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Panelists of Strengthening and Scaling the Community Health Workforce and GHDonline staff

Are CHWs lay volunteers or professionals?

Posted: 14 Jun, 2017     Replies: 14

I just want to stress one point in the equation on how to support CHWs so that they can be successful - the debate about whether CHWs should be paid. Some say that we have to pay them because it is morally right to do so, and it allows them to work harder. Others say it is bad to pay them because payment may "kill the spirit of volunteerism.” The following ideas inform my own thinking on this, and I wanted to share them to get your thoughts:

• Time is money; money is time – if you want CHWs to work regular and long hours, you have to pay them because this money enables them to focus on this work instead of other work. By paying them you are buying the time they would be spending otherwise on their work that puts food on the table. Making their CHW job a livelihood sets the stage for effective contributions.

• Money is not (only) motivation – a salary enables, but so much more is needed to motivate. There are many models available from the business literature on what contributes to a robust motivation, but most will describe the importance of factors such as job design, the organization’s work culture, supporting supervision and mentoring, etc. When working to build a job that CHW love to do, ask whether the job offers them some measure of autonomy, mastery, and purpose. The 360 supervision structures described by the Muso team in another conversation goes a long way in this direction.

• CHWs are human – CHWs will respond to opportunities in ways that are very similar to how you or I would respond: they will weigh the options, assess the risks and benefits, and lean towards what makes the most sense in their lives. Many programs look to “non-monetary incentives” as the primary "motivator," but while bicycles, umbrellas, t-shirts, and gumboots are all great work tools, are they sufficient alone to make a CHW work every day with excellence and fidelity? The ability to grow in their work, make extra money in “moonlighting” opportunities, grow in their standing in the community – these are some of the elements that may lead to that extra spark that distinguishes barely functional CHW programs from those that are truly exceptional.

Replies

 

Kassimu Tani Replied at 2:32 PM, 14 Jun 2017

CHW is a profession and they spent time to provide important services

See the article about CHW time use

https://www.ncbi.nlm.nih.gov/pubmed/27586458

SENI JAMES BARKA Replied at 3:48 PM, 14 Jun 2017

The perspective of Chws differs from one country to another, in Nigeria
CHws are cadre of health professionals that are clinically trained in
colleges of health sciences and Technology and are licensed to practice by
their regulatory board under the federal republic of Nigeria,but I can see
that some of the discussion on Chws seems to look as if they are just some
group of individuals just picked from the community to volunteer in health
promotion, but in Nigeria it's a noble profession that is payable,i suggest
that this should be applicable to other African countries.

Sam A Replied at 3:50 PM, 14 Jun 2017

I would say it depends on the context and project. Whilst i am very pro paying CHWs for the work they put in, i do understand the voluntary aspect that some organisations adhere to like the Red Cross.
If we want to treat them as extensions of the health system who are answerable to the health post or project they are supporting then yes they should be paid.
However, if the CHWs are selected by communities and supported by them as well i feel the community should have a say in what the payment should be, be it monetary or in kind.

Dr Julia Mwesigwa Replied at 5:29 AM, 15 Jun 2017

Dear all,I have followed this discussion very closely and I agree with Mr Seni 100% While CHWs are volunteers in some settings I think we should recruit CHWs who have a basic clinical training (in addition to other qualifications required) since we they assist with distributing contraceptives, anti TBs, ARVs, participant recruitment etc 
 I also agree with what has already been suggested earlier, volunteering doesn't mean we only give incentives. We can turn the tide and advocate for programs/studies to pay CHWs since we pay nurses and doctors and other program staff

Felix Ndagije Replied at 7:31 AM, 15 Jun 2017

Do we have a standard system that accredits CHWs? Who decides their
"professional" work? Many CHWs are self volunteers or are volunteered by
their communities. Do "accrediting" bodies consult communities while
standardizing their services? ... etc!

Ireen Silweya Replied at 7:57 AM, 15 Jun 2017

Daniel this is very true, my experience has been the chw jumping from one
organisation to another based on the motivation they get, not forgetting
mentoring and all.
One time in my country efforts started to consolidate chw motivation by all
organisation working with them but from my memory it died a natural death
as each organisation had its own focus and capacity to work with the chws .
this is a sensitive type of human resource that need consolidated effort to
empower if great results are to achieved.
I hope we are learning from these discussions going on.

Leonard Masele Replied at 9:28 AM, 15 Jun 2017

What is the best way to retain CHWs as several organizations implement similar projects with different approaches in the same community?

Ram Kumar Shrestha Replied at 9:29 AM, 15 Jun 2017

Ram Shrestha:

CHWs and CHVs are used as they are the same cadre. Even though both of them works at the community level their position and link to the formal health system, roles and responsibilities are different. Following information depicts the distinction between CHWs and CHVs. Since CHVs are do not receive salary and not part of the government health system most of the developing countries are facing sustaining their motivation.

A formal health system structure consists of a regional referral hospital, district hospital and health centers, (or health posts/sub-health posts or dispensary, or CHPS compound etc.) at region, district and sub-district level respectively. Below sub-district level there is no formal health system structure.
Each Health Center/Health post is responsible for providing health services in 3-5 villages covering 500 to 1000HHs. Each village covers approximately 150 to 200 HHs. The Community Health Workers (midwives, nurse, enrolled nurse etc.) of the health facility are responsible for providing health service at the community level. Because of the large area coverage CHWS are facing the challenges of lack of transportation, shortage of staff, community support, etc.
To support CHWs most countries have selected Community Health Volunteers (CHVs) in every village to provide promotive and preventive health services. Each CHV is expected to provide health services to 100 to 200 HHs. Since they are volunteers they will not be able to provide their time and commitment as paid workers. The volunteers also have their family obligations every day which they cannot ignore. In addition, it is physically difficult for a volunteer to visit every house to provide health services. Therefore, the main challenges for community health volunteers are lack of transportation, resources, community support, supervision, motivation etc.
Since a developing country not able to pay salary to CHVs a few countries have used different models to sustain motivation of Community Health Volunteers. For example, Bangladesh has used business model to motivate CHVs to deliver health services in rural areas. The local government in Nepal has established Endowment fund from their yearly budget to motivate FCHVs. Rwanda has used corporate model to sustain motivation of CHVs. Technical people should help government to establish motivation program using existing community system structure to sustain the CHVs network/program.

Jim Lloyd Panelist Replied at 9:32 AM, 15 Jun 2017

Daniel:

Thanks for this interesting debate. I agree with your points, and if I could add some of our experiences.

Our perspective is from the United States, where if CHWs are used, they are part of a well-established sector of the economy that accounts for ~17% of our GDP. Accordingly, it's considered a job here (though some organizations we work with use volunteers to help with CHW-like responsibilities). The organization for which they are working may be a well-resourced health system, and so the economic context of a health system asking for volunteers is quite different from that of a clinic or NGO.

Volunteers can also add administrative burden to an organization, since while they may have strong, non-monetary motivations to do the work, fitting them into existing workflows can be challenging when you can't necessarily make them do anything. If the CHW is being integrated into a practice with a specific system of care, for example, it may involve much more "management" of the volunteers than an organization may want to do. It can also be challenging to plan for the future based on volunteers, especially if an organization is pursuing a longer-term funding stream -- and again, the context of "fitting into a large, well-established sector of the economy" may be a big part of this concern.

Jim

Rajan Dewar Replied at 11:23 AM, 15 Jun 2017

Thanks to Daniel and others who have shared their experience.
Regulating CHW or CHV with professional requirements or certifications can
become very quickly burdensome. However, in my opinion, if a volunteer or
Worker is involved in even a semi-professional capacity they should be
monitored for their quality. Can an uncertified CH worker or volunteer
reliably perform clinical tasks such as taking blood pressure, teaching
breast self examination, or Cervical examination?
Double edged...
Thank you,

Ram Kumar Shrestha Replied at 11:37 AM, 15 Jun 2017

I agree with Daniel suggestions. His suggestion is also applicable in the urban areas of developing countries where the development activities are mostly managed by Municipality with the tax money. The information that I provided mostly applicable in rural settings of developing countries. Attached distinction between CHWs and CHVs in the operational level.

Attached resource:

Maggie Sullivan Replied at 11:57 AM, 16 Jun 2017

On the topic of designing programs, and how to utilize research to design better programming, I came across this interesting and recent publication (PubMed link provided below). It is, unfortunately, not an open access journal, but members may be able to access through their institutional affiliations.

Household coverage of Swaziland's national community health worker program: A cross-sectional population-based study

ABSTRACT
Objectives:
To ascertain household coverage achieved by Swaziland's national community health worker (CHW) program, and differences in household coverage across clients' sociodemographic characteristics.

Methods:
Household survey from June to September 2015 in two of Swaziland's four administrative regions using two-stage cluster random sampling. Interviewers administered a questionnaire to all household members in 1,542 households across 85 census enumeration areas.

Results:
While the CHW program aims to cover all households in the country, only 44.5% (95% confidence interval: 38.0% to 51.1%) reported that they had ever been visited by a CHW. In both uni- and multivariable regressions, coverage was negatively associated with household wealth (OR for most versus least wealthy quartile: 0.30 [0.16 to 0.58], p<0.001) and education (OR for >secondary schooling versus no schooling: 0.65 [0.47 to 0.90], p=0.009), and positively associated with residing in a rural area (OR: 2.95 [1.77 to 4.91], p<0.001). Coverage varied widely between census enumeration areas.

Conclusions:
Swaziland's national CHW program is falling far short of its coverage goal. To improve coverage, the program would likely need to recruit additional CHWs and/or assign more households to each CHW. Alternatively, changing the program's ambitious coverage goal to visiting only certain types of households would likely reduce existing arbitrary differences in coverage between households and communities. This study highlights the need to evaluate and reform large long-standing CHW programs in sub-Saharan Africa.

Link: https://www-ncbi-nlm-nih-gov.ezp-prod1.hul.harvard.edu/pubmed/?term=Household...

Kenneth Maes Replied at 12:24 PM, 16 Jun 2017

So sorry to be late to this discussion. I agree wholeheartedly with the points that Daniel Palazuelos has raised. I would add that we should remember that an important premise to this discussion is the very high levels of unemployment and poverty that countless people face today. The contexts in which CHWs work are typically characterized by unacceptable levels of unemployment and poverty. That is a big reason why people are sick in the first place. Creating good jobs in both public and private sectors is a key yet contested way to reduce poverty. So then the question perhaps should be: why wouldn't we pay CHWs? The default, I believe, should be to pay them well. But we should think carefully about what payment will do for the lives of CHWs and the people they serve. We should encourage volunteerism when it is appropriate and desired by the people who are providing that labor. And we should remember what Daniel P said, that payment is an enabler (of good work and a better life), while motivation depends on so many other factors that also demand attention. Thank you! - Kenny Maes (http://liberalarts.oregonstate.edu/users/kenneth-maes)

Daniel Palazuelos Panelist Replied at 11:57 PM, 16 Jun 2017

Thank you everyone for your input and insights.

As a parting word, I'd like to make just two points:

1) please consider reading "The Lives of Community Health Workers: Local Labor and Global Health in Urban Ethiopia" by Kenny Maes - this book puts a very real human face on the people who form the reality behind our enthusiasm for community health. A point he makes astutely in the book is that CHWs may be seen as wonderful by experts like us, but yet they are rarely invited to speak or represent themselves in our circles. How many of the posts in this series were written by CHWs themselves? What does that say about the future of our work?

2) I agree with Ram and others that there are distinctions between CHVs and CHWs. There IS a role for volunteerism, indeed, but I think most now recognize that substantive work needs to be paid. As health systems struggle to find appropriate financing, I worry that we will stop being intellectually honest about the differences between CHVs and CHWs. In short: when the world runs short on funding, will we squeeze the volunteers. What does this say about the future of our work?

To continue the conversation, please feel free to contact me at:

Attached resource:

This Expert Panel is Archived.

While this Expert Panel is no longer active, we invite you to review and recommend past replies and resources. Membership for this Expert Panel is closed, but we hope you'll join us in one of the many communities on GHDonline.

Panelists of Strengthening and Scaling the Community Health Workforce and GHDonline staff