Abstract
BackgroundBRAC, a large Bangladeshi NGO, recently has been using female volunteer community health workers (CHWs) in Dhaka urban slums to provide maternal and child health services. Due to erratic performance-based income and higher opportunity cost the urban CHWs lose motivation which contributes to high dropout and poor performance. This results challenges for the cost effectiveness and sustainability of the urban health program. CHWs also consider their performance-based income very low compare to their work load. So, CHWs raise their voice for a fixed income. In order to understand this problem we explored fixed income for CHWs and the correlates that influence it. We surveyed a sample of 542 current CHWs. We used bidding game approach to derive the equilibrium reservation wage for CHWs for providing full-time services. Then, we performed ordered logit models with bootstrap simulation to identify the determinants of reservation wage.ResultsThe average reservation wage of CHWs to continue their work as full-time CHWs rather than volunteer CHWs was US$24.11 which was three times higher than their current performance-based average income of US$ 8.03. Those CHWs received additional health training outside BRAC were 72% and those who joined with an expectation of income were 62% more likely to ask for higher reservation wage. On the contrary, CHWs who were burdened with household loan were 65% and CHWs who had alternative income generating scope were 47% less likely to ask for higher reservation wage. Other important factors we identified were BRAC village organization membership, competition with other health services providers, performance as a CHW, and current and past monthly CHW income.ConclusionsThe findings of this study are relevant to certain developing countries such as Bangladesh and Tanzania which commonly use volunteer CHWs, and where poor retention and performance is a common issue due to erratic and performance-based income. So, the study has implications in improving retention of health workers as well as their level of performance. The study also suggests that the financial incentives provided to CHWs should be clearly based on their qualifications and opportunity cost to ensure a high performing and motivated health workforce.
Highlights
BRAC, a large Bangladeshi NGO, recently has been using female volunteer community health workers (CHWs) in Dhaka urban slums to provide maternal and child health services
With a view to exploring the correlates of reservation wage we perceived a set of hypotheses to test. Those volunteer CHWs have joined with an expectation of income are more likely to ask for higher reservation wage; those who have more education and training are more likely to ask for higher reservation wage; and those who perform better and earn higher income are more likely to ask for higher reservation wage
We found that CHWs who joined with an expectation of income rather than serving the community were more likely to ask for higher reservation wage
Summary
BRAC, a large Bangladeshi NGO, recently has been using female volunteer community health workers (CHWs) in Dhaka urban slums to provide maternal and child health services. The typical scenario of health workforce in Bangladesh exacerbates poor provider-population ratios [3] as it does in many other low-income countries This is, a reflection of global crisis which is considered as a major obstacle to achieving the health-related millennium development goals (MDGs) by 2015 [4,5]. Under these circumstances, community health workers (CHWs) provide a crucial and strategic solution to the shortage of skilled health workforce filling this gap in many developing countries including Bangladesh.
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