A conversation with: Ingrid Zuleta and Maryse Kok
Community health worker programmes (CHWPs) are effective strategies to increase access to primary health services in low- and middle-income countries. Within these programmes, there is a wide range of factors that can influence the motivation of community health workers (CHWs). One of them is career advancement, however, there is currently not much information on how a system for career advancement should be organised to yield optimal motivation. The Royal Tropical Institute conducted a study on the system and current possibilities for career advancement for CHWs. Career advancement was defined as both the opportunities to perform a job at its best and promotion (upgrading).
We analyzed policy documents of human resources for health, available qualitative data from the REACHOUT consortium, and complemented it with an online questionnaire (n=40) and interviews to inventory the perspectives on career advancement of policymakers and programme coordinators in Ethiopia, Kenya, Malawi, and Mozambique and international experts on CHWs (n=9). Study respondents were recruited from the wide network of the Thematic Working Group on CHWs of Health Systems Global. The main elements we studied were: advancement possibilities; training; supervision; performance appraisal; incentives and supply systems.
Underlying systems necessary to organise a career advancement system
Performance appraisal, supervision and training were found to be important elements for a career advancement system.
Although performance appraisal was ranked as the most important element for career advancement, the only country with a formal appraisal system for CHWs was Ethiopia, however, there were concerns on the objectivity of the appraisal. Malawi, Kenya and Mozambique did have checklist to assess performance, but no complete appraisal system.
Supervision was ranked as the second most important element for career advancement. In the four countries under study, supervision was organised hierarchically, with health workers from the health centres supervising CHWs either monthly or quarterly. The supervision did not always happen and in many cases there was no feedback on how to improve performance or how to deal with daily challenges. Study respondents commonly mentioned that supervision should have a supportive instead of a punitive approach, so that the CHWs can enhance their competencies.
Training was ranked as the third essential element for career advancement, and this element was the most diverse among the four countries. The initial trainings ranged from 10 days in Kenya to 1 year in Ethiopia, and the curricula also differed in health areas. Refresher trainings depended mostly on donor funding and availability of vertical programmes that offered extra training for CHWs. Experts were of the opinion that training for CHWs need harmonization of the curricula and a surveillance system to monitor the competencies that each CHW has acquired.
The state of career advancement in the four countries
The state of career advancement was depending upon three main factors. First, the level of integration of the CHWP into the health system an important determinant of how the career advancement system looked like.When CHWPs are formalized and integrated into the health system, the organization of training, supervision and performance appraisal is better gathered for, an example is Ethiopia.
Second, the remuneration of CHWs plays a role.Performance expectations of voluntary and salaried cadres differ. For voluntary cadres, the performance appraisal tends to be more flexible, this might be explained because their motivation is assumed to be more altruistic and not financial, thus systems could not strongly follow-up on performance.
Third, the distribution of administrative power, especially the extent of decentralization influences the state of career advancement.For decentralized nations, a national policy on career advancement for CHWs can only be prescriptive, thus improvement of performance through a career advancement system will depend on the district level and their implementation of training, supervision and performance appraisal.
From performance to upgrading
Even though we used a broad definition for career advancement, it is necessary to separate what is needed for optimal performance (in CHWs’ current positions) and for upgrading or promotion to other jobs or levels. We found that if a career advancement system is developed to improve performance, the underlying systems of performance appraisal, supervision and training should complement each other. In other words: supervise CHWs according to what they have been trained on, appraise CHWs through supervision and offer trainings depending on the necessities as found out during appraisal.
To make promotions to other jobs or levels possible, even a more comprehensive system needs to be in place. It is important to ensure that an objective performance appraisal is available, and to make sure that jobs and funds to provide salaries for the higher cadres after upgrading are available. When CHWs who went for upgrading trainings have no sense of change in responsibilities and salaries, the upgrading system is demotivating for the CHWs, as mentioned by both HEWs in Ethiopia and Malawian HSAs. In addition, capacity for recruitment and training of new CHWs should be in place: if CHWs are upgraded to other cadres, they need to be replaced by new CHWs to keep the connection with the community.
Our research shows that considerable human resource planning and investments are needed for career advancement of CHWs. If, based on the vision of countries’ health workforce plans, the development of an upgrading system for CHWs is desired, then the CHWPs first need to reach a certain level of organization, integration, and functionality. Such conditions are necessary, in order to assure regular recruitment, training and objective performance assessment, which are preconditions for the development of upgrading systems for CHWs.
Photo Credit: Living Goods – Creative Commons