Valuing the work of unpaid community health workers and exploring the incentives to volunteering in rural Africa

Abstract

Community health worker (CHW) programmes are currently being scaled-up in sub-Saharan Africa to improve access to healthcare. CHWs are often volunteers; from an economic perspective, this raises considerations whether reliance on an unpaid workforce is sustainable and how to appropriately cost and value the work of CHWs. Both these questions can be informed by an understanding of CHWs’ workload, their opportunity costs of time and the perceived benefits of being a CHW. However, to date few studies have fully explored the methodological challenges in valuing CHW time. We examined the costs and benefits of volunteering in a sample of 45 CHWs providing integrated community case management of common childhood illnesses in rural Uganda in February 2012 using different methods. We assessed the value of CHW time using the minimum public sector salary rate and a CHW-elicited replacement wage, as well as the opportunity cost of time based on CHW-estimated annual income and alternative work opportunities, respectively. Reported monthly CHW workload, a median of 19.3 h (range 2.5–57), was valued at USD 6.9 (range 0.9–20.4) per month from the perspective of the healthcare system (applicable replacement wage) and at a median of USD 4.1 (range 0.4–169) from the perspective of the CHWs (individual opportunity cost of time). In a discrete choice experiment on preferred work characteristics, remuneration and community appreciation dominated. We find that volunteering CHWs value the opportunity to make a social contribution, but the decision to volunteer is also influenced by anticipated future rewards. Care must be taken by those costing and designing CHW programmes to acknowledge the opportunity cost of CHWs at the margin and over the long term. Failure to properly consider these issues may lead to cost estimations below the amount necessary to scale up and sustain programmes.

Quantifying and Valuing Community Health Worker Time in Improving Access to Malaria Diagnosis and Treatment

“…The daily volume of time spent on childcare was modest both before and after the intervention, and the bulk of the time was spent on diagnosis of malaria, with a smaller fraction on treatment. Our findings are considerably less than the 4.8 hours per day found in Ghana, but comparable to findings in Uganda reporting about 40 minutes daily taken by CHWs to provide integrated care for common childhood illnesses [10, 11]. …”

“…In Burkina Faso, the hourly minimum wage was 176.83 XOF (about 28 292 XOF per month or USD $52.10) [14]. In Nigeria, the monthly minimum wage was 18 000 Nigerian naira (NGN) (USD $100) [14] and in Uganda, USD $54 [11]. CHWs’ time value is presented in US dollars (USD $) using average exchange rates between 2014 and 2015: USD $1 = 542.75 XOF (Burkina Faso) and USD $1 = 180 NGN ().…”

“…The time CHWs contribute to their community reduces the time they can allocate to other tasks, including care of their own children and, as their healthcare activities are voluntary, their income may also decrease. However, assessments of the volume of activities CHWs provide, the time allocated to these tasks, and whether and how this time load affects other tasks and income are extremely rare [10, 11]. …”

Population-based screening for pulmonary tuberculosis utilizing community health workers in Ethiopia

“…The driving force for their active involvement needs to be investigated in terms of motivation. It was observed in Uganda, for example, that volunteer community health workers (CHWs) were actually participating with an expectation of future rewards (Kasteng et al, 2016). In contrast, a qualitative study from this region of Ethiopia suggested the current dominance of intrinsic motivators (such as community recognition and appreciation) among the HEWs and their supporters (Tulloch et al, 2015).…”

Maternal and newborn health implementation research: programme outcomes, pathways of change and partnerships for equitable health systems in Uganda

“…At the same time, monetary incentives and means of transport such as bicycles were found to be essential for VHTs to undertake their roles. Other studies also indicate a nuanced approach to CHW motivation requiring both financial and non-financial incentives [30][31][32].…”