What Community Health Workers Want: A Combination of Incentives
Udochisom Anaba, Frontline Health project, Population Council
The World Health Organization (WHO) estimates that by 2030, global health systems won’t have enough health workers to achieve universal health coverage (UHC) - in fact, we will be short by 18 million. This shortage has left the global community scrambling to recruit and train community health workers (CHWs). To mitigate this projected shortage, there is a renewed interest in CHWs, especially in low- and middle-income countries (LMICs).
CHWs are “health workers carrying out functions related to healthcare delivery; trained in some way in the context of the intervention and having no formal professional or paraprofessional certificate or degree in tertiary education” as defined by Lewin & colleagues. They have a deep understanding of the communities in which they live and serve, are a link between formal health systems and communities, and bring vital, life-saving services closer to the families who need them.
CHWs are not a new piece of the health systems puzzle – in fact, they have been utilized to make up for a lack of trained doctors and nurses in rural areas, and limited access to health facilities by providing health services to vulnerable and poor populations in hard-to-reach areas for the past 60 years. And they have been instrumental to national ministries of health in delivering primary health services following the 1978 Alma Ata Conference and Declaration. But with the rising numbers of HIV/AIDS related illnesses in the 1980s and a stronger emphasis on vertical disease-specific programs, CHW initiatives lost favor, in part due to sustainability issues such as low retention rates and motivation of CHWs.
Research from different settings suggests that the retention and motivation of CHWs can improve with a combination of financial incentives, such as regular salaries, performance-based monetary incentives, and non-financial incentives like trainings, adequate access to supplies, supportive supervision, respect, and trust. But what is still lacking, are the perspectives of CHWs on the combination of incentives they would need for improved performance. And so, the questions remain: If we ask CHWs what they want, what would they say? And why should we care?
We should care because CHW attrition, is not only costly to the health system, it also directly affects families within the communities they serve. Health systems bear the costs of retraining and recruiting new CHWs and any possible loss of morale for other CHWs, who may now have additional work responsibilities. Within the communities themselves, attrition can cause a discontinuation of care and may have a devastating effect on the most vulnerable families.
To promote retention and motivation of CHWs, we know that a package of incentives is needed to meet their expectations. So, in 2006, the WHO identified the need to understand the levels and methods of remuneration and types of non-financial incentives to strengthen CHW programs. Twelve years later, the global community is still trying to understand what package of incentives is needed. Now is the time for stakeholders in LMICs to sit with their CHWs and understand what will motivate them to be successful and stay in their roles.
At the recent primary health conference in Astana, Kazakhstan, the Astana Declaration, celebrated the 40th anniversary of the Alma-Ata Declaration, and global leaders reaffirmed the importance of community health systems and CHWs in strengthening primary health care. The World Health Organization also unveiled the first ever guidelines for community health workers, that will guide CHW policy and programming. However, our efforts cannot be sustainable without adequate attention to understanding the factors that can keep CHWs active in their roles and committed to the welfare of their communities. Incentives are at the heart of this matter. Most ministries of health in low-and middle-income countries do not have enough resources allocated to commit to a regular salary for the large cadres of CHWs; this gives more credence to the idea of a “package” of interventions. International donors and other policymakers should incentivize high performance by CHWs, by ensuring that they have the training and remuneration they need and that their voices are heard.