IntroductionCommunity health workers (CHWs) have been proposed as a means for bridging gaps in healthcare delivery in rural communities. Recent CHW programmes have been shown to improve child and neonatal health outcomes, and it is increasingly being suggested that paid CHWs become an integral part of health systems. Remuneration of CHWs can potentially effect their motivation and focus. Broadly, programmes follow a social, monetary or mixed market approach to remuneration. Conscious understanding of the differences, and of what each has to offer, is important in selecting the most appropriate approach according to the context.Case descriptionsThe objective of this review is to identify and examine different remuneration models of CHWs that have been utilized in large-scale sustained programmes to gain insight into the effect that remuneration has on the motivation and focus of CHWs. A MEDLINE search using Ovid SP was undertaken and data collected from secondary sources about CHW programmes in Iran, Ethiopia, India, Bangladesh and Nepal. Five main approaches were identified: part-time volunteer CHWs without regular financial incentives, volunteers that sell health-related merchandise, volunteers with financial incentives, paid full-time CHWs and a mixed model of paid and volunteer CHWs.Discussion and evaluationBoth volunteer and remunerated CHWs are potentially effective and can bring something to the health arena that the other may not. For example, well-trained, supervised volunteers and full-time CHWs who receive regular payment, or a combination of both, are more likely to engage the community in grass-roots health-related empowerment. Programmes that utilize minimal economic incentives to part-time CHWs tend to limit their focus, with financially incentivized activities becoming central. They can, however, improve outcomes in well-circumscribed areas. In order to maintain benefits from different approaches, there is a need to distinguish between CHWs that are trained and remunerated to be a part of an existing health system and those who, with little training, take on roles and are motivated by a range of contextual factors. Governments and planners can benefit from understanding the programme that can best be supported in their communities, thereby maximizing motivation and effectiveness.

BackgroundThe International Conference on Population Development held in Cairo in 1994 identified the importance of male involvement in reproductive health programs. Since then, there has been an increase in reproductive health initiatives that target both men and women in an attempt to fulfill the 5th Millenium Development Goal. Yet, while the benefits of male involvement have been acknowledged, there continues to be a challenge in creating a space for and engaging men in maternal health. This is problematic due to the role of men as the head of the household in many countries, especially developing countries, which suffer from higher rates of maternal mortality. Furthermore, men are important as partners, fathers and health care professionals and as such it is important to involve and engage with men in maternal health education, and antenatal care.MethodsThe purpose of this study undertaken in two rural villages in southeastern Uganda, was twofold: firstly to understand men’s current participation in antenatal, pregnancy care and childbirth and secondly to gain insight into both men and women’s attitudes toward increased male involvement. Focus group discussions and semi-structured questionnaires were used to collect information from 35 men and women. The women were either pregnant or had been involved in a birth experience in the past 3 years and the men had wives who were pregnant or had given birth recently.ResultsMen interviewed in the two villages believed that issues related to pregnancy and childbirth were the domain of women. Involvement tended to be confined (to removed) strictly to traditional gender roles, with men’s main responsibility being provision of funds. The women, on the other hand, were interested in receiving more support from their husband through planning, attendance to antenatal care and physical presence in the vicinity of where the birth was taking place.ConclusionThis cross-sectional study has highlighted the space for increased male involvement and participation in maternal health, proposed recommendations and the need for community health education directed at men that engages them in this important area.

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When trusted, Community Health Workers (CHWs) can contribute to improving maternal and newborn health outcomes in low- and middle-income countries through education. Issues of acceptability of CHWs by communities were explored through experiences gained in a qualitative study that is part of a cluster randomized trial in East Uganda. Initially, focus group discussions with key community members and leaders were undertaken regarding preventative health and 40 CHWs were observed making home visits by supervisors during the initial 6 months of fieldwork of the trial in eight villages in the Jinja District in Uganda. The results were analyzed using the 5-SPICE framework. Observation of CHWs in the field identified a number of unanticipated issues including a general mistrust of the public health system by community members in areas that had an impact on maternal and newborn health. At the outset, CHWs often did not trust their own abilities and faced community expectations that they would provide curative rather than preventative care. Early community engagement, non-threatening home visits that enhanced friendship and supportive supervision improved the confidence of the CHWs and improved the trust and acceptance of the CHWs and the willingness of the community members to act on what was discussed.

BackgroundCommunity Health Volunteers (CHVs) can be effective in improving pregnancy and newborn outcomes through community education. Inadequate supervision of CHVs, whether due to poor planning, irregular visits, or ineffective supervisory methods, is, however, recognized as a weakness in many programs. There has been little research on best practice supervisory or accompaniment models.MethodsFrom March 2014 to February 2015 a proof of concept study was conducted to compare training alone versus training and supportive supervision by paid CHWs (n = 4) on the effectiveness of CHVs (n = 82) to deliver education about pregnancy, newborn care, family planning and hygiene. The pair-matched cluster randomized trial was conducted in eight villages (four intervention and four control) in Budondo sub-county in Jinja, Uganda.ResultsIncreases in desired behaviors were seen in both the intervention and control arms over the study period. Both arms showed high retention rates of CHVs (95 %). At 1 year follow-up there was a significantly higher prevalence of installed and functioning tippy taps for hand washing (p < 0.002) in the intervention villages (47 %) than control villages (35 %). All outcome and process measures related to home-visits to homes with pregnant women and newborn babies favored the intervention villages. The CHVs in both groups implemented what they learnt and were role models in the community.ConclusionsA team of CHVs and CHWs can facilitate families accessing reproductive health care by addressing cultural norms and scientific misconceptions. Having a team of 2 CHWs to 40 CHVs enables close to community access to information, conversation and services. Supportive supervision involves creating a non-threatening, empowering environment in which both the CHV and the supervising CHW learn together and overcome obstacles that might otherwise demotivate the CHV. While the results seem promising for added value with supportive supervision for CHVs undertaking reproductive health activities, further research on a larger scale will be needed to substantiate the effect.