Study: How Do Incentives Affect Community Health Worker Performance in Madagascar and Malawi?

Throughout sub-Saharan Africa, community health workers represent the foundation of the health system, addressing priority health areas ranging from maternal and newborn health to family planning and Ebola prevention. Not only do community health workers extend access to health services for the underserved and those living in hard-to-reach areas, they help countries accelerate certain health outcomes, and achieve the Sustainable Development Goals and related targets for universal health coverage.

A vast majority of community health workers are unpaid volunteers. Despite increasing calls by global development partners and national governments for expanding the number of community health workers and strengthening community health systems, questions remain on how such investments can maximize the performance and impact of this health worker cadre in the face of systemic challenges. Many community health worker programs are under-funded and disease-focused, lack long-term financing, and suffer from high attrition. Community health workers may receive a mix of financial and non-financial incentives, among them per diems for trainings; equipment; certifications; user fees from the sale of commodities; and public recognition.

To better understand and document the impact of incentives on community health worker performance and retention and service delivery, the US Agency for International Development (USAID)-funded African Strategies for Health (ASH) project, led by Management Sciences for Health (MSH), conducted in-depth research in Madagascar and Malawi. MSH staff with the ASH project analyzed a range of quantitative and qualitative programmatic data and conducted interviews with 123 people, including nine cadres of community health workers supported by international NGOs, ministries of health, and UNICEF. Using a set of performance measurements, as discussed by Naimoli and colleagues and Kok and colleagues, including the quality and number of services provided, utilization of health services, and job satisfaction, the study found that both financial and non-financial incentives have considerable impact on community health worker performance.

Financial incentives affect motivation and can improve participation in trainings, increase knowledge and capacity, and ensure availability of heath commodities for preventive and curative services. Non-financial incentives, such as training and education opportunities, mentorship and supervision, public recognition, and opportunities for job advancement, can also improve motivation and capacity. Likewise, insufficient incentives, delays in payments, heavy workloads, and volunteering “opportunity costs” (i.e. time commitment) contribute to lower motivation, poor performance, and in some cases, interruptions in the delivery of health services to the community.

Study findings suggest three ways to improve the performance of community health workers and the delivery of community-based services:

1. Community health worker incentives must reflect the context: workload, opportunity costs, and the environment in which they work. Consistent incentives, whether for salary, allowances, or per diem payments, can help encourage accountability, commitment, and motivation, and, in many cases, facilitate an uninterrupted provision of health services. 
2. Non-financial incentives must be included as essential components of any community health program, including paid and volunteer programs. Such incentives, including regular training, supervision, public recognition, and opportunities for advancement and professional development, improve the capacity of community health workers and ensure high-quality service provision.
3. Implementing agencies, government partners, and donors supporting community health worker programs must harmonize incentives, trainings, reporting, and supervision, to reduce duplicative costs and improve capacity, use of services, and limit frustration related to inconsistent incentives.

This study is unique in that it examined specific incentives within community health worker cadres of two countries using program data, and related such incentives to performance. If program implementers know how certain features of an intervention affect performance, such interventions can be shaped and adjusted to yield optimal performance. Recommendations from this study are useful for countries considering introducing, modifying, or scaling up a community health program.

Download the Malawi and Madagascar reports and additional resources on community health workers on the ASH website

Led by MSH, USAID’s African Strategies for Health (ASH) project improves the health status of populations across Africa by identifying and advocating for  best practices, enhancing technical capacity, and engaging African regional institutions to address health  issues in a sustainable manner. ASH provides information on trends and developments on the continent to USAID and other development partners to enhance decision-making regarding investments in health.