Table 5 CHWs in the system: findings on incentives within the health system

5.1 CHW motivation is sustained when they feel they are a valued member of the health system and have a clear role and set of responsibilities within it

In what ways are CHWs recognized for their contributions to the health system? Do they have the chance to get positive feedback from other staff or from managers on a day-to-day basis? Are there more formal opportunities for recognition from members of the health system?

Do CHWs have clear job descriptions and distinct roles in the settings where they work? Have their roles and responsibilities been communicated to the other healthcare workers with whom they work? Are there areas of ambiguity in their roles, or overlap with the roles of other workers?

5.2 A sense of the “do-ability” of the CHW role is critical in maintaining CHW motivation

How is the CHW’s set of responsibilities decided on and how do managers ensure CHWs have the capacity to fulfil these responsibilities? How will managers know if the workload or the requirements of the job are exceeding the capacities of individual CHWs?

Do CHWs have the opportunity to speak about issues of workload or technical complexity? How are these issues managed? Do CHWs or local programme managers have the flexibility to reorganize tasks in ways that improve the “do-ability” of the role?

5.3 CHWs are best motivated by work that provides opportunities for personal growth and professional development, irrespective of the direct material and technical skills

What elements of the CHW role promote personal growth (e.g., social, emotional, psychological, or intellectual development)? How do CHWs understand and value the place of personal growth in their work? How can these elements be strengthened in the programme?

What elements of the CHW role promote basic professional development (e.g., computer, administrative, financial, or logistical skills)? How do CHWs understand and value the place of this professional development in their work? How can these elements be strengthened in the programme?

5.4 Working and social relationships among CHWs themselves and between CHWs and other healthcare professionals and community members strongly shape CHW motivation

Do CHWs ever get the chance to work with or interact with each other in their daily work? If they work alone, are there other opportunities for them to engage with other CHWs?

Are there formal or informal opportunities for CHWs to spend time with each other outside of the context of daily work? Are there CHW associations or networks? Do they even get the chance to meet CHWs working in other districts/regions to share experiences?

What are the relationships like between the CHWs and healthcare professionals in your context? Does the work environment promote positive relationships? Are there conflicts between CHWs and other healthcare providers, and if so, how can these be addressed?

5.5 Relationships of recognition and accountability with the health system, community, and other stakeholders are multiple and complex and also affect CHW motivation

Are there processes for recognizing service and dedication among CHWs by the health system, the community at large, or other stakeholders?

Are there issues of mistrust or antagonism of CHWs with the community or with other higher-level health workers?

How are conflicts or issues of poor performance among CHWs handled and by whom? Are there multiple or confusing lines of accountability for CHWs (e.g., to both the health system and the community)? If so, how can these be clarified or reconciled?

5.6 Incentives operate within a social system and can affect these relationships as well

How are incentives offered to CHWs interacting with the existing social relationships among CHWs and between CHWs and others? Are the incentives exacerbating internal differences or hierarchies? Or, are they helping to build solidarity and common purpose among CHWs? Are incentives introducing new dynamics into these social relationships such as competition, status conflicts, or other forms of division? How can incentives be designed and managed in a way that limits any negative effects on these social relationships?