Becoming and remaining community health workers: Perspectives from Ethiopia and Mozambique

Abstract

Many global health practitioners are currently reaffirming the importance of recruiting and retaining effective community health workers (CHWs) in order to achieve major public health goals. This raises policy-relevant questions about why people become and remain CHWs. This paper addresses these questions, drawing on ethnographic work in Addis Ababa, the capital of Ethiopia, between 2006 and 2009, and in Chimoio, a provincial town in central Mozambique, between 2003 and 2010. Participant observation and in-depth interviews were used to understand the life histories that lead people to become CHWs, their relationships with intended beneficiaries after becoming CHWs, and their social and economic aspirations. People in Ethiopia and Mozambique have faced similar political and economic challenges in the last few decades, involving war, structural adjustment, and food price inflation. Results suggest that these challenges, as well as the socio-moral values that people come to uphold through the example of parents and religious communities, influence why and how men and women become CHWs. Relationships with intended beneficiaries strongly influence why people remain CHWs, and why some may come to experience frustration and distress. There are complex reasons why CHWs come to seek greater compensation, including desires to escape poverty and to materially support families and other community members, a sense of deservingness given the emotional and social work involved in maintaining relationships with beneficiaries, and inequity vis-à-vis higher-salaried elites. Ethnographic work is needed to engage CHWs in the policy process, help shape new standards for CHW programs based on rooting out social and economic inequities, and develop appropriate solutions to complex CHW policy problems.

Paid staff or volunteers – does it make a difference? The impact of staffing on child outcomes for children attending community-based programmes in South Africa and Malawi

“…Swartz and Colvin [59] suggest that the lack of payment is reflective of a broader, gendered, and structural lack of recognition of the female workforce. The requirement of a fair wage and a secure livelihood is the leading philosophical argument in favour of a paid workforce [7,14]. We provide data that such a philosophy would also have benefits for child recipients of care.…”

“…Countries that use this model include Malawi [6], Ethiopia [7], Zambia [8], South Africa [9], India [10], and Nepal [11]. It has been estimated that there are approximately 60 000 CHWs now working in South Africa [9].…”

“…Summarising the arguments in favour of volunteer CHWs, Kaschko [14] notes that key concerns include the fact that, often, funds are not available to pay CHWs; that inconsistent remuneration reduces motivation; that payment may lead to tension between paid and unpaid staff; that altruism is discouraged by payment; and that compensation may lead to unintended consequences for the programme. Exploring these arguments further, it becomes apparent that it is true that in many cases funding bodies and governments do not or cannot, make funding available for salaries for CHWs [7,15]. Traditionally, there are differences in the activities performed by, and duties expected of, paid and volunteer CHWs [16].…”

Nurses’ perceptions of universal health coverage and its implications for the Kenyan health sector

“…Scholars in health policy and systems research (HPSR) are increasingly interested in understanding more about how international health priorities affect individuals responsible for executing carrying them out (Sheikh et al 2014). For example, research from medical anthropology has demonstrated the difficulties faced by community health workers in Ethiopia (Maes and Kalofonos 2013) and healthcare providers in Malawi (Rosenthal 2015) working in HIV/AIDS programs. Despite the fact that nurses, as frontline health workers, are key actors in carrying out policy directives, research on how they understand policy or respond to policy change in their professional lives is largely underrepresented in the HPSR literature (Richter et al 2013, Juma et al 2014).…”

Towards Promotion of Community rewards to Volunteer Community Health Workers? Lessons from Experiences of Village Health Teams in Luwero, Uganda

“…Subsequently, many sub-Saharan countries have scaled-up CHW interventions especially in rural and remote areas (Maes & Kalofonos, 2013). The Ugandan government began implementing its CHW strategy in 2001 through Village Health Teams (VHTs)-a group of volunteers at the village level trained to become the "vehicle" through which interventions would reach local communities.…”