Table 6 The impact of the cultural, political, and economic context on CHW motivation
From: Community health workers at the dawn of a new era: 8. Incentives and remuneration
Findings | Policy and management prompts |
|---|---|
6.1 Culture and community are powerful contextual forces that can shape CHW motivation, but their meaning is often contested, and their impact is often more limited than expected | What aspects of local culture (norms, practices, and beliefs) and local community (the social relationships in which one is directly embedded) might have an effect on CHW motivation? Are there, for example, dominant religious values or social pressures to motivate one to serve or to even make sacrifices? How widely are these aspects of local culture really shared? How culturally diverse is the local community? What are the internal lines of division (linguistic, gendered, ethnic, and so forth) that might complicate the prevailing ideas in the community about CHW values and motivations? |
6.2 While civil society is an important terrain for the development and support of CHW programmes, its characteristics, and its impact on CHW motivation, also vary considerably from place to place, even within the same country | What is the character of local civil society (e.g., NGOs, community-based organizations, faith-based organizations, and other forms of community organization) and how does civil society engage with CHWs? Is it highly organized or not? Well funded or not? Who runs civil society organizations, and in what sense do they represent broader community interests and perspectives? What is the relationship between civil society and the health system, and how might this relationship, whether positive or negative, affect CHW motivation? What is the level of (dis)trust of civil society in the health system and the government? To what extent does the CHW programme rely on civil society? Is this relationship positive? Is it sustainable? |
6.3 The opportunities and barriers embedded in the local labour market define to a large extent how CHWs will interpret the meaning and significance of financial incentives | What is the local economic context like with respect to levels of unemployment, the kinds of jobs available, and the training/skills required, and what are the prospects for further advancement in particular careers? What are the economic opportunities in the local setting that compete most directly for the attention of CHWs, and how many of the CHWs in the programme would be able to take advantage of these opportunities? If these alternative work opportunities either pay more or offer clearer paths for advancement, how do CHWs who remain in their positions explain their staying in place? What role do financial incentives play in this decision? |
6.4 The history of a community’s relationship to the health system, and to the state more broadly, shapes what kinds of incentives matter to CHWs and how motivation can be sustained | What is the historical relationship between the local community and the health system and/or state? If it is one of political antagonism and mistrust, how does this impair CHW motivation? If it is one of solidarity and trust, how does this promote CHW motivation? If the health system or state is regarded positively, what kinds of nonfinancial incentives might increase CHWs’ association with the health system/state (e.g., uniforms, ID cards, and so forth)? Alternatively, if the relationship is more conflicted, how can CHWs be shielded from these negative associations? Would incentives that identify CHWs with community relationships/values or that enhance community representation and accountability better motivate CHWs? |