A Performance-Based Incentives System for Village Health Workers in Kisoro, Uganda

Abstract

Background: Village health worker (VHW) programs in Uganda have achieved limited success, due in part to a reliance on volunteerism and a lack of standardized incentive mechanisms. However, how to best incentivize VHWs remains unclear. Doctors for Global Health developed a performance-based incentives (PBI) system to pay its VHWs in Kisoro, Uganda, based on performance of tasks or achievement of targets. Objectives: 1. To describe the development of a PBI system used to compensate VHWs. 2. To report cost and health services delivery outcomes under a PBI system. 3. To provide qualitative analysis on the successes and challenges of PBI. Methods: Internal organization records from May 2016 to April 2017 were retrospectively reviewed. The results of descriptive and analytic statistics were reported. Qualitative analysis was performed by the authors. Findings: In one year, 42 VHWs performed 23,703 remunerable health actions, such as providing care of minor ailments and chronic disease. VHWs earned on average $237. The total cost to maintain the program was $29,844, or $0.72 per villager. There was 0% VHW attrition. Strengths of PBI included flexibility, accountability, higher VHW earnings, and improved monitoring and evaluation. Conclusions: PBI is a feasible and sustainable model of compensating VHWs. At a time where VHW programs are sorely needed to address limitations in healthcare resources, yet are facing challenges with workforce compensation, PBI may serve as a model for others in Uganda and around the world.

Chronic Disease in the Community (CDCom) Program: Hypertension and non-communicable disease care by village health workers in rural Uganda

“…When delivering NCD care as part of a comprehensive preventative and primary care service, like the VHW program, potential cost drops. Even after incorporating the cost of initial training, our overall VHW program—the care of acute illnesses, prenatal and newborn counseling and referral, targeted health education talks, door-to-door health census, CDCom providers (not drugs), and more—costs 0.72 USD/villager [ 29 ]. While these costs seem relatively low, scaling this kind of (intensive) program nationally for 42 million people would require a substantial increase in consistent government or third-party investment.…”

“…VHW Performance-based Incentive System: Since 2010, the program has employed performance-based incentives: VHWs do not receive a base pay and are instead compensated for the performance of various activities which are validated by their supervisors twice a month [ 29 ]. Stipend amounts, varied seasonally to incentivize performance during certain periods (e.g.…”

Community Perceptions of Village Health Workers in Kisoro, Uganda

“…Financial compensation in Kisoro is provided on a performance-based incentives (PBI) model, similar to fee-for-service, in which VHWs receive remuneration for completing tasks or achieving certain targets. Although the majority of participants indicated a preference for fixed payments, in a previous study we found that PBI incentivized health services delivery and improved accountability, which ultimately may improve acceptability by the community [ 23 24 ]. Regardless of the mechanism, the communities in this study strongly believed that VHWs should be remunerated, and the fact that they are remunerated, if not the particulars, should be made known.…”

Family health sheets: a vital instrument for village health workers providing comprehensive healthcare

“…Over the years, additions have been made to the VHW program to target geriatric and mental health as well [32,33]. VHWs are paid according to a performance-based incentive system of stipends for particular activities with high public health or clinical importance, taking into account disease incidence and effort required by VHWs [34,35].…”