Salaried and voluntary community health workers: Exploring how incentives and expectation gaps influence motivation

Background: The recent publication of the WHO guideline on support to optimise community health worker (CHW) programmes illustrates the renewed attention for the need to strengthen the performance of CHWs. Performance partly depends on motivation, which in turn is influenced by incentives. This paper aims to critically analyse the use of incentives and their link with improving CHW motivation. Methods: We undertook a comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries. These studies had used a conceptual framework on factors influencing CHW performance, where motivational factors were defined as financial, material, non-material and intrinsic and had undertaken semi-structured interviews and focus group discussions with CHWs, supervisors, health managers and selected community members. Results: We found that (a mix of) incentives influence motivation in a similar and sometimes different way across contexts. The mode of CHW engagement (employed vs. volunteering) influenced how various forms of incentives affect each other as well as motivation. Motivation was negatively influenced by incentive-related “expectation gaps”, including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of CHWs. Furthermore, we found that incentives could cause friction for the interface role of CHWs between communities and the health sector. Conclusions: Whether CHWs are employed or engaged as volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the demotivation derived from the perceived low level of financial reward. Overall, introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Adequate expectation management regarding financial and material incentives is essential to prevent frustration about expectation gaps or “broken promises”, which negatively affect motivation. Consistently receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives.

This study is a comparative analysis of qualitative studies carried out in Bangladesh, Ethiopia, Kenya, Indonesia, Malawi and Mozambique. These countries were part of the REACHOUT research programme (2013-2018) focusing on factors influencing CHW performance [38]. The countries have well-established CHW programmes but considerable variation in CHW typology. In 2013, REACHOUT programme undertook an initial international literature review [39] and developed a conceptual framework modelling the factors influencing health worker performance, with a special focus on CHWs [19, 25]. Using this unifying framework approach [40], the six countries derived topic guides for semi-structured interviews (SSIs) and focus group discussions (FGDs) with purposefully sampled CHWs, their supervisors, health managers and selected community members. SSIs were used to enable individual discussion (and took place in homes and offices) and allowed for sensitive areas to be probed, avoiding possible issues of power which can shape group discussion. FGDs used group interaction to generate findings to help understand community and organisational norms, common health issues and the need for access and use of healthcare services [41]. Sampling of study participants was based on their involvement in CHW programmes; variation was achieved based on demographic characteristics of participants and geographical characteristics of study sites. All six country studies explored participants’ perspectives on factors influencing CHW motivation, addressing incentives in terms of expectations and actual (perceived) incentives. Altogether, 250 interviews and 65 FGDs were undertaken as part of the six country qualitative context analyses, referred to as the REACHOUT country studies [42–47]. Details of data collection and respondents per country are presented in Table ​Table1;1; these as well as details regarding study design (participant selection, setting, data collection), data analysis and reporting can be found in detail in the referred six REACHOUT country study reports. Interviews and focus group discussions conducted per country, by informant type (2013–2014) Village midwives and village nurses—3 Kader—8 Formal CTCPs—8 Informal CTCPs—16 Kebele administrator—3 Health centre in charge—3 Delivery case team leaders—3 HEP coordinators—3 Regional HEP coordinator—1 Zonal HEP coordinator—1 CHEWs—16 SCHMT members—3 Facility in charges—4 National level policy makers—4 District level staff—13 Health centre in charges—2 NGO staff—9 Health facility supervisors—3 District supervisors—2 Paramedic—2 Clinic manager—2 Counsellor—2 Nurse—1 Program officer—1 Head of PHC or Puskesmas—4 Midwife coordinator—2 Head of district MCH section—2 Women—6 Men—2 Women—7 Volunteers—6 Married women—8 Married men—4 Mothers—12 TBAs—6 Mothers—1 TBAs—6 Traditional leaders—3 Volunteers—2 Mothers—39 TBAs—8 Head of village and head of PKK—17 APE Agentes polivalentes elementares (elementary multipurpose agents), CHEW community health extension worker, CHW community health worker, CTCP close-to-community provider, FGD focus group discussion, FWA family welfare assistant, HEP health extension programme, HEW health extension worker, HSA health surveillance assistant, Kader volunteer CHW, MCH Maternal and child health, PHC primary health care, PKK Pembinaan Kesejahteraan Keluarga (refers to the “family welfare movement”—an Indonesian women’s organisation), SSI semi-structured interview, NGO non-governmental organisation, Puskesmas sub-district community health centre, SCHMT sub-county health management team TBA traditional birth attendant For the current study, we performed a comparative analysis of the existing datasets of the six country studies, analysing them from various perspectives. We started off with a cross-country review of the six country study reports. To further deepen the themes that emerged from the initial analysis, we then performed secondary data analysis by reviewing existing datasets in Nvivo 10, for codes related to incentives (various forms of incentives and disincentives, motivation, job satisfaction, training, career advancement). Main themes were identified, narratives developed and contextual comparative analyses conducted to explore how the realities of CHWs’ role within different countries shaped their experiences and expectations (Table ​(Table22). CHW typology in the six study countries by type of organisation and mode of engagement Volunteers, with some form of financial incentive Note: time inputs vary across countries/cadres Allowance: USD40 Uniform Sometimes: bicycles, airtime NGO Bangladesh: Shasthya shebikas (SS) APE Agentes polivalentes elementares (elementary multipurpose agents), CHW community health worker, FWA family welfare assistant, HEW health extension worker, HSA health surveillance assistant, kader volunteer CHW, MoH Ministry of Health, NA not available, NGO non-governmental organisation, SK health workers, SS health volunteers, USD United States dollars

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