Abstract
IntroductionCommunity health workers (CHWs) have been proposed as a means for bridging gaps in healthcare delivery in rural communities. Recent CHW programmes have been shown to improve child and neonatal health outcomes, and it is increasingly being suggested that paid CHWs become an integral part of health systems. Remuneration of CHWs can potentially effect their motivation and focus. Broadly, programmes follow a social, monetary or mixed market approach to remuneration. Conscious understanding of the differences, and of what each has to offer, is important in selecting the most appropriate approach according to the context.Case descriptionsThe objective of this review is to identify and examine different remuneration models of CHWs that have been utilized in large-scale sustained programmes to gain insight into the effect that remuneration has on the motivation and focus of CHWs. A MEDLINE search using Ovid SP was undertaken and data collected from secondary sources about CHW programmes in Iran, Ethiopia, India, Bangladesh and Nepal. Five main approaches were identified: part-time volunteer CHWs without regular financial incentives, volunteers that sell health-related merchandise, volunteers with financial incentives, paid full-time CHWs and a mixed model of paid and volunteer CHWs.Discussion and evaluationBoth volunteer and remunerated CHWs are potentially effective and can bring something to the health arena that the other may not. For example, well-trained, supervised volunteers and full-time CHWs who receive regular payment, or a combination of both, are more likely to engage the community in grass-roots health-related empowerment. Programmes that utilize minimal economic incentives to part-time CHWs tend to limit their focus, with financially incentivized activities becoming central. They can, however, improve outcomes in well-circumscribed areas. In order to maintain benefits from different approaches, there is a need to distinguish between CHWs that are trained and remunerated to be a part of an existing health system and those who, with little training, take on roles and are motivated by a range of contextual factors. Governments and planners can benefit from understanding the programme that can best be supported in their communities, thereby maximizing motivation and effectiveness.
Highlights
Community health workers (CHWs) have been proposed as a means for bridging gaps in healthcare delivery in rural communities
Case descriptions: The objective of this review is to identify and examine different remuneration models of CHWs that have been utilized in large-scale sustained programmes to gain insight into the effect that remuneration has on the motivation and focus of CHWs
The purpose of this review is to understand broadly five remuneration models utilized by large-scale, well-established CHW training programmes in different parts of the world and to gain insight into their effect on the motivation and focus of the CHWs and how this might impact on government planning of CHW programmes
Summary
Community health workers (CHWs) have been proposed as a means for bridging gaps in healthcare delivery in rural communities. CHWs can be viewed as individuals whose primary role is to extend the reach of the existing mainstream health system [2] or playing a broader role by serving as cultural mediators or change agents by facilitating grass-roots community engagement to improve health outcomes [2,3,4]. They have been proposed as a means of bridging the gap in the current health systems in many low- and middle-income countries (LMIC) but have shown promise, with chronic disease management in high-income countries [5,6]. The need to systematically and professionally train lay community members to be part of the health workforce has emerged not as a stop-gap measure, but as a core component of primary health care systems in low-resource settings.” [7]
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