at September 1988 and September 1993.
870 Pakistani rupees, whose value against In October 1992 the project decided to cut
the U.S. dollar fell steadily to about half over salary supplementation to 25 percent of the
the life of the project. Each BHW received an original amount by April 1992 and later to 50
initial kit of medical supplies and basic percent. The contents of medical kits were
equipment that could be resupplied every revised and quantities reduced to reflect the
three to six months. actual average patient load of the BHWs. No
Moving between their assigned working increase in dropout rates was seen over the
places and Pakistan for training, supplies, and 12 months following the initial cuts.
salary payment was hazardous for the BHWs Interestingly, BHWs active in the
because of the geography and infrastructure provinces bordering Pakistan had a much
of the country and the political and military higher dropout rate (63 percent of all trained)
A NN E X 1

instability. Most of the 22 BHWs killed during than those from other provinces (32 percent of

46
all trained). Reasons proposed to explain this ■ The border provinces were occupied by a
difference include the following: mosaic of political factions and to a large
extend made up the former “tribal belt” of
■ Refugee families in Pakistan were Afghanistan, making it difficult for the
originally mostly from the border areas BHWs to link with possible referral health
and often had “split families,” part of facilities in the hands of other
whom still occupied land inside commanders. In the nonborder provinces,
Afghanistan. BHWs from such families larger regional political entities had
had less incentive to work permanently emerged by 1989, offering more local
inside Afghanistan. support to BHWs and in some cases an
■ The location of most cross-border health opportunity to fit into regional health
projects in the border provinces created systems.
opportunities for more gainful employment
of BHWs once they were trained, as well (This appendix was drafted by Paul Ickx from
as competition with more skilled health project reports and discussions with Laurence
workers. Ickx-Laumonier, former field operations officer
of the AHSSP.)

A NN E X 1

47
Annexes

Annex 2
Questionnaire for E-mail and Initial
Interviews

1. Please give examples of incentives that were successful or unsuccessful in retaining CHWs
on a long-term basis and keeping them motivated.

2. Please relate any specific positive or negative experiences regarding the use of the following
types of incentives for CHWs:

a) Public recognition
b) Income-generating activities
c) Management of a first aid, drug, or commodity fund or kit
d) Training
e) Supervision
f) Personal development opportunities
g) Provision of food
h) Provision of a monetary stipend
i) Provision of a bicycle or moped
j) Mentoring
k) Other

3. Have you found any differences between regions of the world (Africa, Latin America and the
Caribbean, Asia, the Newly Independent States) and the types of incentives that were
successful in promoting long-term retention and motivation of CHWs? Please give examples.

4. Do you track information regarding retention rates of CHWs and the cost of rehiring and
retraining?

5. Can you tell us how to obtain documentation on your project experiences with CHWs?

6. Who else would you recommend that we speak to regarding incentives for CHWs? How can
we reach them through e-mail or by phone?

7. Is there any additional information on CHWs that would be useful to you if collected and
analyzed?
A NN E X 2

49
Annexes

Annex 3
Interview Guide for BASICS Examples

Learning about CHWs: Semi-structured Interview Guide


1. Background:
■ What is the population served by your program?
■ What is the total number of CHWs active at any one time?
■ How many CHWs leave the program or become inactive each year?
■ How many CHWs do you recruit each year?

2. CHW selection: How were CHWs selected? What criteria were established? Who established
them? What role did the community play?

3. CHW characteristics: Could you describe some of the characteristics of the CHWs (e.g., sex,
literacy level, previous experience)?

4. Duties: What are the specific duties of the CHWs? What is the relative balance between
curative and preventive activities? How many households does each CHW cover? How much
time is a CHW expected to spend on his/her duties?

5. Drugs: What drugs, especially antibiotics or antimalarials, were CHWs supplied with? How are
they resupplied? How common are stock-outs?

6. Training: What resources do you put into training of newly recruited CHWs each year? How
many training courses for new CHWs are there in a year? How many CHWs are trained each
time? What was the length of training that CHWs received? What is the frequency and duration
of in-service (or refresher) training? Were per diem or travel allowances provided?

7. Incentives: What incentives did the program plan for the CHWs? What do you think motivated
the CHWs to work? Can you give examples of incentives that were successful in keeping
CHWs motivated over a period of time? Please relate any specific positive or negative
experiences regarding the use of the following incentives:
■ Cash in any form, including sale of drugs
■ In-kind incentives such as farming help, dishes, or t-shirts
■ Job aids, special identification
■ Community recognition

8. Multiple incentives: Is there more than one incentive for the CHWs to work? If so, did these
evolve? Were they planned? How do they work together?

9. Disincentives: Have any CHWs dropped out? What do you think are the main reasons for
dropping out? Do you feel that the program has a problem with high turnover or dropouts or
attrition? Why or why not?
A NN E X 3

51
10. CHW/facility link: What is the relationship between the CHW and the health facility? Is the
facility staff supposed to supervise the CHWs? How does this work? What difficulties are
there?

11. CHW/community link: What is the status of CHWs in the community? Are they perceived as
government health workers or volunteers? What CHW functions does the community value
most? How are CHWs linked to community groups, including health committees?

12. Peer support: Do the CHWs work alone? In pairs? In groups of three? How are they meant to
work together? What opportunities are CHWs given to interact with other CHWs from other
areas?

13. Information on CHWS: What information do you routinely collect on CHWs (e.g., retention
rates, costs of training, costs of incentives)? Is this type of information important to you? If
so, how do you use this data (e.g., to modify incentives)?

14. Documentation: Do you have any documentation of experiences with CHWs that you can
send to us?
A NN E X 3

52

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