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 standardized questionnaire was developed and targeted at local law firms. The questionnaire covered legal structures and requirements for compensation of CHWs, CHW compensation mechanisms, CHW legal protections and benefits, and alignment of national CHW policies with global guidelines. 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 public sector, in terms of ease of implementation, are outlined. Conclusions While a strong legal framework does not necessarily translate into high-quality implementation, it is the first necessary step. While certain approaches to CHW compensation - particularly public-sector or hybrid models with public sector wage floors - best institutionalize recommended CHW protections, political will and long-term financing often remain obstacles. Removing ecosystem barriers - such as multilateral and bilateral restrictions on the payment of salaries - can help governments institutionalize CHW payment.

The Lancet Global Health Commission on financing primary health care: putting people at the centre

“… 37 Debates about paying community health workers typically focus on the trade-offs between reliance on volunteerism underpinned by intrinsic motivation of volunteers and the need to recognise and remunerate work fairly (and in doing so, addressing gender disparities, as most of the community health worker workforce is female). 38 , 39 Section 5 includes a brief summary of the evidence on paying community health workers.…”

Health Care Professionals' Perspectives on Implementation, Adoption, and Maintenance of a Community Health Worker–Led Advance Care Planning and Cancer Symptom Screening Intervention: A Qualitative Study

“…Globally, albeit in noncancer interventions, adequate remuneration and processes to retain CHWs remain challenging. 30 In 2018, the WHO strongly recommended compensation for CHWs commensurate with job demands, training, and their roles. 31 Appropriate compensation, equitable work conditions, opportunities to advance CHW careers, and in-depth interdisciplinary training among CHWs, the clinical team members, and patients on team-based approaches may enhance integration of CHWs into clinical teams and help to overcome retention barriers as noted in this study.…”

Exploring the Challenges for Universal Health Coverage: A Call to Africa by AfroPHC

“…It is recommended that CHWs be professionalized and remunerated in all countries in Africa as they form an integral part of the health ecosystem. 44 [ Box 8 ]…”