Abstract
BackgroundThe World Health Organization recommends that community health workers (CHWs) receive a mix of financial and non-financial incentives, yet notes that there is limited evidence to support the use of one type of incentive (i.e. financial or non-financial) over another. In preparation for a larger scale trial, we investigated the acceptability and feasibility of two different forms of incentives for CHWs in Malang District, Indonesia.MethodsCHWs working on a cardiovascular disease (CVD) risk screening and management programme in two villages were assigned to receive either a financial or non-financial incentive for 6 months. In the financial incentives village, CHWs (n = 20) received 16,000 IDR (USD 1.1) per patient followed up or 500,000 IDR (USD 34.1) if they followed up 100% of their assigned high-risk CVD patients each month. In the non-financial incentive village, CHWs (n = 20) were eligible to receive a Quality Care Certificate for following up the highest number of high-risk CVD patients each month, awarded in a public ceremony. At the end of the 6-month intervention period, focus group discussions were conducted with CHWs and semi-structured interviews with programme administrators to investigate acceptability, facilitators and barriers to implementation and feasibility of the incentive models. Data on monthly CHW follow-up activity were analysed using descriptive statistics to assess the preliminary impact of each incentive on service delivery outcomes, and CHW motivation levels were assessed pre- and post-implementation.ResultsFactors beyond the control of the study significantly interrupted the implementation of the financial incentive, particularly the threat of violence towards CHWs due to village government elections. Despite CHWs reporting that both the financial and non-financial incentives were acceptable, programme administrators questioned the sustainability of the non-financial incentive and reported CHWs were ambivalent towards them. CHW service delivery outcomes increased 17% for CHWs eligible for the non-financial incentive and 21% for CHWs eligible for the financial incentive. There was a statistically significant increase (p < 0.0001) in motivation scores for the performance domain in both villages.ConclusionIt was feasible to deliver both a performance-based financial and non-financial incentive to CHWs in Malang District, Indonesia, and both incentive types were acceptable to CHWs and programme administrators. Evidence of preliminary effectiveness also suggests that both the financial and non-financial incentives were associated with improved motivation and service delivery outcomes. These findings will inform the next phase of incentive design, in which incentive feasibility and preliminary effectiveness will need to be considered alongside their longer-term sustainability within the health system.
Highlights
The shortage of health workers in low- and middleincome countries (LMICs) is forecast to reach approximately 15 million by 2030, representing a major challenge to achieving universal health coverage (UHC) [1, 2]
It was feasible to deliver both a performance-based financial and non-financial incentive to community health worker (CHW) in Malang District, Indonesia, and both incentive types were acceptable to CHWs and programme administrators
Evidence of preliminary effectiveness suggests that both the financial and non-financial incentives were associated with improved motivation and service delivery outcomes
Summary
The shortage of health workers in low- and middleincome countries (LMICs) is forecast to reach approximately 15 million by 2030, representing a major challenge to achieving universal health coverage (UHC) [1, 2]. Many LMICs have placed greater emphasis on the role of community health worker (CHW) programmes to expand coverage of primary health care services. CHWs are defined as members of the communities where they work, selected by and answerable to communities, supported by the health system but not necessarily a part of its organization, and with shorter training than professional workers [3]. In the 40 years between the Alma Ata and Astana Declarations, a substantial body of evidence has emerged demonstrating the pivotal role of CHWs in improving access to essential health care services and health outcomes [5,6,7]. The World Health Organization recommends that community health workers (CHWs) receive a mix of financial and non-financial incentives, yet notes that there is limited evidence to support the use of one type of incentive (i.e. financial or non-financial) over another. In preparation for a larger scale trial, we investigated the acceptability and feasibility of two different forms of incentives for CHWs in Malang District, Indonesia
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