Compensation models for community health workers: Comparison of legal frameworks across five countries

Abstract

Background Despite the life-saving work they perform, community health workers (CHWs) have long been subject to global debate about their remuneration. There is now, however, an emerging consensus that CHWs should be paid. As the discussion evolves from whether to financially remunerate CHWs to how to do so , there is an urgent need to better understand the types of CHW payment models and their implications. Methods This study examines the legal framework on CHW compensation in five countries: Brazil, Ghana, Nigeria, Rwanda, and South Africa. In order to map the characteristics of each approach, a review of the regulatory framework governing CHW compensation in each country was undertaken. Law firms in each of the five countries were engaged to support the identification and interpretation of relevant legal documents. To guide the search and aid in the creation of uniform country profiles, a standardized set of questions was developed, covering: (i) legal requirements for CHW compensation, (ii) CHW compensation mechanisms, and (iii) CHW legal protections and benefits. Results The five countries profiled represent possible archetypes for CHW compensation: Brazil (public), Ghana (volunteer-based), Nigeria (private), Rwanda (cooperatives with performance based incentives) and South Africa (hybrid public/private). Advantages and disadvantages of each model with respect to (i) CHWs, in terms of financial protection, and (ii) the health system, in terms of ease of implementation, are outlined. Conclusions While a strong legal framework does not necessarily translate into high-quality implementation of compensation practices, it is the first necessary step. Certain approaches to CHW compensation – particularly public-sector or models with public sector wage floors – best institutionalize recommended CHW protections. Political will and long-term financing often remain challenges; removing ecosystem barriers – such as multilateral and bilateral restrictions on the payment of salaries – can help governments institutionalize CHW payment.

Motivation and Performance of Community Health Workers: Nothing New Under the Sun, and Yet…

“…We have now entered the age where this principle is recognized by both advocates and technical authorities, 1 although practice struggles to follow the principle. 9 , 10 Given the scale of CHW programs required to achieve their potential, appropriate compensation has a nonnegligible cost, even if the investment is cost-effective. 9 , 11 Does this mean, however, that volunteerism should be retired completely once governments and programs have budgeted for enough CHW staff costs?…”

Continuity of community-based healthcare provision during COVID-19: a multicountry interrupted time series analysis

“…CHWs who were prepared and protected were able to maintain essential services for 5.2 million people across five regions in four different country contexts. Given that the majority of CHWs globally remain unpaid 34 and largely unsupported, this paper suggests that the opportunity cost of not professionalising CHWs may be larger than previously estimated, particularly as we look to better prepare for future pandemics. 35…”

The Disconnect Between Gender-Transformative Language and Action in Global Health

“…Where these efforts have been partially successful, higher compensation and status for female health workers has frequently been followed by growing male interest in undertaking work previously performed by women (e.g. the growing share of male nurses in the US) [26,27]. Thus, the transformative potential of such efforts lies in a longer-term process, and one that is neither linear nor without contestation [28,29].…”

“…While there is no question that community-level resources, agency, and insights, as well as the engagement of women, men and grassroots groups, are essential for addressing gender inequalities in health, a disproportionate focus on community-level programmatic solutions can perpetuate and further distort existing power dynamics and imbalances in the locus of responsibility for change [27,38]. Communities are very important actors for change, but they are neither benign nor homogenous, and the powerbrokers in communities who benefit from current hierarchies can, and frequently do, undermine programmatic efforts that might result in shifting their power base.…”