By: Dr. Rebecca Furth
This is the eleventh chapter of the CHW Reference Guide produced under the Maternal and Child Health Integrated Program, the United States Agency for International Development Bureau for Global Health’s flagship maternal, neonatal and child health project.
Policy makers, program managers, and donors are frequently preoccupied by the question of what incentives to provide CHWs to keep them motivated and performing. It’s no wonder, as many workers need compensation to do their work and incentives can have major implications for program costs and sustainability. Experience shows that lack of or inappropriate incentives are a common problem in CHW programs that frequently contribute to demotivation and turnover. However, the answer to the question, “What is the right amount to provide CHWs?” is not an easy one.
The reality, as Christopher Colvin points out in his chapter “What Motivates Community Health Workers? Designing Programs that Incentivize Community Health Worker Performance and Retention,” is that no one incentive or incentive amount will fit every context, nor can incentives remain static over time and still sustain CHW motivation. Instead, this chapter makes the case for a broad conceptualization of incentives, inclusive approaches for determining incentives, and systematic processes for monitoring, evaluating, adjusting and sustaining incentives. It addresses two key questions: What forms of incentives are there; and what are the decisions related to incentives that must be made?
The chapter defines incentives broadly as “all those factors that affect the motivation of CHWs” and notes that “there is no easy, one-to-one relationship between incentives, motivation and practice.” To help navigate the complex terrain of incentives and motivation, it provides a useful framework that outlines three principal categories of incentives: direct incentives, indirect incentives and complementary/demand-side incentives. The case study of diverse community health workers in India is presented to illustrate both the range of incentives that may be used, even in a single country, and some of the challenges or pitfalls of incentives, including unintended negative consequences along with positive results.
Direct incentives – Both financial and non-financial incentives
Financial: Salary, pension, insurance or performance
Non-financial: Role clarity, supportive supervision,
Indirect incentives – Health system and community elements
Health system: Effective system management,
Community: Community involvement, the support of
Complementary incentives – Policy and legislation
A broad perspective of incentives and systemized approaches to incentive management are needed to guide national decision-makers in establishing effective incentive schemes that increase or sustain motivation and performance. Colvin notes that “Like any other aspect of the health system, incentives need to be 1) properly designed through review of the evidence and consultation with stakeholders, 2) implemented, managed and monitored on an ongoing basis and finally, 3) evaluated to assess their effectiveness and plan for changes.”
With regard to financial and non-financial incentives, the chapter stresses that these are not an either-or, but a continuum of often complex offerings. When designing incentives schemes, policymakers and program managers need to consider a number of factors from local precedents and expectations to fairness and labor market factors.
Indirect and complementary incentives need to be considered in tandem with direct incentives. Key questions policymakers and program managers need to deliberate include: clear CHW roles, responsibilities and feedback; personal growth and professional development; day-to-day working relationships; accountability in the health system and community; CHW “champions;” the role of civil society partners; and the community’s relationship to the health system and government.
Finally, putting in place plans to monitor, evaluate and modify incentives over time is a critical step that policymakers and program managers need to consider from the start. Colvin remarks that “there is much more attention paid and evidence available with respect to the initial design of incentive packages, and much less is known about how to effectively manage and adjust these packages over time. In many cases, it appears that, once instituted, incentive packages either do not change or they change due to external circumstances (e.g. loss of funding) rather than a planned process.” To address this gap, the chapter stresses that management of incentives needs to be included in the design process and views and expectations of CHWs need to be integrated into this process. The key question, Colvin stresses, “is not what kinds of incentives will last the longest over time, but what kind of local process for designing, managing and re-evaluating incentives will be most effective at responding to changes over time.”
Policy makers, program managers, donors, and others will find in this chapter valuable tables that frame the major questions that need to be considered when designing and managing incentives for CHWs. The most salient learning points to take away from the chapter are that incentives need to be tailored to the context; financial incentives are only one type of incentive and planners should consider the whole range of direct, indirect and complementary incentives when designing programs; and that planning needs to incorporate not just the incentive, but processes for monitoring, evaluating and adjusting incentives over time.
Rebecca Furth is a Senior Technical Advisor with Initiatives Inc., a Boston-based public health organization that manages CHW Central. Dr. Furth supports Initiatives’ human resources management, organizational development, quality improvement and operations research activities. She holds a PhD in cultural anthropology.