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Table 8 Summary of key prompts for policy-makers and managers

From: Community health workers at the dawn of a new era: 8. Incentives and remuneration

Theme

Key questions to consider

Incentives at the individual level

 Managing the relationship between altruism and CHWs’ basic survival needs

What altruistic motivations keep CHWs engaged in their work?

How does the CHW programme reinforce or undermine these sources of altruism?

Are there tensions between CHWs’ altruistic motives and their need to provide for their basic material needs? How does the CHW programme balance these different motives?

 Other extrinsic motivations besides salary

How can your programme address some of CHWs other material needs like training and certification opportunities, referrals for/preferential access to health, welfare, housing, or educational benefits, food parcels, transport money, airtime, etc.?

Can you provide these material benefits in a way that is socially acceptable and avoids breeding competition or conflict

 Identifying and maintaining intrinsic motivation

How can your programme identify and support intrinsic CHW motivations, such as a personal connection to the health problem addressed or some other altruistic motivation?

Incentives within the health system

 Valuing CHW team members and clarifying roles and responsibilities

In what ways are CHWs recognized for their contributions to the health system?

Do CHWs have clear job descriptions and distinct roles in the settings where they work?

Do others clearly understand their roles and responsibilities

 Ensuring CHW work feels “do-able”

How are CHW responsibilities decided on, and how do managers ensure CHWs have the capacity to fulfil them?

Do CHWs have the opportunity to speak about issues of workload or technical complexity?

Can CHWs or local programme managers reorganize tasks to improve the “do-ability” of the role?

 Supporting personal growth and professional development

What elements of the CHW role promote personal growth (e.g., social, emotional, psychological, or intellectual development)?

What elements of the CHW role promote basic professional development (e.g., computer, administrative, financial, or logistical skills)?

How can these elements be strengthened in the programme?

 Supporting CHWs’ working and social relationships with others

Do CHWs ever get the chance to work with or interact with each other in their daily work?

Are there formal or informal opportunities for CHWs to spend time with each other outside of the context of daily work?

How could the relationships between CHWs and healthcare professionals be improved?

 Effective forms of recognition and accountability for CHWs

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

How are conflicts or issues of poor performance among CHWs handled and by whom? Can this be improved?

 Managing the social impact of CHW incentives

Could CHW incentives introduce new dynamics into CHW 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?

Incentives in cultural, political and economic context

 Culture and community in CHW programmes

What aspects of the local cultural and community context might increase or reduce CHW motivation?

What are the potential lines of division within a community—linguistic, gendered, ethnic, and so forth—that might complicate CHW experiences and motivations?

 Complex engagements with civil society

What is the character of the local civil society and how does civil society engage with CHWs?

What is the relationship between civil society and the health system, and how might this relationship, whether positive or negative, affect CHW motivation?

 CHW incentives in the context of local labour conditions

What is the local economic context like, and what economic opportunities compete most directly for the attention of CHWs?

If these alternative work opportunities either pay more or offer clearer paths for advancement, how does this affect CHW motivation?

 CHW incentives and their relationships to the government

Are the relationships between the local community and the health system and/or state positive or negative, and how does this affect CHW motivation?

What kinds of incentives might increase CHW’s motivation by building on a positive relationship, or shielding a CHW from a negative relationship?

Changes over time in CHW motivation

 Managing the changing impact of incentives over time

Has the motivating impact of CHW incentives lessened over time, and if so, how can the incentive package be adjusted?

As CHWs get older and have families, are previous incentives less relevant, and are alternative incentives potentially more effective?

 Approaching the CHW policy cycle as an ongoing process

What kind of planning and consultation went into the design of incentives at the beginning of the CHW programme?

What do CHWs feel about the current package of incentives?

Are there opportunities for meaningful CHW feedback to be solicited and fed into ongoing management, evaluation, and programme design cycles?

 Matching incentives to changes in social, cultural, political, economic, health systems, and demographic contexts

Since the initial design of the CHW programme and its incentives, what has changed in the broader social, political, economic, or health systems context that might impact on these incentives?

How should the incentive package be adjusted in response to these changes?