Community Health WorkerIncentives and Disincentives:How They Affect Motivation, Retention,and Sustainability

Contributors

Karabi Bhattacharyya Peter Winch

Karen LeBan Marie Tien

Karabi Bhattacharyya

Peter Winch

Karen LeBan

Marie Tien

Community Health WorkerIncentives and Disincentives:How They Affect Motivation, Retention, and Sustainability

AbstractThis paper examines the experience with using various incentives to motivate and retain communityhealth workers (CHWs) serving primarily as volunteers in child health and nutrition programs indeveloping countries. It makes recommendations for more systematic use of multiple incentives basedon an understanding of the functions of different kinds of incentives and emphasizes the importance ofthe 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 CHWprograms.

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

CreditCover 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 theBureau for Global Programs, Field Support, and Research of the U.S. Agency for InternationalDevelopment (USAID). BASICS II is conducted by the Partnership for Child Health Care, Inc., undercontract no. HRN-C-00-99-00007-00. Partners are the Academy for Educational Development, JohnSnow, Inc., and Management Sciences for Health. Subcontractors include Emory University, The JohnsHopkins University, The Manoff Group Inc., the Program for Appropriate Technology in Health, Save theChildren Federation, Inc., and TSL.

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

1600 Wilson Boulevard, Suite 300 • Arlington, Virginia 22209 USATel: 703-312-6800 • Fax: 703-312-6900E-mail address: infoctr@basics.org • Website: www.basics.org

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Table of Contents

Acknowledgments .............................................................................................................. v

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

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

Section 1CHWs: The Context ......................................................................................................... 1

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

Section 2Methodology ................................................................................................................... 9

Organization of This Review ........................................................................................ 9Methodology ............................................................................................................... 9

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

Characteristics of CHWs ........................................................................................... 11Duties of CHWs ........................................................................................................ 11

Section 4Monetary Incentives and Disincentives ........................................................................... 15

Money as an Incentive .............................................................................................. 15Problems with Using Money as an Incentive ............................................................... 16In-kind Payments as an Effective “Compromise” ......................................................... 17

Section 5Nonmonetary Incentives and Disincentives ..................................................................... 19

Supervision or Recognition ........................................................................................ 19Personal Growth and Development Opportunities ........................................................ 21Training .................................................................................................................... 21Peer Support and CHW Networks ............................................................................... 24

Section 6Relationship with the Community .................................................................................... 25

Enhancing the Relationship Between CHWs and Communities ..................................... 25Selection of CHWs .................................................................................................... 26Community Recognition of CHW Work ........................................................................ 27Community Organizations that Support CHW Work ..................................................... 29

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Section 7Putting It All Together: Multiple Incentives ....................................................................... 31

Behavioral Model ...................................................................................................... 31Examples of Multiple Incentives ................................................................................ 31

Section 8Conclusions and Recommendations ............................................................................... 35

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

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

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

TablesTable 1. Alternative Titles for CHWs ............................................................................... 2Table 2. Comparison of CHWs with Professional Health Staff ........................................... 3Table 3. Roles of CHWs in the Implementation of the Three Elements of the

HH/C IMCI Framework ...................................................................................... 7Table 4. Motivation Model ............................................................................................ 32Table 5. CHW Incentives and Disincentives Organized by a Systems Approach .............. 33

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Acknowledgments

he authors would like to acknowledge the following people who made comments on thevarious drafts of the paper: Renata Seidel, Mark Rasmuson, Rene Salgado, Marilyn Rice,Paul Ickx, Lisa Sherburne, Stephan Solat, Judianne McNulty, William Brieger, EricT

Swedberg, Peter Gottert, and Michael Favin. Adwoa Steel, Marcia Griffiths, Tina Sanghvi, andAlfonso Contreras were interviewed for some of the examples. Paul Ickx drafted the example fromAfghanistan. The authors also thank Wendy Hammond and Kathleen Shears for editing the paperand Kathy Strauss for layout and design.

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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

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Executive Summary

Over the past couple decades, anumber of studies have shown thatcommunity health workers (CHWs)

can help reduce morbidity and mortality incertain settings. Health programs haverecruited and trained these primarily volunteerworkers to carry out a variety of healthpromotion, case management, and servicedelivery activities at the community level.CHWs can serve as a bridge betweenprofessional health staff and the communityand help communities identify and addresstheir own health needs. They can provideinformation to health system managers thatmay otherwise never reach them and canencourage those in the health system tounderstand and respond to community needs.CHWs can help mobilize communityresources, act as advocates for thecommunity, and build local capacity.

The overall environment of internationalpublic health has changed dramatically withhealth sector reform and decentralization.Local governments have greater autonomyand authority to develop and finance healthsolutions appropriate to their locales. In childsurvival programs, the IntegratedManagement of Childhood Illness (IMCI)approach is changing the way sick childrenare managed and health facilities areorganized. As these dramatic changes in thepublic health context create new opportunitiesfor programs that include community healthworkers, this is a critical time to review thepast experience and draw lessons for thefuture.

One of the most critical problems forCHW programs is the high rate of attrition.Attrition rates are reported between 3.2percent and 77 percent. Higher rates aregenerally associated with volunteers. Suchhigh attrition rates lead to a lack of continuityin the relationship between a CHW andcommunity, increased costs in selecting andtraining CHWs, and lost opportunities to build

on experience. Indeed, the very effectivenessof CHW work usually depends on retention.

This paper examines experience withvarious incentives for CHWs and their impacton retention of CHWs and the sustainability ofCHW programs. It reviews the types ofincentives that are needed to motivateinvolvement, to retain CHWs once they havebeen trained, and to sustain their performanceat acceptable levels. Although there areimportant lessons to learn from othercommunity-based development workers, thispaper focuses primarily on community-basedworkers who provide some type of health ornutrition service.

Organization of the PaperThe paper is organized into the followingsections. Section 1 discusses the context ofCHW programs, including the changesbrought on by health sector reform and theIMCI approach. Section 2 describes theobjectives and methodology of the review.Section 3 reviews the typical characteristicsof CHWs and provides an overview of thewide range of their functions. Section 4 looksat the various ways that cash can be both anincentive and a disincentive and reviews in-kind incentives. Section 5 discusses some ofthe other program features that can motivateCHWs to continue their work, including theirrelationship to other health staff, their senseof personal growth and accomplishment,training opportunities, and peer support.Section 6 examines the critical relationshipbetween CHWs and their communities.Section 7 reviews how the use of multipleincentives can contribute to CHW retention,and Section 8 contains conclusions andrecommendations.

ConclusionsPerhaps the most important conclusion of thisreview is that there is no tidy package of threeincentives that will ensure motivated CHWs

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who will continue to work for years. Rather, acomplex set of factors affects CHWmotivation and attrition, and how these factorsplay out varies considerably from place toplace. However, program planners can drawon the extensive experience of the publichealth community with CHW programs. Asummary of the main conclusions of thereview follows.

CHWs do not exist in a vacuum. Theyare part of and are influenced by the largercultural and political environment in whichthey work. The process of health sectorreform, the adoption of the IMCI strategy,and the progress made by community-basednutrition programs have generated renewedinterest in the potential contribution of CHWs.Health sector reform has changed thesupervisory structure within health systemsand given more autonomy to peripheralhealth facilities. It has also decentralized thecontrol of health funds, allowing greaterflexibility in spending for various types ofCHW incentives. The IMCI strategy includesa training curriculum on assessing andtreating mild and moderate childhoodillnesses. Such training allows CHWs to playa curative role, which is usually whatcommunities demand. Policies on CHWdistribution of antimicrobials andantimalarials can have tremendous effectson their relationship with the community.

The motivation and retention of CHWs isinfluenced by who they are in the communitycontext. The inherent characteristics ofCHWs, such as their age, gender, ethnicity,and even economic status, will affect howthey are perceived by community membersand their ability to work effectively.

At the micro level, the specific tasks andduties of CHWs affect their motivation andretention. When given too many tasks, CHWsfeel overwhelmed with information or mayspend so much time in training that theyrarely practice what they have learned. Oftenthe catchment areas they cover are too largewith too many households, making it difficultfor a CHW to spend the time or find the

transportation to go to all the households.Many CHWs are restricted to preventive andpromotive roles that leave them unable torespond to community demands for curativecare (and usually medicines).

Monetary incentives can increaseretention. CHWs are poor people trying tosupport their families. But monetaryincentives often bring a host of problemsbecause the money may not be enough, maynot be paid regularly, or may stop altogether.Monetary incentives may also causeproblems among different cadres ofdevelopment workers who are paid and notpaid. However, there are some successstories of programs paying CHWs. Manyprograms have used in-kind incentiveseffectively.

Non-monetary incentives are critical tothe success of any CHW program. CHWsneed to feel that they are a part of the healthsystem through supportive supervision andappropriate training. Relatively small things,such as an identification badge, can provide asense of pride in their work and increasedstatus in their communities. Appropriate jobaides such as counseling cards and regularreplenishment of supplies can help ensurethat CHWs feel competent to do their jobs.Peer support can come in many forms, suchas working regularly with one or two otherCHWs, frequent refresher training, or evenCHW associations.

In the end, the effectiveness of a CHWcomes down to his or her relationship with thecommunity. Programs must do everythingthey can to strengthen and support thisrelationship. First, program planners mustrecognize the social complexity ofcommunities and that communities are not allalike. Different communities will needdifferent types of incentives, depending on theother job opportunities available, priorexperience with CHWs, the economicsituation of the community, and other factors.Unfortunately, very little experience orguidance is available on how best todifferentiate communities. It is important to

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involve communities in all aspects of theCHW program but especially in establishingcriteria for CHWs and making the finalselection. Programs can provide opportunitiesfor quick visible results that will promotecommunity recognition of CHWs’ work. CHWsmust be trained in appropriate and respectful

interactions with all community members andin how to respond to difficult people orsituations. Community-based organizations,such as religious groups or youth clubs, canprovide support to CHWs and significantlylessen their load by taking on healtheducation activities.

Incentives Disincentives

Monetary factors ■ Satisfactory remuneration/ ■ Inconsistent remunerationthat motivate Material Incentives/Financial ■ Change in tangible incentivesindividual CHWs Incentives ■ Inequitable distribution of

■ Possibility of future paid incentives among differentemployment types of community workers

Nonmonetary factors ■ Community recognition and ■ Person not from communitythat motivate respect of CHW work ■ Inadequate refresher trainingindividual CHWs ■ Acquisition of valued skills ■ Inadequate supervision

■ Personal growth and ■ Excessive demands/timedevelopment 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 offactors that motivate CHW selection CHWsindividual 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 andcommunities to ■ Contribution to community expectations (preventivesupport and sustain empowerment versus curative care)CHWs ■ CHW associations ■ Inappropriate CHW behavior

■ Successful referrals to ■ Needs of the community nothealth facilities taken into account

Factors that motivate ■ Policies/legislation that ■ Inadequate staff andMOH staff to support support CHWs suppliesand sustain CHWs ■ Witnessing visible changes

■ Funding for supervisoryactivities from governmentand/or community

CHW Incentives and Disincentives Organized by a Systems Approach

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Many successful programs use multipleincentives over time to keep CHWsmotivated. A systematic effort that plans formultiple incentives over time can build up aCHW’s continuing sense of satisfaction andfulfillment.

RecommendationsSupport the CHW’s relationship with thecommunity.The fact that the effectiveness of the work ofthe CHW depends almost entirely on his orher relationship with the community issurprisingly often overlooked. Many programsfocus on clinical training, supervisorychecklists, and logistics (all of which areextremely important), to the exclusion ofactivities that support the communityrelationship. Effective programs have(explicitly or implicitly) oriented the wholeprogram to support and strengthen everyinteraction that a CHW has with communitymembers. Many examples of such efforts aregiven throughout the paper, from publicrecognition of CHW work by supervisors to jobaides that support the ongoing dialoguebetween community members and CHWs.Programs must continually ask what can bedone to promote beneficial interactions.

Use multiple incentives.In most of the programs reviewed, incentiveswere implemented in an ad-hoc manner ratherthan as part of a systematic program. It wouldbe useful to identify the functions of each ofthe incentives used to understand which arethe critical functions and how those might varybased on the CHW role and type of community.Intrinsic incentives work to promote a sensethat the work is worthwhile, while extrinsicincentives include salary and increased statuswithin the community and with colleagues. It isclear that both intrinsic and extrinsic incentivesshould be implemented and monitored. Thetable on page xi shows a list of CHWincentives, including key disincentivesmentioned in the literature and throughpersonal communi-cations, organized into a

systems approach that helps an implementerconsider what can be done to support a CHWat different levels of the system.

Vary the incentives based on CHW duties. CHWs continue to play an important role inmany international primary health careprograms. While continuing their preventiveand community mobilization tasks, CHWs areincreasingly becoming involved in community-based case management of prevalentchildhood diseases. The Community-IMCIframework lays out three elements ofimplementation and describes different typesof communities where those elements areappropriate. The role of CHWs, andconsequently their incentives, will vary amongthe elements.

Are CHWs volunteers or employees?In general CHWs are not paid salariesbecause the MOH or donors do not considersalaries to be sustainable. Yet CHWs are oftenheld accountable and supervised as if theywere employees. CHW programs mustrecognize that CHWs are volunteers, even ifthey receive small monetary or nonmonetaryincentives. They are volunteering their time toserve the community.

Continue to understand your program.Many programs do not understand why theirCHWs drop out. Programs would be wellserved by monitoring some of the mostimportant factors that affect a CHW’smotivation and desire to stay on the job.Program managers must stay abreast of the“competition”: what other jobs andopportunities are available for the CHWs?When new tasks or functions are added,programs should assess how CHWs aremanaging the increased workload. How docommunity members and the CHW interact?What demands are community membersmaking on the CHWs? How do theirsupervisors and other staff in the healthsystem treat CHWs? Do the CHWs have thetraining and job aides they need to be

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effective and feel competent in their jobs?What monetary or nonmonetary incentiveswould increase their motivation and supporttheir work?

More research is needed.The question of how to sustain a long-termCHW program and to retain workers requiresadditional investigation. It is unfortunate thatdespite the vast experience with CHWs,relatively little scientific evidence is availableto answer some of the basic questions: Whatare the current attrition rates? What are

realistic attrition rates? What is the mostefficient way to monitor CHW programs? Whatare successful ways of reducing attrition andincreasing retention of CHWs? What are somefinancing strategies to pay CHWs in a regularand sustainable manner? What are the criticalfunctions that are achieved by differentincentives? What are the most importantdifferences among communities that affectCHW programs, and what is the best way toassess these differences? How can plannersefficiently tailor their programs to meet localneeds?

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Section 1

CHWs: The Context

Community health workers (CHWs) are not a new concept. Healthprograms have recruited and trained CHWs to carry out a variety

of health promotion, case management, and service delivery activitiesat 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 canprovide 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 helpmobilize community resources, act as advocates for the community,

and build local capacity (Center for Policy Alternatives 1998).

BackgroundYet for many public health practitioners,especially donor agencies, CHWs are a failedconcept. Both the effectiveness of CHWs aschange agents and the feasibility ofimplementing and sustaining large-scale CHWprograms have been called into question.After being touted earlier as a key componentof the strategy of Health for All by the Year2000, CHW programs have frequently failed tolive up to the expectations of a dynamicgrassroots movement.

Despite this perception, CHW programsare worth reviewing. Over the past twodecades, a number of studies have shownthat CHWs can help reduce morbidity andmortality in certain settings. The overallenvironment of international public health haschanged dramatically with health sectorreform and decentralization, giving localgovernments greater autonomy and authorityto develop and finance health solutionsappropriate to their locales. In child survivalprograms, the Integrated Management ofChildhood Illness approach has created a

paradigm shift in the management of sickchildren and organization of health facilities.And with the advent of the communitycomponent of IMCI, CHWs have been soughtout as effective community agents with a roleto play in the prevention of disease, thepromotion of healthy behaviors, and, in someplaces, the case management of sickchildren.

These dramatic changes in the publichealth context have created new opportunitiesfor CHW programs. Now is a critical time toreview past experience and draw lessons forthe future. Although there may be importantlessons to learn from other community-baseddevelopment workers, this paper focuses oncommunity-based workers who provide sometype of health or nutrition service.

CHW programs face many problems,including poor training, inadequate supervision,lack of supplies, and poor relationships withcommunities. One of the most frustratingelements of many CHW programs is their highattrition rate. This paper examines recentexperiences with CHW programs to determine

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the factors that contribute to high motivationand low attrition of CHWs. Identifying theseincentives will help program planners developsustainable CHW programs.

Attrition in CHW ProgramsAttrition rates for CHWs of 3.2 percent to 77percent are reported in the literature, withhigher rates generally associated withvolunteers (Walt 1989). One review (Parlatoand Favin 1982) found attrition rates of 30percent over nine months in Senegal and 50percent over two years in Nigeria. CHWs whodepend on community financing have twicethe attrition rate as those who receive agovernment salary. In the Solomon Islands,attrition was attributed to multiple causes inaddition to inadequate pay, including familyreasons, lack of community support, andupgrading of health posts (Chevalier 1993).

High attrition rates cause severalproblems. Frequent turnover of CHWsmeans a lack of continuity in therelationships established among a CHW,community, and health system.Considerable investment is made in eachCHW, and program costs for identifying,screening, selecting, and training the CHWrise with high attrition rates. When CHWsleave their posts, the opportunity is lost tobuild on their experience and further developtheir skills over time through refreshertraining. The very effectiveness of CHWwork usually depends on retention.

Definitions of Key WordsCommunity Health WorkersSince the role of the CHW was re-emphasizedduring the Alma Ata conference in 1978, therehave been several variations and definitions ofthis term. The specific roles andresponsibilities of CHWs vary greatly amongcountries, depending on people’s access tohealth care and the presence of other cadres ofhealth workers. Table 1 shows the vast array oftitles used for CHWs. In this report the termCHW refers to all of these titles, with the localtitles used to refer to specific examples.

Walt (1998) provides the followingcommon definition of CHWs as:

... generally local inhabitants given alimited amount of training to providespecific basic health and nutritionservices to the mothers of theirsurrounding communities. They areexpected to remain in their homevillage or neighborhood and usuallyonly work part-time as health workers.They may be volunteers or receive asalary. They are generally not,however, civil servants or professionalemployees of Ministry of Health.

Table 1. Alternative Titles for CHWs

Title Country

Activista MozambiqueAnganwadi IndiaAnimatrice HaitiBarangay health worker PhilippinesBasic health worker IndiaBrigadista NicaraguaColaborador voluntario GuatemalaCommunity health agent EthiopiaCommunity health promoter ZambiaCommunity health representative various countriesCommunity health volunteer MalawiCommunity nutrition worker IndiaCommunity resource person UgandaFemale multipurpose health worker NepalHealth promoter various countriesKader IndonesiaMonitora HondurasOutreach educator various countriesPromotora HondurasRural health motivator SwazilandSevika NepalVillage health helper KenyaVillage health worker various countries

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Section 1

A distinction should be made betweenCHWs and other professional health staff toexplain the unique role and background ofCHWs. Table 2 presents an example fromLatin America comparing two groups of healthworkers—professional and volunteer. Thiscomparison applies in most other countriesand regions.

Many definitions of CHWs also reflectexpectations of their roles. For example,“…members of the communities where theywork; should be selected by the communities;should be answerable to the communities fortheir activities; should be supported by thehealth system but not necessarily part of itsorganization; and have a shorter training[period] than professional workers” (Frankel1992). CHWs usually provide services topeople living in specific catchment areas,most often the areas where they themselveslive.

Other DefinitionsThe following definitions and assumptions forthe key concepts of CHW incentives,motivation, retention, and sustainability areused throughout the paper.

Incentives: Positive or negative, intrinsicor extrinsic factorsinfluencing CHW motivationand volunteerism (Note: thispaper focuses on incentivesthat can be addressedprogrammatically.)

Motivation: Desire to serve and performeffectively as a CHW

Retention: Length of time that anindividual CHW activelyperforms appropriatecommunity primary healthcare tasks

Sustainability: A continuing system ofrecruitment, training, andsupervision of a cadre ofvolunteers in a community ordistrict that meets its memberor group health care needs

CHWs and ComprehensivePrimary Health CareDuring the Alma Ata conference in 1978,CHWs were identified as one of thecornerstones of comprehensive primary healthcare. CHWs had the potential to deliverequitable health services to populations livingin remote areas and to help fill the unmetdemand for regular health services in manycountries. Such workers could solve theproblems of poor access to health care and thehigh cost of doctors and reduce the social andcultural barriers to health care. While providingsimple technical and educational interventions,CHWs could also serve as an entry point intothe larger cultural, environmental, political, andsocial factors that affect health. They could beagents of change stimulating communityparticipation in efforts to resolve the causal

Table 2. Comparison of CHWs with Professional Health Staff

Auxiliary nurses or health technicians(professional health staff)

■ Primary education plus 1–2 yearsof training

■ From outside the community■ Employed full time■ Salary usually paid by the program

(not by the community)

Health promoters or village healthworkers (volunteers from the community)

■ Third grade education plus 1–6months of training

■ From the community■ Employed part time■ Supported by farm labor or other

community help■ May be traditional healers

Source: Walt 1988

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factors of illness (Frankel 1992). In otherwords, CHWs were thought to be the magicbullets of primary health care.

After Alma Ata many countries initiatedprograms to scale up local CHW initiatives tothe national level. By the early 1990s,however, enthusiasm for CHWs was waningamong ministries of health and donororganizations for a variety of reasons.

■ Countries could not replicate CHWprograms and take them to scale whilemaintaining the original levels of altruism,commitment, and effectiveness.

■ The barefoot doctor movement in China,which was for many the model for scalingup CHW programs, declined in bothcoverage and effectiveness in the wakeof economic reform and conversion ofmuch of the health sector to the fee-for-service model.

■ Attempts to create a global (one-size-fits-all) approach to CHW programs led toinflexible programs and approaches.

■ Use of the mass media and socialmarketing seemed to be more costeffective than CHWs in promotingchanges in health-related behaviors at thenational level.

■ Attempts were initiated to upgrade the skillsof existing community-level health careproviders (pharmacists, private physicians,traditional healers) rather than to create newcadres of health workers who might ceaseactivities once funds run out.

■ The use of CHWs as agents for specificvertical programs, such as for diarrheaand malaria, diminished the advantagesof the holistic approach and often led tomultiple training with less time on the job.

Despite these limitations, there is evidencethat CHWs can reduce morbidity and mortalityunder certain conditions and therefore provideoutreach and services that governments maynot otherwise be able to deliver. In Egypt infantmortality was reduced by 40 percent when oralrehydration solution (ORS) was distributed to

homes, compared to a reduction of only 15percent when it was available only throughpharmacists (Parlato and Favin 1982). In Nepal,where CHWs were provided with antibiotics andtraining in the diagnosis of pneumonia, anevaluation found that the case management byCHWs was correct in 80 percent of cases(Dawson et al. 2001). A study in Ecuador foundthat CHWs were much more cost effective thanhospital-based workers in vaccinating children(San Sebastian et al. 2001). Among populationswith limited access to basic health care, CHWscan facilitate referrals. There is growingevidence that CHW programs are an appropriateway to address concerns about equity amongunderserved populations, as well as to increasethe effectiveness of programs. Two impactstudies carried out in Colombia suggest thatsmaller-scale programs (within a neighborhood,municipality, district, or ethnic community)developed through community participation aremore effective in changing health-relatedpractices than larger programs (Quinones 1999).Along with other community resource people,CHWs can be critical to the promotion of keypreventive and treatment behaviors.

While CHWs may not be appropriate in allsettings, they cannot be dismissed as aprogrammatic option. Mass media and socialmarketing approaches cannot by themselvesprovide the depth of interaction necessary tochange complex health behaviors. For example,the media may promote eating foods rich invitamin A, but CHWs can work with individualfamilies to develop acceptable recipes and uselocally available foods. Similarly, approachesthat rely exclusively on the private sector mayhave limited impact where commercial outletsare rare. Healthy behaviors need to benegotiated continually so that families can applythem to their own situations. CHWs can be apractical and effective way to do this in many,though not all, situations.

CHWs in the Context ofHealth Sector ReformMost countries in Africa and much of the restof the world are undergoing health sector

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reform that involves the reorganization of theentire health sector. Health sector reformusually includes decentralization, theintroduction of fees for a variety of healthservices, integrated health care packages,and donor coordination.

The focus on health sector reform anddecentralization has led to a renewedemphasis on ways to extend coverage tounderserved areas as well as to increase localinvolvement in decision making regardinghealth service delivery. The problems faced byhealth systems are illustrated in a recent studyof health services in Burkina Faso (Bodart etal. 2001). The study documents a steadydecline in the use of curative services, astrong urban bias in public spending on health,and high cost of care to patients. Policymakersare concerned about how to address these andother issues to improve access to health careamong underserved populations. Health sectorreform, including decentralization of civil andhealth systems, provides a new opportunity torevitalize CHW programs and develop localsolutions to CHW incentives.

The role and tasks of CHWs vary bydistrict and community, and the type ofincentives needed to support the CHWs inthese tasks need to be locally specific aswell. As part of the movement to decentralizehealth services, ministries of health and donororganizations are turning increasingly tonongovernmental organizations (NGOs)1 asnatural partners for extending coverage andscaling up interventions. CHWs frequentlyplay a key role in the operations of NGOs atthe village and district levels.

Because programs funded bygovernments can often change or disappearfrom one administration to the next, manylarge-scale government CHW paymentprograms have not been sustained in the longterm (Frankel 1992). The decentralizedframework provides new opportunities for thesupport and motivation of CHWs.

Governments that have devolved localdecision making and authority to districts,municipalities, and villages seem to besuccessful in applying general governmentguidance flexibly to meet their local healthneeds. Appropriate legislation and policies canhelp CHWs organize and retain members andmaintain a CHW system over time. Twoexamples are discussed on page 6.

CHWs and Community IMCIIn 1995 WHO and UNICEF launched theIntegrated Management of Childhood Illnessstrategy. IMCI is an integrated approach to theassessment, classification, and treatment ofsick children that combines aspects of nutrition,immunization, disease prevention, andpromotion of growth and development. Thestrategy addresses the illnesses and healthproblems responsible for the majority of deathsamong children under five years of age and thefact that children are often ill from multiplecauses. IMCI ensures that a child who isbrought into a health center for diarrhea will alsobe treated for malaria or pneumonia if needed.

Until recently IMCI focused on improvinghealth systems (including drug availability) andthe skills of health workers to assess, classify,and treat children accurately. In 1997 thehousehold and community (HH/C) componentof IMCI was launched (Lambrechts et al. 1999).A framework has been defined for planning andimplementing Community IMCI (Steinwand2001; Winch et al. 2001) that includes the threefollowing elements:

1. Improving partnerships between healthfacilities and services and thecommunities they serve

2. Increasing appropriate and accessiblecare and information from community-based providers

3. Integrating promotion of key familypractices critical for child health andnutrition

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

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The three elements are to be implemen-ted by working across many sectors (a“multisectoral platform”) in order to addressthe social, economic, and environmentalfactors that facilitate or hinder the adoption ofkey family practices. Each of these elementsaddresses a point of influence critical toappropriate child health care. At each point ofinfluence, CHWs are often involved indelivering services and messages and inmobilizing the community (Table 3).

The role of a CHW varies with the strategychosen to implement each element that isappropriate for a specific setting. Clearly,however, CHWs of some sort are critical to thesuccess of Community IMCI. Implementation ofthe community component of IMCI requires acadre of workers to deliver needed services toperipheral areas, promote child wellness andgood nutritional status, prevent child illness, andlink communities with health facilities that maybe underutilized. Although private practitionersof some kind may be available even in remoteareas, the fee-for-service approach does notlend itself to preventive services or to nutrition-related interventions. Organizations such as thePan American Health Organization (PAHO) aretherefore promoting CHWs as the entry point forthe implementation of Community IMCI.

Policy Environment andDecentralizationThe overall health policy environment candramatically affect CHW programs. In Indonesiathe kader system survived on the tradition ofvolunteerism and the support of the PKK, anational organization of the wives of politicalleaders (Favin 2001). In Mozambiquecommunity members who had been happy tovolunteer under socialism are now demandingcash incentives with the move towardcapitalism (Favin 2001). Policies often determinewho is eligible to become a CHW and whetherthe CHWs can administer antibiotics or receivecash incentives. With health sector reform,some ministries of health are restructuring their

CHW programs. Two examples of suchrestructuring are described below.

In 1995 the Philippine government enactedthe Barangay Health Workers Act of 1995,which granted benefits and incentives toaccredited barangay health workers (BHWs).The act included such provisions assubsistence allowance, career enrichmentprograms, recognition of years of primary healthcare, special training programs, and preferentialaccess to loans. Experience from a pilotadvocacy campaign showed that with adequateinformation and motivation, local governmentunits were willing to provide financial andlogistical support, including a transportationallowance and budget for regular upgradetraining, as well as formal recognition of theroles of BHWs. BHWs have now organizedthemselves at the barangay level and in manyareas are federated at the municipal andprovincial levels and are becoming a significantpolitical force for child survival (Paison 1999).

A program in Ceara, Brazil, found that adecentralized approach using paid health agents(HAs) could improve access to health care. TheHAs had to have lived in the community for theprevious five years. They also had to be over18, able to work eight hours a day, andcommitted to social service. Each HA visits 75households (225 in urban areas) once a monthto provide health education and minor curativetreatment. Nurses from the nearest clinicsupervise them. The agents earn the equivalentof US $112 a month (twice the average localmonthly income), which is paid out of tax fundsfrom the state government to insulate the HAsfrom local politics. To ensure local support forthe HAs, municipal governments must usesome of the newly decentralized funds toemploy the nurse supervisors before the statefunds can be released. The results have been awell-trained cadre of health workers anddramatic improvements in child health, with aninfant mortality reduction of 32 percent.Unfortunately, attrition rates are not reported(Svitone et al. 2000).

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

Element

1. Improving partnerships between healthfacilities or services and the communitiesthey serve

2. Increasing appropriate, accessible care andinformation from community-basedproviders

3. Integrating promotion of key family practicescritical for child health and nutrition

CHW role

■ Help health facilities conduct communityoutreach.

■ Involve community members in planning andimplementing health programs and services.

■ Raise awareness in the community aboutimprovements to health services.

■ Educate community members about dangersigns requiring care at health facilities.

■ Participate in data collection for communityhealth information systems.

■ Provide effective basic care (e.g., oralrehydration therapy, antipyretic drugs) forsick children.

■ In some areas, treat sick children with otherfirst-line drugs, such as chloroquine andcotrimoxazole, and advocate against harmfulpractices, such as injections.

■ Refer sick children to appropriate healthfacilities when advanced care is required.

■ Serve as a bridge to other providers (privatesector and traditional healers).

■ Engage communities in selecting behaviorsto be promoted and identifying actions to betaken.

■ Promote key family practices for enhancedphysical growth and mental development,prevention of disease, appropriate homecare, and appropriate care-seeking behaviorthrough individual counseling andcommunity meetings.

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Section 2

Methodology

he renewed interest in CHWs described on pages 5-6 is leadingpolicymakers and program managers to examine critically past

Organization of This ReviewSection 3 of this paper reviews the typicalcharacteristics of CHWs. Section 4 providesan overview of the wide range of theirfunctions. Section 5 looks at the various wayscash can serve as both an incentive and adisincentive and reviews the use of in-kindpayments. Section 6 discusses other programfeatures that can motivate CHWs to continuetheir work, including relationships with otherhealth staff, sense of personal growth andaccomplishment, training opportunities, andpeer support. Section 7 examines the criticalrelationship between the CHW and thecommunity. Finally, Section 8 reviews thecontribution of the overall policy environmentand the mix of incentives that can contributeto CHW retention.

MethodologyA review of incentives for CHWs wasidentified as a priority at a meeting betweenthe staff of the Basic Support forInstitutionalizing Child Survival II (BASICS II)Project and the Child Survival Collaborationand Resources Group (CORE)2 IMCI Working

Group in the fall of 1999. BASICS and NGOstaff had observed that minimal tokens ofrecognition could make a world of differencein enhancing community participation andincreasing volunteer retention. By lookingmore closely at incentives, BASICS II hopedto learn how they affect the motivation,retention, and sustainability of CHWs.

This paper is based on a review of theliterature and interviews with program stafffrom many organizations. A literature searchwas conducted using the Internet databasesPubMed, Medline, and Popline. The key wordsmotivation, incentives, sustainability, CHWs,volunteers, and developing countries wereused in different combinations during thesearch. Several books and articlesrecommended by practitioners working withCHWs were also used for the paper. Sincemuch of the information on CHWs is in theunpublished (“gray”) literature, this literaturewas identified through personal contacts andthrough a request for information that includeda questionnaire sent to the CORE ChildSurvival Community Group list serve and theMSH Community Health list serve. The

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experience with CHW programs. In light of all the problems broughtby 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. Thisreview examines experience with various incentives for CHWs and

their impact on the retention of CHWs and the sustainability of CHW

programs.

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

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questionnaire generated over 30 responses.Some of these responses led to furtherinterviews with over a dozen practitioners.

Two broad categories of literature wereidentified and reviewed. The first categoryincluded papers reviewing the history andexperience of CHW programs, and the secondcategory included specific examples fromprograms working with CHWs. One of the keydocuments used in this paper is the 1982paper Progress and Problems: An Analysis of52 AID-assisted Projects, by Parlato andFavin. Although almost 20 years old, thispaper is unique in systematically reviewingthe experience of a wide range of primaryhealth care programs. The authors provideimportant details about the work of CHWs inthese programs, although they include littleinformation about incentives.

Initial group and private interviews wereconducted with BASICS II staff, NGO staffactive in child survival programs, academics,and current and former staff from programsfunded by the United States Agency forInternational Development (USAID). Theseinterviews were based on the interview guide

in Annex 1 and focused on specific examplesand experiences from work with CHWs.

A draft of this paper was circulated to allBASICS II technical field and headquartersstaff and through the CORE list serve inAugust 2000 to solicit additional informationand comments. Further interviews wereconducted with project staff to elicit theBASICS experience with CHWs.Semistructured interviews were conductedwith staff in the Ecuador, El Salvador,Honduras, Madagascar, Nigeria, and Zambiaprograms. The interview guide in Annex 2covers a wide range of topics, including theselection of CHWs, support from the healthsystem, training opportunities, and monetaryand nonmonetary incentives. On the basis ofthese comments and additional experiences,substantial revisions were undertaken and thefinal paper completed.

The literature review and interviewsfocused primarily on CHWs working in childhealth, rather than other types of developmentworkers, such as family planning workers,traditional birth attendants, or agriculturaloutreach workers.

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Section 3

Who Are CHWs and WhatDo They Do?

L ong before considering money, t-shirts, or other externalincentives, 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.

CHWs, 23 percent women, and 37 percentboth men and women. Many programs requirethat CHWs be literate (primary schooleducated) so that they can record healthinformation and use written materials. Otherprograms have developed ways to recordinformation for nonliterate people, such asusing color-coded cards or pebbles in boxes(Storms 1979). Literacy requirements oftenaffect the age of the selected CHWs: literatepeople tend to be younger. There is someevidence, on the other hand, that older CHWsare more respected in their communities(Ofosu-Amaah 1983).

Duties of CHWsThe responsibilities of CHWs, as in any job,are tied to the need and expectation ofvarious incentives. The specific duties andfunctions of CHWs can dramaticallyinfluence their effectiveness and motivationto stay on the job. A CHW may assist thehealth system in improving access to health,promoting preventive health messages,providing nutritional counseling or curativecare, and helping community residents findother health care options through referrals.Some CHWs work only in health promotionand have no curative functions. All nationalhealth programs operate with financialconstraints and limited trained staff. As aresult, these programs tend to add tasks andfunctions continually to the duties of existingstaff, especially CHWs. Although there is noperfect equation for the combination of CHW

Characteristics of CHWsNo prescription for the ideal CHW exists, butprograms must understand the role andstatus of the people who work as CHWs inorder to plan appropriate incentives. In manycultures men cannot visit and talk withwomen, and women cannot travel alone toother communities or talk with people inunfamiliar households. The ethnic group,religion, or language skills of CHWs are oftencritical to their ability to work effectively.Most non-Western cultures place greateremphasis on ascribed characteristics (thoseinherent in the person, such as age orgender) than on achieved characteristics,such as special training. Thus, in somecultures young unmarried women are notviewed as people with health expertise evenwhen they have received extensive training.Similarly, communities respond differently toCHWs from inside the community than tothose from outside. Some communitymembers may feel that because insiders are“just like me” they have no specialknowledge. Others may feel that insidersunderstand their situation far better thanoutsiders. Such “insider” CHWs “…are armedwith knowledge that no professional canmatch: an intimate knowledge of their ownculture” (Quinones 1999).

Most CHWs are from the communitieswhere they work, but their personalcharacteristics vary widely among countries.One review of 38 projects (Parlato and Favin1982) found that 40 percent enlisted men

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duties, recent experience sheds light onsome of the issues surrounding the role ofthe CHW.

Single or Multiple FocusThe Alma Ata Declaration enumerated thefollowing tasks expected of CHWs: “homevisits, environmental sanitation, provision ofwater supply, first aid and treatment of simpleand common ailments, health education,nutrition and surveillance, maternal and childhealth and family planning activities,communicable disease control, communitydevelopment activities, referrals, record-keeping, and collection of data on vital events”(Ofosu-Amaah 1983). This long list ofresponsibilities would seem unreasonable todemand of volunteer workers. Some programshave trained several people and divided thefunctions among them. For example, in Nepalthe village health worker does the basicpreventive and curative work, while thecommunity health leader motivates thecommunity to participate in special campaigns(Parlato and Favin 1982). A team of workersoften exacerbates the problem of incentives,however, because more people require support.

Many programs have trained CHWs towork in a single area, such as diarrhea,malaria, or nutrition. For example, in manyparts of Latin America, volunteer collaboratorsconduct treatment and surveillance formalaria. They make home visits to people withsymptoms of malaria, complete patientreports, take blood smears, and administerdoses of chloroquine (Ruebush et al. 1994).The advantage of CHWs with a single focus isthat they can be trained and monitored toperform a manageable set of tasks. The maindisadvantage is frequent training andretraining in various vertical programs, with noopportunity for integration. Experience inMadagascar suggests that a CHW canmanage only three or four themes at the most(Gottert 2001).

Apart from a consensus that no oneperson can manage all the activities laid outin the Alma Ata Declaration, there is little

scientific evidence of the optimal number andmix of CHW functions and tasks. Programsmust carefully monitor CHWs’ workloads andtheir effects on motivation as additional tasksare added.

Mix of Curative and PreventiveServicesWhether CHWs have a single or multiplefocus, the balance between curative andpreventive care has been identified as anissue. Prevention is extremely hard to sell inall public health programs. When curative careis offered, it is generally more welcomed andappreciated by the residents (Frankel 1992;Heggenhougen et al. 1987; Walt et al. 1989;Curtale et al. 1995). A report from Tanzanianoted that “CHWs have expressed frustrationat not being able to provide the quality ofservices demanded by the community andtherefore want further training in curativemedicine” (Heggenhougen et al. 1987). Withdisappointment on the part of the villagersand feelings of inadequacy among the CHWs,the relationship has been “characterized by alack of support from the community….” TheTanzania report states that “unless thecommunity’s expectations change, the lack ofsupport for the CHWs will be aggravated if thepreventive role predominates over theircurative activities….”

“Credibility of CHWs is highly dependenton the workers’ curative role,” find Parlato andFavin (1982). In Nepal community healthvolunteers who were able to treat acuterespiratory infection (ARI) greatly increasedtheir credibility among the village population.(Curtale et al. 1995). A lack of curative skillsmay be a disincentive for CHWs,compromising their standing in thecommunity. (Gilson et al. 1989). Given achoice between preventive and curative care,community members demand more curativecare (Walt et al. 1989), and problems oftenarise when CHWs cannot meet communitydemands. The relationship between the CHWand the community must be monitored andsupported to ensure an effective partnership.

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DrugsClosely linked to the importance of providingcurative care are CHWs’ access to and supplyof drugs. The kind of medicines CHWs shouldbe allowed to administer has been the subjectof much debate. Many are concerned thattreatment with antibiotics and antimalarials, inparticular, might lead to overuse and misuseof these medicines and eventual increases indrug resistance. Those who advocateinclusion of these drugs in CHW kits arguethat they are readily available from localpharmacists and drug sellers and that trainedCHWs may be able to promote proper usage.

The respect and status of CHWs in theircommunities unquestionably increases whenthey have drugs at their disposal. In theirreview of 52 projects, Parlato and Favin (1982)found that “CHWs’ credibility suffers whendrug supplies are irregular.” Recent experience

with recruiting CHWs from practicing drugsellers and pharmacists has shown that thisstrategy makes drugs available, gives thedrug sellers greater prestige, and greatlyreduces attrition (Ishan 2001).

In Nigeria’s Gongola State, village healthworkers (VHWs) were trained to work inremote villages to treat common diseaseswith basic drugs and provide health education.An operations research study conducted todetermine what contributed to the high VHWattrition rate found that one of the mainreasons was villagers’ dissatisfaction with theVHWs’ limited curative role. The VHWs’ lackof training or licenses to give injectionscreated a discrepancy between what thecommunity wanted and what the VHW couldprovide (Gray and Ciroma 1987).

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Section 4

Monetary Incentives andDisincentives

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

the ministry of health (MOH) or other organization. The primaryreason is the belief that the MOH cannot afford to pay CHWs over thelong 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 todemands 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 cashincentives of all types.

Money as an IncentiveThere are many advantages to providingCHWs with cash incentives. From the programperspective, paid CHWs can be asked to worklonger hours to achieve specific objectiveswithin a specified time frame. When agentsare paid, rigorous supervision can beexercised, programs can be implementedrapidly, work routines can be standardized,and service quality can be maintained(Phillips 1999). Negative reinforcers such asfiring or punishment can be used to encouragedesired performance. Payment is also seen ashelping to build some economic equity in aminimally literate or economicallydisadvantaged population.

The main programmatic advantage tocash incentives is the apparently lowerattrition rate among paid CHWs. In GongolaState, Nigeria, the Rural Health Program ofthe Christian Reformed Church found thatVHWs left their posts after one to three years(Gray and Ciroma 1987). The VHWs workedone or two hours a day and received a smallsalary (the equivalent of US$13 to $27 a

month in 1984). Men with lower monthlyincomes worked two years and women withlower incomes worked one year, while menwith higher pay stayed an average of 3.25years and higher paid women stayed 1.5years. Small salaries were mentioned mostoften as the reason VHWs found the workdifficult. In a system established in Ethiopia’sGumer District, each household contributedone birr (US$0.15) a year to support thecommunity health agents (CHAs) andtraditional birth attendants (TBAs). Thiscontribution was enough to cover a modeststipend for all trained CHAs and TBAs, andthe attrition rate fell from 85 percent a year tozero (Wubneh 1999).

From the CHW perspective, appropriate,respectful, and regular compensation is a signof acknowledgment and approval that allowsthem to earn a living or supplement otherincome. Cash incentives may come in severalforms. CHWs may be part of the civil serviceand be paid a salary. They may also be givena small stipend. CHWs are often given perdiem and travel allowances to attend training

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or make field visits. Cash incentives may alsobe tied to drug sales.

The source of CHW payments can be thecommunity (contributions from individualhouseholds), the government, an NGO, oreven a for-profit company. The source offunds may affect the role and allegiance ofthe CHW. Several NGOs have tried to createcommunity revolving drug funds or othertypes of community-based credit fundsspecifically for health incentives. Whenassociated with profits that are the “incentive”for the CHW, few of these schemes havebeen successful or achieved any level ofscale (Edison 2000; Henderson 2000). Whencompensation is tied to drug sales, CHWstend to focus on curative care, while CHWswith salaries maintain both preventive andcurative activities (Parlato and Favin 1982).Fee-for-service schemes often result in anincrease of curative over preventive activitiesand the overprescription of medications(Davis 2000). Some NGOs report misuse ofthe funds through “borrowing” from theproceeds of the sales.

There is some indication thatdecentralization increases the flexibility of thelocal government to respond to issues ofCHW remuneration. In the Philippines anincreasing number of honoraria, or travelallowances, have been provided to communityvolunteer health workers (CVHWs) from bothmunicipal governments and villagedevelopment councils. The honoraria, whichrange from US$.50 to US$50 a month, arepossible because of the devolution of healthservices from the provincial level to themunicipality and village levels. At each levellocal support for the health programs isfunded out of the government’s respectiverevenue allocation (Paison 1999).

Some countries have experimented withinsurance plans. In Haiti a combination of aprepaid scheme, existing community groups,and revenue-generating activity has beenused to motivate CHWs to provide preventiveservices. Groups of mothers who coulddemonstrate their knowledge in child survival

interventions and whose children were fullyimmunized and participating in growthmonitoring were eligible to receive low-interestloans for income-generating activities. Eachgroup of mothers paid an annual fee for ahealth card, and the funds were used tosupport the CHW. These funds have beenmatched by a one-time grant from theinstitution sponsoring the CHW program.Mothers had an economic incentive to learnhealth interventions in order to have access tothe loans (Augustin and Pipp 1986).

Problems with Using Money asan IncentiveWhile paying CHWs regularly can solve manyproblems, experience in many countries hasshown that such payment can have unforeseennegative consequences, depending on how it ishandled. Money can be a divisive factor forCHWs and can undermine their commitmentand the relationships they have with theircommunities. Volunteers often cite lack ofremuneration as a key factor causing theirattrition, but they also cite other critical reasons,such as lack of community support and lack ofsupervision (Wubneh 1999). Payment is difficultto disaggregate from other reasons becausethey are often interconnected. When using cashincentives, program managers should calculatehow long such a payment scheme can befunded. When the government or an NGO offersmonetary support, special effort is needed tocompensate for possible distrust or heightenedexpectations in the community. Some examplesof the negative consequences of paying CHWsare described below.

The Money Is Never EnoughThe first problem with money is that workersinevitably demand more money, benefits, andopportunities for promotion. In the SolomonIslands 38 percent of nonworking VHWs leftbecause of irregular remuneration. Ninety-twopercent of the 66 working VHWs surveyedthought their allowances were inadequate andwanted them doubled from US$13.67 toUS$27 a month (Chevalier 1993). In

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Swaziland CHW salaries did not change overa decade in which the local currency gained400 percent in buying power (Green 1996). IfCHWs do not consider their salariesadequate, their performance and retentionlevels may by negatively affected.

Sustainability of PaymentsThe second problem with monetarycompensation is that payment is oftenirregular and may end altogether whenproject funding runs out. Using other termsfor payments, such as “field allowance,”“transport allowance,” or “per diem,” canhave advantages in some circumstancesbecause they create fewer expectations.The sustainability of such incentives,however, ultimately may depend on theirsource.

Payments are often linked to specifictraining sessions. In Zambia the NGOAdventist Development and Relief Agency(ADRA) provided small “meal allowances” toCHWs when they brought their monthlyreports to the health centers (Edison 2000). Tocircumvent salary issues, an NGO in Boliviagave very small financial incentives to CHWsfor discrete tasks that were easy to measureand track (Shanklin 2000). Staff had to spendtime evaluating over-reporting and doublereporting among CHWs, however.

Inequity among WorkersComparison of their salaries with those of otherworkers may lead CHWs to call for salaryincreases or benefits such as pensions andhealth care. Payment is rarely consistentamong cadres of workers such as CHWs andcommunity-based distributors of contra-ceptives, who may work side by side andperform similar duties. Such discrepancies canresult in jealousy and enmity. If some but notall CHWs or other community workers are paid,tension can result between the paid and unpaidgroups. In Colombia CHWs who receivefinancial compensation for their work havegenerated tension and envy among otherCHWs and community leaders who do not

receive any remuneration (Quinones 1999).Monitoras who work in Honduras along theborder with El Salvador frequently complainthat their Salvadoran counterparts are paidwhile they are not (Griffiths 2001).

Are CHWs Accountable to theCommunity or to the Government?CHWs who receive a salary or stipend maysee themselves as employees of thegovernment or NGO rather than as servantsof the community. Financial incentives candestroy the spirit of volunteerism and workagainst the volunteer philosophy of a sense ofcommunity (Alonzo and Hurtate 2000). Even atiny allowance can reinforce the community’sperception that the CHWs are governmentemployees and lead to expectations that theygive even more freely of their time andpersonal resources (Taylor 2000; Hilton 2000).A community may become less willing tosupport the volunteers in other ways. Forexample, communities in Mozambique thatthought activistas would receive a monetaryincentive from an NGO or the MOH withheldtheir in-kind support (Snetro 2000). Whenpeople distrust the government, they distrustCHWs who are perceived to be a part of thegovernment system.

In-kind Payments as anEffective “Compromise”Paying CHWs in kind rather than in cash hasadvantages. In-kind payments are less proneto comparison with levels of compensation ofsalaried employees because their exact valuemay be difficult to quantify. CHWs can be paidin kind with cooking, food, housing, and helpwith agricultural work and child care. Mostsuccessful in-kind payments are planned andimplemented by the community. Beneficiaryfamilies in Peru have taken turns working forfree on the farms of the volunteers inrecognition of their important contribution(Buenavente 2000).

Another type of in-kind payment ismaterial items provided by NGOs. Suchitems are often, though not always, related

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to the CHWs’ job functions. Successful in-kind payments provided by NGOs haveincluded bags to carry supplies, agriculturetools, raincoats, backpacks, supplies forhome improvement, educational materials,herbal plants, and fruit trees. Alonso andHurtarte (2000) have found, however, thatincentives given too often or in too manyforms are unsuccessful and demotivating inthe long term. The Shishu Kabar Hearthnutritional program in Bangladesh gave eachvolunteer mother a set of dishes at the endof the sessions, avoiding a cash payment.This incentive helped the volunteers feelappreciated and made it easier for trainersto recruit mothers in new communities(Wollinka 1997). In some instances foodsupplements have been used as payments,but CHWs have been reluctant to continueworking when the food supplements haveended. ADRA’s experience has shown thatany kind of financial support or subsidy,despite its positive short-term impact, isproblematic for long-term sustainability(McHenry 2000). Selectively giving paymentor food to some communities and not toothers can generate animosity amongcommunities and jealousy among families(Shanklin 2000).

Preferential TreatmentSeveral programs demonstrate appreciationfor CHWs’ work through preferential treatment,such as access to credit programs, literacyclasses, or first-in-line treatment at healthposts. For example, CHWs in Guatemala wereexempt from military service (Parlato andFavin 1982). In India the CHW must showsuccess with an income-generating activity togain recognition as a health worker. Ratherthan receiving a salary or wage, the IndianCHW is given access to credit for income-generating activities through a bank loan(Arole 2000). Other NGO programs giveCHWs, especially women, priority forinclusion in other development programs,such as group-guaranteed lending andsavings programs. In the Ashanti Region ofGhana, members of the village healthcommittees (VHCs) receive identity cards thatallow them to be seen quickly at clinics. Whenthere is a death in the family of a VHCmember, a small cash donation is given to thefamily, and the district health managementteam (DHMT) is represented at the funeral(Leonard 2000). In all such cases, preferentialtreatment of CHWs must be monitoredcarefully to ensure that community membersdo not resent special treatment of CHWs.

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Section 5

Nonmonetary Incentivesand Disincentives

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

they are not sufficient to maintain and retain CHWs’ motivation.EOther types of incentives, often intangible, are critical to jobsatisfaction and fulfillment. These incentives include a good

relationship with health staff, personal growth and development

opportunities, training, and peer support. Perhaps the most importantnonmonetary incentive, a good relationship with the community, is

discussed in the following section.

Supervision or RecognitionCHWs occupy a unique position in the healthsystem. They are usually not full-time salariedhealth workers, yet they are the pivotal bridgebetween the community and the healthsystem. Compared with other health workers,they tend to have the lowest status becauseof their low levels of education and pooreconomic status. To ensure that the CHWsremain “of the community,” ministries of healthare usually reluctant to treat them as anothercadre of health worker, while the CHWs areoften eager to be identified with the prestige ofthe health system. These competing andcontradictory tensions create a host ofproblems related to a CHW’s sense ofinclusion in and support from the healthsystem.

The MOH can help CHWs feel supportedand appreciated in many ways. In Indonesia aradio-based health communication campaignmotivated the kaders by publicly praisingthem as “volunteers who work withoutcompensation for our children in our village forthe sake of the future.” After the campaignmothers and village headmen complimentedthe kaders and attended the health postsmore often. Retention improved significantly

as a result (Elder 1992). In Kitwe, Zambia,where the community health promoters(CHPs) had no contact with the healthsystem, frequent visits by outsiders (donorsand NGOs) helped them maintain theircommitment and motivation (Steel 2001).Sometimes the MOH sends letters ofappreciation to the CHWs and their families,although such expressions of appreciation arenot the norm.

Typically, after the initial training a CHW’srelationship with the rest of the health systemis limited to what is usually called supervision.Supervisors can give the CHW opportunitiesto discuss problems, exchange information,and take advantage of continuing education.Supervisory visits help reduce the feelings ofisolation that often accompany a CHW’soccupation. To be effective, supervisory visitsshould be regular and based on a commonunderstanding of the purpose of the visit.CHWs appreciate good supervision given withthe honest intention of capacity building andmentoring. In Guatemala supervised CHWshad attrition rates two to three times lowerthan those of unsupervised CHWs becausetheir link with outside experts gave themhigher status (Parlato and Favin 1982).

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Weak, inadequate, and inconsistentsupervision is cited frequently as a cause oflow rates of CHW retention (Frankel 1992;Ofosu-Amaah 1983; Heggenhougen et al.1987; Walt et al. 1989; Curtale et al. 1995;Ojofeitimi 1987; Schaefer 1985). Problemswith supervision range from the logisticaldifficulties of reaching remote communities tointeractions that are more punitive thansupportive. Ofusu-Amaah (1992) summarizesmany of the problems of CHW supervision ofby health professionals in the following list:

■ heavy clinical and other responsibilities ofhealth professionals

■ inappropriate training of healthprofessionals in primary health care

■ inaccessibility of villages■ multiple uncoordinated supervision visits

by different health personnel working withthe CHWs

■ lack of vehicles or petrol■ lack of per diem■ general shortage of health personnel

In Sri Lanka the frequency and duration ofsupervision was inadequate because of majorshortages of supervisory staff at all levels,and especially at the central MOH level,where a third of the positions were vacant(Ofosu-Amaah 1983). In Tanzania CHWsreceived some supervision from the villageleaders and village council but were notfamiliar with CHW training or job descriptions(Heggenhougen et al. 1987). Poormanagement can also affect the quality ofsupervision at all levels of peripheral healthservices and primary level services. Gilson etal. (1989) describe this effect as “thereluctance to supervise which comes fromlack of incentives, lack of confidence insupervisory techniques, and lack ofobjectives and targets for which to work.”

While often beneficial, close contact withhealth staff can create problems when CHWscompare themselves with professional healthworkers. For example, CHWs in Colombiaaffiliated with health institutions such as

hospitals felt that their work was undervaluedand that they were treated differently from theother health workers and assistants, eventhough they performed the same tasks. Thisperception was seen as a major demotivaterand reason for attrition (Quinones 1999).

When supervision is inconsistent, CHWsmay not feel supported by the health system.Ensuring that supervisors are trained tosupervise and soliciting the community’sinvolvement in supervision can increaseretention of CHWs and help ensure their long-term sustainability in the community. A studyin Colombia (Robinson and Larsen 1990)found that the community had more influenceon the CHWs than the health system,contrary to widely held assumptions. If thecommunity and not the health system is theprimary reference group for CHWs, thenfeedback from the community has asignificant influence on motivation andperformance. This study suggests that thesupervisor should ask, “How can my contactwith the CHW contribute to furtherdevelopment of the relationship with thecommunity?” These findings indicate that ahealth facility or NGO supervisor should fostermore positive interactions and dialogue withcommunity members on pertinent issues.

Identification and Job AidsOne of the commonest and easiest ways tostrengthen a CHW’s affiliation with the MOH orsupporting organization is to provide some formof identification. Identification cards, badges, ordiplomas can provide security in politicallyvolatile situations and are status symbols in thecommunity. Many NGOs have given CHWs t-shirts, notebooks, caps, ponchos, and bagswith identifying logos that promote groupsolidarity and facilitate entry into householdsduring a project (Pearcy 2000; Rubardt 2000).Some programs provide bicycles or motorcyclesfor CHWs to use but usually not own. Peoplewho completed the Ghana Red Cross trainingprogram were allowed to purchase and wear theRed Cross smock or t-shirt. The Red Crosssymbol identified them as Red Cross volunteers

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and provided recognition and respect from theircommunities and from the MOH (Leonard 2000).

Job aids are materials that help a CHWperform the required tasks. While providing asense of affiliation and enhancing the CHW’sauthority, appropriate job aids also strengthenskills and are invaluable in increasingconfidence. Job aids have includedmedicines, health education materials suchas counseling cards, first aid kits, pots fordemonstrating preparation of weaning foods,pens and pencils, flipcharts, notebooks, andboxes to store records. These frequently citedincentives are important to CHWs’ self-esteem and ability to fulfill their role(Henderson 2000).

Personal Growth andDevelopment OpportunitiesPersonal growth and development ismentioned consistently in the gray literatureas a major incentive for CHWs. Acquisition ofknowledge and skills is seen as a steppingstone to future employment and a necessarycomponent in meeting community healthneeds. Their jobs put CHWs living in ruralareas with little chance of employment on thepath of lifelong learning. Ongoing skilldevelopment (acquisition and promotion ofpreventive messages, basic curativeservices, problem analysis, and problem-solving skills) is viewed as important to jobsatisfaction.

CHW posts have been an entry intogovernment employment in some situations, butin many other situations the training and jobduties provided are too minimal to prepareCHWs for such employment, where it exists. InSolapar District in India, 93 percent ofvolunteers were not satisfied with their dutiesbecause they believed they would be a steppingstone to future government jobs that nevermaterialized (Kartikeyan and Chaturvedi 1991).

Personal AccomplishmentWitnessing positive change is a strongmotivator for CHWs. A sense of quickaccomplishment often comes from providing

curative services and nutritional interventionsrather than from preventive services. In Haitivolunteer mothers, or animatrices, aremotivated by seeing their lethargic childrenwith no appetite become “bright, energeticchildren who eat ravenously” (Wollinka et al.1997). This dramatic change convince theanimatrice “that her efforts have had animpact, which appears to strengthen hercommitment to the program, the balancedmenu, and the more frequent feeding patternthe program recommends.” In Ghana volunteermothers are motivated by the health of theirchildren and their desire to help other mothershave healthy children (Leonard 2000).Mothers’ support groups meet regularly withthe support of health workers to discussbreastfeeding and help new breastfeedingmothers solve problems. The volunteers oftenuse their own children as examples of healthy,exclusively breastfed babies.

CHWs can derive a sense ofaccomplishment at a collective level as well asfrom seeing changes in individual children,which is often difficult. CHWs who collect anduse health information can monitor and feelproud of their own progress. In Bolivia CHWs,health care providers, and communitymembers meet monthly to discuss community-collected health data and plan action based onthe data (Howard-Grabman 2000). This processhas resulted in increased communityawareness, more concern for maternal andchild health issues, and positive attitudinalchanges in the community and among healthcare providers. CHWs are seen as the bridgefor these empowering meetings between healthcare providers and the community. Vaccination,vitamin A usage, and growth monitoringprograms increased in the Boliviancommunities using this “integrated communityepidemiological system,” and women in pilotcommunities were 2.2 times more likely tobreastfeed within one hour postpartum.

TrainingLack of general and skills-based training isfrequently mentioned as a barrier to effective

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CHW performance (Walt et al. 1989; Gilson etal. 1989; Kaseje et al. 1987; Robinson andLarsen 1990). Most observers of community -based contraceptive distribution programsagree that the quality and intensity of agents’training is the most important singledeterminant of program quality and impact(Phillips 1999). Training can provide CHWswith the opportunity to learn skills, receiveeducation, interact with higher levels ofprofessional staff, and obtain other benefitsthat they would not be able to obtainotherwise. Learning skills is one of the mainreasons CHWs volunteer.

Training is essential if CHWs are to carryout their work effectively. Training covers notonly providing preventive, curative, or otherrelevant services to the community, but alsoteaching and communicating with communityresidents. In Nepal more training allowed thecommunity health volunteers (CHVs) toidentify causes and treatment of nightblindness and to recognize fast breathing as amajor sign of ARI (Curtale et al. 1995). Theirability to deliver treatment increased theirmotivation.

To be effective, training has to be doneregularly and continuously, with the needs ofthe community in mind (Gilson et al. 1989;Kaseje et al. 1987; Robinson and Larsen 1990;Walt et al. 1989). VHWs in Gongola State,Nigeria, said in interviews that they felt thatfurther health care training would allow themto advance to professional health care workand receive higher pay (Gray and Ciroma1987).

The right combination of skills can help aCHW become a more qualified worker. Havingskills that the community values raises thestatus of a CHW in the community. InColombia and Tanzania training strategieswere based on community surveys completedby CHW candidates before training began(Robinson and Larsen 1990). The skills theCHWs learned were directly related to thehealth issues in the communities. Robinsonand others further explain how this trainingorientation solidifies the CHWs’ connection

with the communities while enhancing theirstanding as they try to meet communityneeds.

Without the ability to provide treatment orprevention, a CHW can lose standing in thecommunity. The volunteers in the Sri Lankastudy state, “Often we have to go to thepublic health nurse midwife to get an answer,and then tell the householder. When thishappens, the community loses faith in us andrefuses to accept any advice we give them”(Walt et al. 1989). Those designing trainingshould consider the way material is taught,the place where training is carried out, andrelevant skills that strengthen CHWs’ ability toeducate community members (Ofusu-Amaah1983; Gilson et al. 1989; Kaseje et al. 1987;Robinson and Larsen 1990). Problem-solvingskills are a critical part of the training neededto promote behavior change rather thanknowledge accumulation.

Training Methods Make a DifferenceMany training methods are inadequate. Themethods tend to be too theoretical, tooclassroom based, and too complicated(Gilson et al. 1989). Such methods can be adisincentive to CHWs who are learningunfamiliar information. The following lessonslearned for participatory training haveemerged through NGO work with CHWs(LeBan 1999):

■ CHW functions need to be clearly definedbefore training.

■ Curricula, tools, and methods must covereach specific CHW task, with ampleopportunity for hands-on management ofreal cases.

■ Role modeling and one-on-one tutorialtraining approaches work extremely well.

■ Adult participatory learning methodologiesand problem-solving approaches helpCHWs assume the role of change agentat the community level.

The training venue is also important tothe CHW’s ability to learn. Training is more

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effective in a setting that matches CHWs’places of residence, whether urban or rural.Robinson reports that most training shouldtake place in the community. Time spent inhands-on activities increases visibility andreinforces the relationship with the community(Robinson and Larsen 1990). Trainers andCHWs should go together to the rural or urbansetting to work and assess skills in realsituations (Gilson et al. 1989). CHWs shouldbe trained in the closest health facility byhealth facility staff trainers to better link theformal health care system with the community(LeBan 1999). After training, the awarding ofcertificates to CHWs or a communitycelebration or recognition ceremony can beinvaluable in recognizing the CHWs’accomplishments (Hilton 2000; Henderson2000; Edison 2000; Pearcy 2000).

Using other CHWs to assist with thetraining can help ensure that it is relevant tothe local situation. In an adaptation of thetraining-of-trainers approach in Mozambique,lead activistas (the strongest CHWs) wereexcellent auxiliary trainers, and theirassistance reduced the time and costs oftraining (Koepsell et al. 1999).

Refresher TrainingContinuous training has been cited as “anessential prerequisite for an effective CHWprogram” (Frankel 1992) and an importantfactor in retaining the motivation of workers, inlight of the short training periods available andthe low levels of education of most CHWs(Ofosu-Amaah 1983). Refresher trainingallows the CHWs to learn new skills, take onnew challenges, and interact with peers,keeping the job interesting and promotingpersonal development. Little information isavailable on best practices associated withthe periodicity of refresher training or thesequencing of messages and skilldevelopment. In most situations refreshertraining depends on budgets and is often cutwhen resources are scarce.

Experienced community-basedrehabilitation kader in Indonesia became

frustrated as they became more proficient inidentifying disabilities. They realized that theyneeded additional education to handle morecomplex rehabilitation problems (Lysack andFrefting 1993). In Kenya continuous trainingprovided enough motivation for the villagehealth helpers to continue working evenwithout financial support (Kaseje 1987). InMozambique monthly refresher trainingfeatured a specific health theme, whichallowed activistas to emphasize that themeduring the following months’ health education(Koepsell et al. 1999).

Sometimes training alone is enough tokeep motivated workers going. La LecheLeague mothers in Guatemala continued toprovide counseling and referrals four yearsafter the end of the project grant (Rasmusonet al. 1998). Their motivation was attributed toa combination of refresher training, annualworkshops, peer support, and visible change.

Training, however, has a negative side.CHWs, especially effective ones, tend to betargeted by a variety of vertical healthprograms (such as tuberculosis, malaria, andonchocerciasis) and taken frequently fortraining in these topics. Usually the CHWsenjoy the additional perks of training (achance to leave the community, travelallowances, interaction with peers, learningnew skills), but the communities are leftwithout CHWs during the training. In ElSalvador CHWs were found to spend moretime in training than on the job (Contreras2001).

Training is clearly a critical and ongoingpart of any CHW program. The NGO CARE(2000) describes a comprehensive trainingstrategy in Nyanza, Kenya, that has theinvolvement of both the MOH and thecommunity. CARE combined a training andsupervision strategy for CHWs using NGO,MOH, and community trainers andsupervisors. Community health committees(CHCs) recruited CHWs to serve 20 familieseach. The district health office (DHO) providedhealth facilities for training, quarterly in-service training, and referral. Practical training

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took place at the hospital. CARE and MOHstaff provided additional incremental trainingfor three months following the initial training.The DHO and the CHCs assumed overallsupervisory responsibility for the performanceof the CHWs. Within two years, 319 CHWswere managing sick children at thecommunity level. The clinical proficiency ofthe CHWs was equal to or better than that ofthe MOH clinicians in that setting (LeBan1999; Steinwand 2001). The motivation of theCHWs, which had been high early in theproject, began to subside after a few years.The community elders, already engaged insupervision, promised to take a moreaggressive role in solving the problems ofCHW incentives in their areas.

Peer Support and CHWNetworksInteraction with other CHWs can be a criticalmotivator for people who often work with littlesupervision or tangible evidence of theireffectiveness. Peer support comes in severalforms. Several NGO programs havesuccessfully paired CHWs so that they canwork together and support each other. In theAtención Integral a la Niñez (AIN) program inHonduras, for example, monitoras worked ingroups of three. Working in teams allowsCHWs to divide their work and reduces thesense of isolation and completeresponsibility for a geographic area. In LibenDistrict, Ethiopia, Save the Childrenmobilized communities to form “bridge tohealth” teams (BHTs). Each BHT included awisewoman, a wiseman, and a youngtraditional apprentice. Two-thirds of the BHTmembers were influential, respected TBAs,bone setters, herbalists, or circumcisers.Most traditional healers in the district wereelected as BHTs. The teams decreased theisolation of the BHTs, provided mutual

support, and allowed for local exchange ofinformation (Marsh et al. 1999).

Group meetings can provide motivationfor CHWs through peer support. Findings fromColombia, Mozambique, Nepal, and Ugandashow that peer support is as important toCHW performance as supervisory feedback(Snetro 2000; Robinson and Larsen 1990;Taylor 2000; Oriokot 2000). Successfulprograms have brought CHWs together inmonthly meetings and used these meetings topromote CHW bonding, as well as provide in-service training and supervision (Robinsonand Larsen 1990). In the Shishu Kabar Hearthnutritional program in Bangladesh, trainershad the freedom to be creative and makesuggestions to improve the program. Theirideas were incorporated into the program togive them a sense of ownership andinvolvement in decision making. Theircontributions were recognized at weeklymeetings. The trainers were encouraged todiscuss successes and solve problemsamong themselves to exchange informationand create a supportive environment(Wollinka 1997).

Examples of supporting groups of CHWsin forming CHW associations exist in manycountries. In Peru CARE has effectivelymobilized community volunteers into localcommittees that cover specific geographicareas. Representatives of these committeesorganize themselves into district associations.The committees meet monthly to discussexperiences and mutually reinforcecommitment. They raise funds to cover theirown activities, organize training events, andadvocate for health with government and theMOH. This arrangement has resulted indedicated, well trained, and active CHWs whohave strong ties to the MOH but are notdependent on it (McNulty 2000).

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Section 6

Relationship with the Community

orking with the community gives health workers a platform fromwhich to strengthen their relationship with the community andW

receive community feedback, as well as a structure for regularinteraction 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 Relationshipsbetween CHWs andCommunitiesIn many programs the potential of the CHWhas not been realized because of a poorrelationship with the community. In theSolomon Islands, 32 percent of thenonworking village health workers surveyedleft their posts because of a lack ofcommunity support (Chevalier 1993).Programs and organizations that do notengage communities actively in CHWprograms from their inception generallyexperience low morale among their CHWs.This lack of shared ownership generallytriggers a separation and distance from activecommunity participation in the CHW program,resulting in high attrition.

If CHWs are to serve as the bridgebetween the health system and thecommunity, the relationship with thecommunity must receive great attention. Yetthis relationship is often given plenty ofrhetoric but few if any financial or technicalresources. Two misconceptions of thecommunity have been common: a naiveconcept of community and an assumptionthat all communities are alike. Much currentunderstanding of the complexity ofcommunities comes from the work of socialscientists and the field experiences of NGOs.

Programs have tended to oversimplify the“community” and underestimate its social

complexity. Communities are not homogenousgroups of people who always work welltogether. Like all communities, those indeveloping countries are made up of variousgroups of people based on such criteria asreligion, ethnicity, and economic status. Withnotable exceptions, the most marginalized andpowerless groups—women and the very poor—need CHW services the most, yet rarely havereal involvement in CHW programs. Programsthat do not recognize the complexity of localcommunities or ensure that the marginalizedare given a voice may find that their CHWs arepawns of the local elites. One way to guardagainst this is to work through existingcommunity groups and to increase the totalnumber of CHWs in a community.

All poor communities are not alike. Ifprograms make any distinction amongcommunities, it is the distinction betweenrural and urban communities. Planning tendsto be inflexible in responding to the diversityamong communities. Of course, communitiesdiffer considerably. Some have moreresources than others. Some have access tohealth facilities, markets, and cash crops,while others are on the verge of famine, withlittle food or other resources. The morestressed communities cannot and should notbe expected to provide labor, money, or otherresources to support CHWs. Communitieswith access to better job markets may have ahard time recruiting volunteers, as Catholic

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Relief Services found in El Salvador (see p.32). Communities may also have differentepidemiological profiles, as in Ethiopia, wheremalaria is a problem only in some altitudes.Clearly, the relationship between a CHW andcommunity varies with the characteristics ofthe community. Little has been documentedon approaches to differentiating communities.

Selection of CHWsIdeally, a community should be involved in allaspects of a CHW program, includingselection, training, and supervision, butcommunity members may not have the timeand resources to invest in all these areas.Community involvement in selecting CHWs,as well as in using their services andcontributing in-kind payments, appears to becritical to CHW programs.

Criteria for SelectionSelecting a CHW involves many steps.Criteria must be established, candidatesidentified, and a final selection made, perhapsafter a trial period. Although the communitycould have a role in each step, usually it isinvolved only in proposing candidates whomeet criteria established by program staff. Asdiscussed in Section 4, the personalcharacteristics of CHWs play an importantrole in their relationships with the communityand their continued motivation.

When given the opportunity, communitiesare often able to develop criteria that ensureCHWs stay on the job. In trying to revive theCommunity Health Agent (CHA) program, theMOH in Ethiopia established literacy as theonly criterion for recruitment. When askedwhat criteria they would use to select CHAs,however, local communities listed 16characteristics, including selection by thecommunity, married status (so the CHWswould not leave the community), and noaddiction to chat, an herbal stimulant(Bhattacharyya et al. 1997). In Guatemalalocal residents thought the volunteercollaborators should be “responsibleindividuals” and “able to take care of patients

at all times of the day, even when they werebusy” (Ruebush 1994). Candidates should alsobe selected on the basis of their demon-strated involvement in and commitment to thecommunity (Robinson and Larsen 1990).Community members are often much moreaware of the characteristics that will ensureCHW retention.

Process of SelectionOnce criteria for selection are established, the“community” is usually asked to nominatecandidates. Because this process is often ablack box to outsiders who know little ifanything about the internal social dynamics ofthe community, many problems can occur atthis stage. Communities may not beorganized to choose CHWs representative ofthe majority of residents, or they may not fullyunderstand the functions of the CHWs.Communities that do not understand the roleof the CHWs are less likely to give the CHWsthe necessary support and may notunderstand their own role in improving theirhealth. In Saradidi, Kenya, the responsibilitiesof the village health helper were discussed inopen community meetings and formal andinformal exchanges (Kaseje 1987). In manycases, however, selection of CHWs iscompleted well before the community has aclear understanding of what they do. CHWs’ability to carry out their tasks effectively canbe enhanced when communities are investedin trying to improve their own health.

Communities understanding of their ownrole in changing their health status can helpsustain the CHWs’ activities. Communitymembers should be informed of the jobdescription, capabilities, and commitment ofCHWs (Frankel 1992; Ofosu-Amaah 1983;Heggenhougen et al. 1987; Walt et al. 1989). Ifthe communities understand what the CHWsare trained to do, there is less chance thatresidents’ expectations of a CHW will gounmet. Community understanding will alsoreduce inappropriate demands and frustrations(Heggenhougen 1987).

Ideally, a CHW should be chosen with the

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input of the community so that residents’health needs are considered and they respectand feel comfortable interacting with the CHWfor their health services. In some cases,however, CHWs have been selected by villageleaders who choose relatives or friends or byvillage committees that disregard communityinput. A survey-style CHW evaluation byUNICEF in 1989 reported that 45 percent ofthe CHWs surveyed were related to the localchief or subchief. The percentage would havebeen higher if other kinship ties and filialconnections with members of the chiefs’councils had been included (Green 1996). Abrief evaluation in Swaziland found thatnepotism and self-interest determined thechoice of the CHW by the local chief and hiscouncil, with no consideration of thecandidates’ interest in or qualifications for thejob (Green 1996).

Extensive field experience and longassociation with specific communities havehelped many NGOs find ways to ensure thatthe CHW selection process is fair andrepresentative of marginalized groups. Forexample, CHVs in Senegal were chosen duringcommunity meetings by community leaderswho did not include women or representativesof all community groups. Although the chosenCHVs were motivated in the beginning, 60percent had abandoned their jobs after twoyears, and many of those who remained wereno longer motivated to carry out communityhealth activities. During the following phase ofthe project, volunteers were chosen insteadthrough in-depth discussion with communitymembers and village health committeesestablished by World Vision. Five years laterfew CHVs had left their posts, an achievementattributed to official community recognition oftheir roles and to moral encouragement fromtheir communities (Aubel et al. 1999).

Community Recognition ofCHW WorkCommunity recognition and appreciation ofthe work of CHWs can have a snowball effectas communities demand more services and

the MOH is able to respond with additionaltraining and support. This is the ultimate goalof many CHW programs. In Mozambique,where activistas have worked for many years,their roles seem to have matured, andcommunities seem to accept their work to ahigh degree. Community members nowapproach activistas for family planningservices and other types of support (Snetro2000). When sevikas in Nepal were asked whythey continued their volunteer work, they said,“Our neighbors won’t let us resign; they insistwe continue because their children’s healthdepends on us” (Taylor 2000).

Several programs have mentioned thesupport of the community as an incentive forCHWs. Trust, prestige, mobility, and socialinteraction are other factors that are favorablymentioned (Walt et al.; Kaseje 1987; Lysackand Krefting 1993; Ruebush 1994). ManyCHWs volunteer because they enjoy servingthe community.

Visible BenefitsCommunities that have directly and visiblybenefited from CHW programs are the mostwilling to support the continued presence ofCHWs. The community’s interest in sustaininga CHW program is based in large part onevidence of positive changes in health statusbecause of the CHW or on benefits such aseffective referrals to health facilities. Visiblechange is limited by the predominance ofpreventive health in a CHW’s work. With theexception of nutritional rehabilitation or theuse of ORS for dehydrated children, fewdramatic changes in health are visible tocommunity members.

One way CHWs and communities cancreate visible change is to monitor simplehealth indicators over time. In Kitwe,Zambia, communities monitor the number ofchildren who gain weight in the past monthas an overall indicator of child health (Steel2001). In Eastern Province, Zambia,communities use risk maps to monitorindicators such as immunization status andavailability of latrines. Risk maps identify

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households using color codes to markindicators, such as green for fullyimmunized children and red for those notfully immunized (Bhattacharyya and Murray1997). The collection and analysis of healthinformation to chart changes in behavior (forexample, more use of health services) orhealth status (for example, fewer cases ofdehydration) allows CHWs to show thecommunities the results of their work.

Encouraging communication andinteractions between CHWs and communitymembers is critical to building anunderstanding of the CHWs’ role and supportfor their work. There are a number ofexamples of community supervision of CHWs.While community health committees cannotbe expected to do clinical supervision, theycan monitor CHW performance at thecommunity level. For example, the barefootdoctors in China were accountable to thevillages and were given technical supervisionby the health centers (Frankel 1992).

Individual InteractionsNegative CHW behavior has a negative effecton community support of CHWs and themessages they promote. Health workers inNiger did not treat mothers respectfully orpatiently and did not counsel them onpossible side effects of the vaccinationsgiven to their children. The mothers reportedthat this negative behavior was a major barrierto their using the CHWs’ health services(Boyd and Shaw 1995).

To be effective change agents, CHWsneed to demonstrate the positive effects ofnew practices in their own homes. InMozambique CHWs who had pit latrines intheir homes stimulated community interest intheir messages promoting the use of suchlatrines, while those who did not discouragedsuch interest (Snetro 2000). In Honduras,Save the Children and the MOH posted thephotos and names of CHWs on the healthpost wall, bringing public recognition to theCHWs and increasing their visibility andretention (Amendola 1999).

StatusBeing identified as a CHW and affiliated withthe health system is usually, though notalways, a status symbol that generates powerand respect within the community. CHWs inColombia ranked “having influence in thecommunity” as the most important extrinsicreward affecting their performance. Informalobservations indicated that this influencemade the CHWs opinion leaders on a varietyof issues of concern to the community. Thefact that influence in the community is highlyvalued by community-based workers adds adimension to their role that few other healthworkers, particularly those based ininstitutions, can share (Robinson and Larsen1990). Identification badges, uniforms, andrelationships with “outsiders,” as in the Kitweexample, can increase the status of a CHW ina community.

Praise and respect from communityresidents and peers can motivate CHWspositively and increase their length of service.The appreciation of the people they serve is astrong incentive that is often cited as impor-tant to CHWs’ job satisfaction. MinnesotaInternational Health Volunteers has trainedabout 2,000 community volunteers in Ugandafor a variety of tasks. Community recognitionhas proved to be a valuable tool in motivatingand retaining community volunteers byincreasing their status in the community.About 70 percent of them have been electedto various positions on their local councilssince becoming volunteers (Mullins 2000).

Especially for women, public recognitionoutside the family can generate self-respectand empowerment to act in the community.Poor women in Dhaka, Bangladesh, whoserved as CHWs for ten years were seen asvaluable members of their communities(Silimperi 2000). The activistas in Mozambiquerepeatedly emphasized the importance ofcommunity value and support, demonstratedby their neighbors’ increased respect,reciprocal gestures of help, and acceptance ofhealth behavior change messages; communityleaders’ understanding of and support for their

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role; frequent visits by NGO staff; andopportunities to learn (Snetro 2000).

Community Organizations thatSupport CHW Work In addition to community recognition, theformation of community organizations or villagedevelopment committees has been cited asuseful in supporting and sustaining the role ofCHWs. Some form of viable communityorganization is necessary to establish anoperational relationship between thecommunity and the government. In GongolaState, Nigeria, the support and encouragementof the village health committee emerged as animportant factor in VHW job satisfaction. Theaverage length of service for 13 former VHWswho had met monthly with their localcommittees was three years, while that of 14others who had never met with their localcommittees or met with them rarely was 1.3years (Gray and Ciroma 1987).

In another example, Save the Childrenand the MOH trained BHTs in Ethiopia in

emphasis behaviors and communitymobilization. Health action committees(HACs) of ten to 12 elected members weretrained to support the four to six BHTs ineach kebele (village) and to support TBAs insafe delivery and danger sign recognition.Mothers and primary health caregiversbelieved that BHT health messages camefrom traditionally respected sources. BHTmembers were motivated by training,effectiveness in the community, and supportfrom local leadership in the HACs (Marsh etal. 1999).

When support from community groups ismissing, CHWs face an uphill battle in gainingthe respect of the community. CHWs fromCochabamba, Bolivia, felt that the communitywas unsupportive and unaware of theiractivities. They saw themselves as divorcedfrom important decision-making organizations.They also felt that institutional support fromhighly visible community leaders wouldincrease their motivation and their credibilitywith the villagers (Gonzalez 1987).

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Section 7

Putting It All Together:Multiple Incentives

uccessful CHW programs depend on a framework of incentives

at the individual, community, and health system levels thatStogether can motivate people to become CHWs and continue in thiscapacity 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 multipleincentives simultaneously to motivate CHWs. Understanding the

functions of various incentives can help programs combine these

incentives effectively.

Behavioral ModelSeveral models in the behavioral scienceliterature apply to motivation in a workplacesetting. A model by Pareek (1986) identifiessix primary needs or motivators relevant tounderstanding the behavior of people inorganizations. This model identifies keymotives that contribute to employeesatisfaction and fulfillment (Table 4). Itsuggests that incentives that positively affectand reinforce each of these motives wouldcontribute to higher motivation and retentionof CHWs, and that incentives that exacerbate“fears” would likely lead to higher attrition.

The third column in Table 4 categorizesthe incentives that have been reviewed in thispaper according to the motivation model. Thistype of categorization can help programplanners choose several incentives thatreinforce positive aspects of all six motivessimultaneously.

The same list of CHW incentives,including the key disincentives mentioned inthe literature and in personal communications,can be organized into a systems approachthat shows an implementer what can be done

to support CHWs at different levels of thesystem (Table 5).

Examples of Multiple IncentivesAs the rest of this paper shows, appropriateincentives depend on the social status ofCHWs, their duties, and other opportunities inthe community. This section reviews severalexamples of programs that have used multipleincentives. More detail about each programcan be found in Annex 1.

Catholic Relief Services, El SalvadorCatholic Relief Services (CRS) has used thePareek behavioral model to plan andimplement multiple incentives for CHWs in ElSalvador. This is the only example found of anorganization using an explicit behavioralmodel to plan CHW incentives and trackingattrition rates to evaluate the effects of theincentives. The El Salvador experience yieldsseveral lessons. First, the use of multipleincentives based on the model was critical notonly in reducing attrition but also in involvingthe community (Rosales et al. 2000). Second,attrition rates fell by 18 percent over all three

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Motive Definition CHW incentives

Achievement Concern for excellence; setting of ■ Possibility of future employmentchallenging goals ■ Personal growth and

development■ Acquisition of skills

Affiliation Concern for establishing and ■ Peer supportmaintaining close, personal ■ CHW associations andrelationships networks

■ Community involvement■ Identification (badges, shirts,

etc.)

Extension Concern for others; urge to be ■ Community recognition of andrelevant and useful to larger respect for CHW workgroups ■ Successful referrals

Influence Concern with making an impact ■ Status in the communityon others; desire to change ■ Accomplishmentmatters and develop others ■ Visible changes

Control Concern for orderliness; desire to ■ Clear rolebe and stay informed; urge to ■ Job aidsmonitor and take corrective action ■ Feedback to the MOH andwhen needed community

■ Support from the health system■ Policies or legislation that

support CHWs

Dependency Desire for the help of others in ■ Satisfactory remunerationone’s own self-development; urge (monetary and nonmonetary)to maintain an “approval” ■ Training and refresher trainingrelationship ■ Supervision

■ Preferential treatment

Table 4. Motivation Model

communities studied and by 54 percent in twoof the communities. Third, as discussedabove, not all communities are alike. Theestablishment of garment factories in one ofthe communities led to very high attrition ofCHWs who took jobs in the factories. Themain lesson of the CRS experience may bethat creating a cadre of volunteer workersmay not be the best approach to establishingCHWs in areas with growing opportunities forpaid employment.

Atención Integral a la Niñez, HondurasThe MOH of Honduras has implemented theAIN program with technical assistance from

the BASICS Project since 1995. The AINprogram has a very strong group of monitoraswho weigh children under two years old eachmonth and counsel mothers whose childrenhave not gained weight adequately. Severalfactors appear to be critical to the monitoras’success. First, they work in groups of threeand are free to divide their tasks any way theylike. Second, the monitoras, health centernurses, and program staff all focus on thesame indicator: adequate child growth in theprevious month. Because of this unified goal,every actor in the program knows whichchildren are not growing adequately and why,as well as what actions have been taken to

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Motivating factors Incentives Disincentives

Monetary factors that ■ Satisfactory remuneration; ■ Inconsistent remunerationmotivate 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 communitythat 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 ofmotivate CHWs CHW selection CHWs

■ Community organizations that ■ Lack of community involvementsupport CHW work in CHW selection, training, and

■ Community involvement in supportCHW training

■ Community information systems

Factors that motivate ■ Visible change ■ Unclear role and expectationscommunities to support ■ Contribution to community (preventive versus curativeand sustain CHWs empowerment care)

■ CHW associations ■ Inappropriate CHW behavior■ Successful referrals to health ■ Failure to take community

facilities needs into account

Factors that motivate ■ Policies or legislation that ■ Inadequate staff and suppliesMOH staff to support support CHWsand sustain CHWs ■ Visible change

■ Government or communityfunding for supervisoryactivities

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

improve the children’s growth. Third, theprogram has used a variety of smallincentives to encourage and support themonitoras.

Jereo Salama Isika, MadagascarIn Madagascar BASICS has providedtechnical assistance to the Jereo Salama

Isika project, which implements community-based IMCI and community-based nutritioninterventions using an integratedcommunication strategy. The Madagascarapproach to using community volunteers, oranimateurs, is unique in several respects. Theprogram expects that 50 percent of theanimateurs will drop out after 12 to 18 months.

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After the animateurs leave the program,however, they are still viewed by thecommunity as important sources of healthinformation. For this reason, the programcelebrates its graduates rather than worryingabout its dropouts. The program’s goal is totrain as many people as possible (at least 1percent of the population) in a two-day trainingworkshop. The technical focus of the programis on promoting “small, doable actions” thatare illustrated on counseling cards (forexample, taking a child to be immunized). AllNGOs and donors in the country use thesame illustrations in a wide range ofmaterials, resulting in consistency andcontinuity to health communication.

The Jereo Salama Isika program alsohighlights the importance of considering theinteraction of the role of the volunteers (inMadagascar they are health promoters only,with no curative functions) and theirincentives. Finally, the word supervision is notused to describe the relationship betweenhealth staff and volunteers. Instead,communities and health staff celebrate theachievements each year in a health festival.

Afghanistan Health Sector SupportProject (AHSSP)The Afghanistan Health Sector SupportProject (HSSP) began in 1986 to providebasic health care to the rural Afghanpopulation scattered among small villagesseparated by natural barriers or war. The

project trained over 2000 basic health workers(BHWs) to provide preventive and curativecare. While the project faces the uniquechallenges of war, cross-border traffic, andlarge numbers of refugees, it shares withother CHW projects the issues of selectingBHWs and providing them with incentives.

The BHWs were selected carefully toensure that they were committed to improvinghealth services in Afghanistan and to servingthe resistance movement. Their work wasmonitored by checking administrative records,reviewing reports of border crossings, andmaking annual (in some cases triannual)visits. After their training the BHWs receiveddiplomas, which were considered prestigious.The project decided to pay the BHWs to givethem an incentive to stay in Afghanistanrather then move to Pakistan, as many peoplewere doing. AHSSP demonstrated tightaccountability by cross-matching three datasources, an approach that the BHWsappreciated because they felt the project wasable to identify “cheaters.” The BHWs alsovalued their contact with foreign agencies. Theattrition rates were fairly low, with an averageof 5 percent, and the average time ofparticipation was just over two years. Thesestatistics did not change much even whensalaries were cut by 50 percent. The BHWswho served in areas that bordered Pakistanhad much higher dropout rates, probablybecause of family connections and betteropportunities in Pakistan.

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Section 8

Conclusions and Recommendations

he experiences with CHW programs reviewed in the previoussection show that no one CHW program will work for allT

communities in all countries. Nevertheless, because program plannersfind 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 tospecific situations? What issues should be considered? How should

decisions about incentives be made?

Perhaps the most important conclusion of thisreview is already known: there is no tidypackage of three incentives that will ensuremotivated CHWs who continue to work foryears. Instead, a complex set of factors affectCHW motivation and attrition, and the waythese factors play out varies considerablyfrom place to place. Program planners do notneed to start from scratch, however: they candraw on the public health community’sextensive experience with CHW programs.

In summary, CHWs do not exist in avacuum. They are part of and are influencedby the larger cultural and political environmentin which they work. The process of healthsector reform, the IMCI strategy, and theachievements of community-based nutritionprograms have generated renewed interest inthe potential contribution of CHWs. Healthsector reform has changed the supervisorystructure within health systems and givenmore autonomy to peripheral health facilities.Reform has also decentralized the control ofhealth funds, allowing greater flexibility inspending for various types of CHW incentives.The IMCI strategy includes a trainingcurriculum for the assessment and treatmentof mild and moderate child illnesses. Thisstrategy allows CHWs to play a curative role,which is usually what the community

demands. Policies on CHW distribution ofantimicrobials and antimalarials can havetremendous effects on their relationship withthe community.

At a micro level, the position of CHWs intheir communities influences their motivationand retention. The inherent characteristics ofCHWs, such as their age, gender, ethnicity,and even economic status, affect the waythey are perceived by community membersand their ability to work effectively.

The specific tasks and duties of CHWsaffect their motivation and retention. Given toomany tasks, CHWs may feel overwhelmedwith information or spend so much time intraining that they rarely practice what theyhave learned. Often the catchment areas aretoo large, making it difficult for CHWs to findthe time or transportation to visit all thehouseholds. Many CHWs are restricted topreventive and promotive roles that leavethem unable to respond to communitydemands for curative care (and usuallymedicines).

Monetary incentives can increaseretention. CHWs are poor people trying tosupport their families. But monetaryincentives often bring a host of problems: themoney may not be enough, may not be paidregularly, or may stop altogether. Monetary

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incentives may also cause problems amongdifferent cadres of development workers,some of whom are not paid. Nevertheless,some programs have paid CHWs success-fully, and many have used in-kind incentiveseffectively.

Nonmonetary incentives are critical to thesuccess of any CHW program. CHWs need tofeel through supportive supervision andappropriate training that they are part of thehealth system. Relatively small tokens, such asidentification badges, can give CHWs a senseof pride in their work and increased status intheir communities. Appropriate job aids, such ascounseling cards and regular replenishment ofsupplies, can ensure that CHWs feel competentto do their jobs. Peer support can come in manyforms, such as working regularly with one or twoother CHWs, receiving frequent refreshertraining, or joining CHW associations.

In the end a CHW’s effectiveness dependson his or her relationship with the community.Programs must do everything possible tostrengthen and support this relationship. First,program planners must recognize the socialcomplexity and diversity of communities.Different communities need different types ofincentives, depending on other local jobopportunities, prior experience with CHWs, theeconomic situation, and other factors.

Unfortunately, little experience orguidance on differentiating communities isavailable. Programs should involvecommunities in all aspects of the CHWprogram, but especially in establishing criteriafor CHWs and making the final selection.Programs can provide opportunities for quick,visible results that promote communityrecognition of CHWs’ work. CHWs must betrained in appropriate and respectfulinteractions with all community members andin appropriate responses to difficult people orsituations. Community-based organizationssuch as religious groups or youth clubs canprovide support to CHWs and lessen theirload significantly by taking on healtheducation activities.

Many successful programs use multiple

incentives over time to keep CHWsmotivated. A systematic effort that plans formultiple incentives over time can build aCHW’s continuing sense of satisfaction andfulfillment. Identifying the functions of each ofthe incentives would be useful to clarify thecritical functions and how those might varybased on the CHW role and type ofcommunity.

Support the CHW’s Relationshipwith the CommunitySurprisingly, the fact that the effectiveness ofthe work of CHWs depends almost entirely ontheir relationship with the community is oftenoverlooked. Many programs end up focusingon clinical training, supervisory checklists,and logistics (all of which are extremelyimportant) to the exclusion of activities thatsupport the community relationship.

Effective programs have (explicitly orimplicitly) oriented the whole program tosupport and strengthen every interaction ofCHWs with community members. The paperincludes many examples of such orientation,from public recognition of CHW work bysupervisors to job aids that support theongoing dialogue between communitymembers and CHWs. Programs must askcontinually what they can do to promotebeneficial CHW-community interactions.

Use Multiple IncentivesIn most of the programs reviewed in this paper,incentives were implemented ad hoc ratherthan as part of a systematic program. Whilemultiple incentives are used in successfulprograms, new incentives are often proposed inreaction to a crisis of low morale rather than aspart of an overall program effort to maintainhigh morale. Programs should consider asystematic effort to plan for multiple incentivesover time to build CHWs’ continuing sense ofsatisfaction and fulfillment.

Programs might find it useful to identifythe functions of each of the incentives usingPareek’s model or some other model tounderstand the critical functions and how

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those might vary based on the CHW role andtype of community. Intrinsic incentives workto promote a sense that the work isworthwhile, while extrinsic incentives includesalary, increased status in the community,and the support of colleagues. Both intrinsicand extrinsic incentives clearly should beimplemented and monitored. An incentivesplan could address the multiple motives ofachievement, affiliation, extension, influence,control, and dependency, as presented byPareek. Alternatively, the plan could combineincentives targeted at different parts of thesystems—monetary or nonmonetary factorsthat affect the individual CHW, communityfactors that encourage and support CHWs,and health system factors that supportCHWs. Ideally, an incentive plan wouldinclude a combination of both approaches.

Match Incentives with DutiesCHWs continue to play an important role inmany international primary health careprograms. While continuing their preventiveand community mobilization tasks, CHWs areincreasingly becoming involved in community-based case management of prevalentchildhood diseases. While CHWs’ successrate is often lauded in the early stages of anew and exciting project, their motivationdiminishes over time unless frequent stepsare taken to maintain their enthusiasm fortheir essential but voluntary role.

The Community IMCI framework lays outthree elements of implementation anddescribes the types of communities in whichthose elements are appropriate. The role ofCHWs, and consequently their incentives, willvary among the elements. The first elementemphasizes building strong partnershipsbetween health facilities and communities,which depend to a great extent on the CHWs’acting as bridges. In such situations, wherepersonal relationships are critical, incentivepackages should be developed to avoidfrequent turnover.

The second element of the CommunityIMCI framework focuses on improving

community-based workers’ ability to providepreventive services and some curativetreatment of childhood illnesses. For thiselement CHWs will use IMCI concepts andtools to classify and treat illnesses and alsoto provide health education. In thisarrangement, which is similar to that in theexamples from El Salvador and Hondurasdescribed on pages 31-33, the main problemwith high attrition is the training costs.Programs therefore should plan incentivesand develop realistic expectations of thelength of service.

The third element of the Community IMCIframework involves promoting the key familypractices critical for health and nutrition. WhenCHWs work as health promoters, as in theMadagascar example on pages 33-34,programs should consider maximizing thenumber of training graduates so that healthybehaviors are spread widely.

Employees or Volunteers?In general CHWs are not paid salariesbecause the MOH or donors do not considersalaries to be sustainable. Yet CHWs are oftenheld accountable and supervised as if theywere employees. CHW programs mustrecognize that CHWs are volunteers, even ifthey receive small monetary or nonmonetaryincentives. They are volunteering their time toserve the community. Too often CHWs aretreated as inferior employees instead ofhelpful volunteers.

Perhaps high attrition is not a problem,but an opportunity to involve more communitymembers in promoting good health andnutrition. The example from Madagascarshows ways to change the way people thinkof CHWs: to celebrate graduates rather thanworry about dropouts, plan for high turnover,and hold shorter, more frequent trainingsessions.

Importance of MonitoringMany programs do not understand why theirCHWs drop out. Such programs would be well-served by monitoring some of the most

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important factors that affect CHWs’ motiva-tion and desire to stay on the job. Suchmonitoring need not be complex orquantitative. Much could be done qualitatively,through interviews with and observations ofCHWs and community members duringroutine field visits.

Perhaps the most important issue thatshould be monitored by CHW programs iswhether the programs are able to stay abreastof the “competition” for CHWs; that is, otherjobs and opportunities. Another issue formonitoring is how CHWs manage the increasedworkload when new tasks or functions areadded. Yet another is the interaction ofcommunity members and CHWs. Whatdemands do community members make on theCHWs? How are CHWs treated by theirsupervisors and other staff in the healthsystem? Do the CHWs have the training andjob aids they need to be effective and feelcompetent in their jobs? What monetary ornonmonetary incentives would increase theirmotivation and support their work?

Topics for ResearchUnfortunately, despite the vast experiencewith CHWs, relatively little scientific evidenceis available to answer some of the basicquestions: What are current attrition rates?What attrition rates are realistic? What is themost efficient way to monitor CHW programs?How can CHW attrition be reducedsuccessfully and retention increased? Whatfinancing strategies can be used to ensurethat CHWs are paid regularly and sustainably?What critical functions are achieved bydifferent incentives? What importantdifferences among communities affect CHWprograms, and what is the best way to assessthese differences? How can plannersefficiently tailor their programs to meet localneeds?

These issues, touched on in this paper,require further investigation. Much research isstill needed to determine the best ways tosustain long-term CHW programs and retainvolunteer health workers.

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Section 9

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Annexes

Annex 1Examples of the Use of Multiple Incentives

Catholic Relief Services,El SalvadorThe Catholic Relief Services/CARITAS childsurvival project began in El Salvador in 1995.Community health committees, healthpromoters, and health collaborators wereelected during community meetings. The roleof the health committees was to maintain alink with health facilities and promoteintersectoral collaboration. The healthpromoters collected local health informationand supervised the health collaborators. Thehealth collaborators were responsible forholding monthly meetings and making homevisits to mothers to discuss breastfeeding,vaccination, and diarrhea management.

The midterm evaluation of the projectfound a high attrition rate among thecollaborators. The project used the Pareekmotivational model to plan multiple incentivesfor the volunteers. The achievement motivewas addressed by using participatory trainingthat reflected community needs, included thedevelopment of community organizing skills,and took place in the community. Formingwomen’s support groups and healthcommittees, providing ID badges, andpromoting volunteer networks addressed theaffiliation motive. The extension and influencemotives were achieved when the communityand MOH recognized and expressed supportfor the volunteers through “achievement days”every six months. The dependency motivewas attained by periodic supervision by healthstaff and preferential treatment of volunteersat health facilities. The control motive wasachieved through the use of the healthinformation system.

The final evaluation showed that theattrition rate had dropped from 59 percent to41 percent (a difference of 18 percent) amongthree communities. When the data were

disaggregated by community, two of thecommunities had lower rates (Santiago deMaria fell from 85 percent to 15 percent andSan Vicente from 67 percent to 33 percent),while the third community, Zacatecoluca,increased its attrition rate from 40 percent to60 percent. The project found that garmentfactories recently opened in Zacatecoluca haddrawn the volunteers away for paidemployment (Rosales 2000).

Atención Integral a la Niñez,HondurasThe Atención Integral a la Niñez project isfound in about three-fourths of the healthareas in Honduras. It is implemented by theMOH with technical assistance from BASICS.All health centers (HCs) in those areasparticipate and are phasing in the number ofcommunities served, for a total of about 1500communities. While the numbers varyconsiderably, three monitoras cover 25 to 35households with children under two years old.

HC nurses select communities with thelowest health indicators on the basis of ahealth needs assessment. Communities areasked whether they would like to participate inthe program. Two communities have refused.The nurses hold community meetings in whichcommunity members are asked to nominatetwo to five people to be trained as monitoras.The only criterion for selection is that one ofthe nominees must be highly literate. About athird of the volunteers have previousexperience as midwives or health promoters.Most are women with children of all ages.Literate people are often younger and withoutchildren. Many are among the better off in thecommunity, and all tend to be extroverts andhave a “presence” in the community.

The monitoras’ duties include thefollowing:

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■ Weigh all children under two each monthand provide individual nutritionalcounseling based on the child’s weightgain in the previous month.

■ Identify and seek out all children undertwo who do not attend the weighingsession and keep the lists of children upto date.

■ Keep track of children who are not gainingweight.

■ Make follow-up home visits to childrenwho were sick or did not gain weight inthe previous month.

■ Hold community meetings three times ayear to report the results of the monthlyweighing sessions.

■ Be available at set times to treat sickchildren under five using a modified IMCIalgorithm and, if needed, provide oralrehydration solution or antibiotics. (Themonitoras do not make follow-uphousehold visits for this component,which was added recently and is beingphased in).

The monitoras spend about a day or halfa day a month conducting the weighingsessions and perhaps another two daysmaking home visits. Three monitoras usuallywork in each community. Working as a groupis critical to their success. The groups candecide how to divide their work. All seem towork well together. The program has not heardof any problems within the groups.

The initial training lasts five days, afterwhich the monitoras are given three days oftraining for disease treatment. For this trainingthey receive a minimal travel allowance. Thefrequency of refresher training and reviewmeetings varies greatly, usually depending onthe interest and initiative of the health centernurse. About 60 percent of monitoras receivesome type of refresher training, primarilyfocused on counseling.

The monitoras receive no financialcompensation for their work. Their mainincentives seem to be their recognition bythe community and their sense of altruism

and commitment to volunteer work, of whichthere is a long history in Honduras. Theirwork is celebrated in a yearly party, whichusually includes several hours of training.Initially, the program laid out a year’s worthof incentives, including a letter to themonitoras’ families from the MOH thankingthem for allowing the monitoras to work,certificates of achievement, identificationbadges, and t-shirts.

Anecdotal evidence shows a fairly lowdropout rate among the monitoras. Those whodo drop out tend to be younger, literate peoplewho find paying jobs. Some of the monitoraswho work on the border with El Salvadorborder often ask for payment because theirSalvadoran equivalents are paid a salary.Monitoras were very upset when theirreimbursement for travel costs for trainingwas delayed.

Monitoras report monthly on the results ofthe weighing sessions. Sometimes the HCnurses attend the weighing sessions tovaccinate children. Increasingly, the nursesrecognize the critical role played by themonitoras in decreasing their workload.Sometimes monitoras help at the HC duringnational immunization days and other healthevents. Attempts are being made to make themunicipalities more responsive to communityneeds, such as improved water supply(Griffiths 2000; Griffiths and De Alvarado1999).

Jereo Salama Isika, MadagascarThe Jereo Salam Isika program began in twopilot districts in 1997 and is now going toscale in 20 districts, with a total population of4.5 million people. When the decision wasmade to go to scale, a number of changeswere made in the pilot program, includingexpanding the topics to include familyplanning, dropping one cadre of healthvolunteers (the amis de santé), and decidingto use only existing community groups ratherthan create new ones.

The current program has two levels ofcommunity volunteers: encadreurs and

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animateurs. The encadreurs are selected bythe MOH from existing community leaders.The animateurs are volunteers who arenominated by the community. The only criteriafor selection are that they want to serve asanimateurs and are nominated by thecommunity. The program is so popular thatpeople knock on the doors of the encadreursasking to become animateurs. In eachcommunity served, ten encadreurs support 30animateurs. The main tasks of the animateursare organizing village theatre 20 to 30 times ayear, using the counseling cards with groupsof people, and planning health festivals.Sometimes the animateurs go to the healthcenter to help organize people when crowdsgather for occasions such as immunizationdays. The animateurs are trained in groups of20 in two-day workshops, where they learn theuse of counseling cards and village theatretechniques.

Most of the animateurs are women withyoung children with a range of literacy,although some are men. When asked whythey want to be animateurs, most say theywant to improve the health of their ownfamilies and increase their respect in thecommunity. The program expects that 50percent of the animateurs will stop workingafter 12 to 18 months. The animateurs givetwo reasons for stopping their work: 1) theirchild is seven years old, and there is nothingmore to learn and 2) they can have jobs andstill be seen as resources in the community.

A number of principles and lessonslearned from the pilot program have benefitedthe current program (see Gottert et al. 2000for the complete description). “Small, doableactions” rather than increasing knowledge, arethe focal points of the overall strategy. Theseactions were agreed on by all MOH and NGOpartners, ensuring complementary andconsistent collaboration. Counseling cardswere developed to show each of the small,doable actions, and the same images wereused in a variety of other materials. The two-day workshops allow many more people to betrained. During the pilot program, the creation

of village animation committees proved to bea labor-intensive process. The current programworks only with existing community groups.The program also uses mass media,broadcasting 45-second radio spots and shortrural radio programs frequently over tenstations. Volunteers are not supervised, butare supported and celebrated through healthfestivals (Sanghvi 2001; Gottert et al. 2000).

Afghanistan Health SectorSupport Project (AHSSP)In October 1986 a cooperative agreement wassigned in Peshawar, Pakistan, betweenManagement Sciences for Health and USAIDto begin the Afghanistan Health SectorSupport Project (AHSSP). Very early on theproject developed an accelerated strategy totrain a high volume of community or primaryhealth care workers, called basic healthworkers. The BHWs would provide preventive,promotive, and simple curative services andwould be expected to enroll in ongoing 12-dayrefresher courses when they went to replenishtheir supplies.

The BHWs were selected according to thefollowing criteria:

1. ability to read and write2. equivalent sixth class education3. age of at least 16, preferably 20 to 304. residence in the assigned work location5. immediate family inside Afghanistan6. no employment in Pakistan7. willingness to participate in the resistance

movement inside Afghanistan aftercompletion of the course

8. Muslim religion and previous participationin the resistance movement

The first three criteria established thecandidates’ capacity to complete trainingsuccessfully. The next three were aimed atselecting candidates with a personal interestin seeing improved health services insideAfghanistan. The seventh criterion reinforcedthe expectation that the BHW would workinside Afghanistan: serving the resisting

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population was part of the resistancemovement. The last criterion tried to eliminatecandidates who had not yet served theirregular term as mujahideen and consequentlymight be called to serve in the armed forcesof the resistance.

From 1987 to 1993, 2,242 BHWs weretrained and 2,190 served for some period.With very few exceptions, all BHWs trainedwere male because of the travel requirements.Every BHW’s location inside Afghanistan wasvisited at least once a year, and many up tothree times a year. Visiting project monitorstook pictures, obtained signed statements ofmilitary and civil authorities on the BHWs’performance, and recorded structuredinterviews with patients. Quality control wasthe most difficult aspect of the project: fewhighly skilled health workers, such asphysicians and nurses, were willing to risktraveling around the country for technicalsupervision visits.

BHWs were given several incentives.Upon graduation from the initial training andcompletion of each refresher course, eachBHW received a written document confirminghis new skills. This document was valuedhighly for the prestige it gave the BHW andthe accountability it ensured to communityleaders for the time spent in Pakistan.Although aware of the possible negative long-term effects of providing salaries, the AHSSPdecided to pay the BHWs because salarieswere seen as “cash for work” and gave Afghanfamilies still living in rural Afghanistan anincentive to stay there. The amount was set at870 Pakistani rupees, whose value againstthe U.S. dollar fell steadily to about half overthe life of the project. Each BHW received aninitial kit of medical supplies and basicequipment that could be resupplied everythree to six months.

Moving between their assigned workingplaces and Pakistan for training, supplies, andsalary payment was hazardous for the BHWsbecause of the geography and infrastructureof the country and the political and militaryinstability. Most of the 22 BHWs killed during

the life of the project lost their lives whiletraveling. The BHWs were not reimbursed fortheir travel to Pakistan for the initial training,but they were often sponsored by thecommunity inside Afghanistan. Travel fromPakistan to the locality of assignment andtransport of medical supplies were advancedat going rates.

Cross matching of three data sources, aswell as having monitoring reportscountersigned by local community leaders,gave the BHWs a sense of being treatedfairly. Particularly those who stayed in theproject for several years appreciated theproject’s ability to pick up and single out“cheaters.” In many communities the BHWsreceived recognition as “doctors” because noother source of Western medical care wasavailable. Many BHWs expressed theirsatisfaction with being able to conversedirectly with the agency implementing theprogram rather than depending on Afghanauthorities, who were often perceived aspartisan and corrupt. The BHWs—even thoseexcluded from the program for their poorperformance—expressed appreciation forgetting a “fair deal.”

The average time of active participationof all the BHWs who dropped out of theproject was 25 months, with a minimum ofless than a month and a maximum of 67months. The average (and median) attritionrate was 5 percent of the total BHWs enrolleda quarter, with a minimum of 1 percent and amaximum of 8 percent a quarter betweenSeptember 1988 and September 1993.

In October 1992 the project decided to cutsalary supplementation to 25 percent of theoriginal amount by April 1992 and later to 50percent. The contents of medical kits wererevised and quantities reduced to reflect theactual average patient load of the BHWs. Noincrease in dropout rates was seen over the12 months following the initial cuts.

Interestingly, BHWs active in theprovinces bordering Pakistan had a muchhigher dropout rate (63 percent of all trained)than those from other provinces (32 percent of

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all trained). Reasons proposed to explain thisdifference include the following:

■ Refugee families in Pakistan wereoriginally mostly from the border areasand often had “split families,” part ofwhom still occupied land insideAfghanistan. BHWs from such familieshad less incentive to work permanentlyinside Afghanistan.

■ The location of most cross-border healthprojects in the border provinces createdopportunities for more gainful employmentof BHWs once they were trained, as wellas competition with more skilled healthworkers.

■ The border provinces were occupied by amosaic of political factions and to a largeextend made up the former “tribal belt” ofAfghanistan, making it difficult for theBHWs to link with possible referral healthfacilities in the hands of othercommanders. In the nonborder provinces,larger regional political entities hademerged by 1989, offering more localsupport to BHWs and in some cases anopportunity to fit into regional healthsystems.

(This appendix was drafted by Paul Ickx fromproject reports and discussions with LaurenceIckx-Laumonier, former field operations officerof the AHSSP.)

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Annex 2Questionnaire for E-mail and InitialInterviews

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

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

a) Public recognitionb) Income-generating activitiesc) Management of a first aid, drug, or commodity fund or kitd) Traininge) Supervisionf) Personal development opportunitiesg) Provision of foodh) Provision of a monetary stipendi) Provision of a bicycle or mopedj) Mentoringk) Other

3. Have you found any differences between regions of the world (Africa, Latin America and theCaribbean, Asia, the Newly Independent States) and the types of incentives that weresuccessful 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 andretraining?

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 canwe reach them through e-mail or by phone?

7. Is there any additional information on CHWs that would be useful to you if collected andanalyzed?

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Annexes

Annex 3Interview Guide for BASICS Examples

Learning about CHWs: Semi-structured Interview Guide1. 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 establishedthem? 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 betweencurative and preventive activities? How many households does each CHW cover? How muchtime is a CHW expected to spend on his/her duties?

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

6. Training: What resources do you put into training of newly recruited CHWs each year? Howmany training courses for new CHWs are there in a year? How many CHWs are trained eachtime? What was the length of training that CHWs received? What is the frequency and durationof 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 motivatedthe CHWs to work? Can you give examples of incentives that were successful in keepingCHWs motivated over a period of time? Please relate any specific positive or negativeexperiences 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 theseevolve? Were they planned? How do they work together?

9. Disincentives: Have any CHWs dropped out? What do you think are the main reasons fordropping out? Do you feel that the program has a problem with high turnover or dropouts orattrition? Why or why not?

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

11. CHW/community link: What is the status of CHWs in the community? Are they perceived asgovernment health workers or volunteers? What CHW functions does the community valuemost? 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 towork together? What opportunities are CHWs given to interact with other CHWs from otherareas?

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

14. Documentation: Do you have any documentation of experiences with CHWs that you cansend to us?

Community Health WorkerIncentives and Disincentives:How They Affect Motivation, Retention,and Sustainability

BASIC SUPPORT FOR INSTITUTIONALIZING CHILD SURVIVAL1600 Wilson Blvd., Suite 300, Arlington, VA 22209 • Tel: 703.312.6800 • Fax: 703.312.6900E-mail: infoctr@basics.org • Website: http://www.basics.org

Contributors

Karabi Bhattacharyya Peter Winch

Karen LeBan Marie Tien

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