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Nichols C. Equity and empowerment effects: Multiple styles of 'voluntarism' in community-based health projects. WORLD DEVELOPMENT 2024; 174:106448. [PMID: 38304852 PMCID: PMC10753287 DOI: 10.1016/j.worlddev.2023.106448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 02/03/2024]
Abstract
Community health workers (CHW) are individuals with no formal health training who perform various roles to address health disparities. There are long-sustained debates over how different forms of incentives shape CHW programs, which are often staffed with volunteer or minimally remunerated women. These debates are complicated by the diversity of CHW roles and contexts in which they work. Evidence is particularly scant around "change-agent" style CHWs, who shape health knowledge and norms within their community. This paper addresses this gap through an analysis of a change agent-staffed program that provided nutrition participatory education through women's groups in three eastern Indian sites. We examine how contextual factors across sites shaped change-agent management, and analyze the implications of each approach for efficacy, empowerment, and equity. Analyzing 68 interviews and 10 focus groups this study advances a typology of 'varieties' of voluntarism that we name laissez faire, active-cultivation, and honorarium-accountability, and uses comparative analysis to examine the equity and empowerment effects within selection, management, and payment. First, we find tensions in the community-based selection of volunteers because rather than selecting highly motivated women, groups selected women in the most favorable socioeconomic position to volunteer. Second, there is a tension around responsibility and expectations in that greater training and responsibility leads women to see more psychosocial empowerment (e.g., knowledge, confidence), but also may create more 'costs' to participation and leads to wider economic inequities in change-agent ranks. Third, we observe a misplaced focus on payments as central to change-agent motivation. While the two volunteer-only sites see payment as 'the answer' to motivation problems, the honorarium site sees payments as 'the problem' because they attract less intrinsically motivated individuals. We conclude that while payments may not make an unmotivated volunteer into a motivated one, this analysis suggests payments would potentially allow more marginalized women to participate, which may be key to making more equitable and efficacious impacts.
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Affiliation(s)
- Carly Nichols
- Department of Geographical and Sustainability Sciences, University of Iowa, 312 Jessup Hall, Iowa City, IA 52242, USA
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Sanadgol A, Doshmangir L, Majdzadeh R, Gordeev VS. Strategies to strengthen non-governmental organizations' participation in the Iranian health system. Front Public Health 2022; 10:929614. [PMID: 36518578 PMCID: PMC9742430 DOI: 10.3389/fpubh.2022.929614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 11/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background Non-governmental organizations (NGOs) added a new dimension to intersectoral action for health. Involving the NGOs in health system strengthening could lead to a more efficient, equitable, and better-governed healthcare system. This qualitative study explored effective strategies for NGO participation in the Iranian health system to achieve broader health system goals. Method We conducted 33 semi-structured interviews with health policymakers and planners, NGO actors at the national and provincial levels, and other key informants. The qualitative data were analyzed through a thematic analysis approach. Trustworthiness in the study was observed at all stages of the study. Result Four main themes- were identified: empowerment for learning leadership and management skills, creating active participation in policy-making, capacity building for participation, clarifying participation process, falling into 17 sub-themes. Along with the government and health sector policymakers, NGOs may have a significant role in improving health system goals and increasing equity, social responsiveness, financial risk protection, and efficiency. Conclusion The participation of NGOs in the Iranian health system is a complex process. All elements and dimensions of this process need to be considered when developing a platform for the appropriate participation of NGOs in the health system functions. Evidence-informed strategies for strengthening the participation of NGOs in the health system should be used to utilize NGOs potential to the fullest.
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Affiliation(s)
- Arman Sanadgol
- Student Research Committee, Department of Health Policy and Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leila Doshmangir
- Social Determinants of Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Health Policy and Management, Tabriz Health Services Management Research Center, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Majdzadeh
- Interdisciplinary Research and Practice Division, School of Health and Social Care University of Essex, Colchester, United Kingdom
| | - Vladimir Sergeevich Gordeev
- Institute of Population Health Sciences, Queen Mary University of London, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Karim A, de Savigny D, Awor P, Cobos Muñoz D, Mäusezahl D, Kitoto Tshefu A, Ngaima JS, Enebeli U, Isiguzo C, Nsona H, Ogbonnaya I, Ngoy P, Alegbeleye A. The building blocks of community health systems: a systems framework for the design, implementation and evaluation of iCCM programs and community-based interventions. BMJ Glob Health 2022; 7:bmjgh-2022-008493. [PMID: 35772810 PMCID: PMC9247653 DOI: 10.1136/bmjgh-2022-008493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/30/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction Almost all sub-Saharan African countries have adopted some form of integrated community case management (iCCM) to reduce child mortality, a strategy targeting common childhood diseases in hard-to-reach communities. These programs are complex, maintain diverse implementation typologies and involve many components that can influence the potential success of a program or its ability to effectively perform at scale. While tools and methods exist to support the design and implementation of iCCM and measure its progress, these may not holistically consider some of its key components, which can include program structure, setting context and the interplay between community, human resources, program inputs and health system processes. Methods We propose a Global South-driven, systems-based framework that aims to capture these different elements and expand on the fundamental domains of iCCM program implementation. We conducted a content analysis developing a code frame based on iCCM literature, a review of policy documents and discussions with key informants. The framework development was guided by a combination of health systems conceptual frameworks and iCCM indices. Results The resulting framework yielded 10 thematic domains comprising 106 categories. These are complemented by a catalogue of critical questions that program designers, implementers and evaluators can ask at various stages of program development to stimulate meaningful discussion and explore the potential implications of implementation in decentralised settings. Conclusion The iCCM Systems Framework proposed here aims to complement existing intervention benchmarks and indicators by expanding the scope and depth of the thematic components that comprise it. Its elements can also be adapted for other complex community interventions. While not exhaustive, the framework is intended to highlight the many forces involved in iCCM to help managers better harmonise the organisation and evaluation of their programs and examine their interactions within the larger health system.
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Affiliation(s)
- Aliya Karim
- University of Basel, Basel, Switzerland .,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Don de Savigny
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Phyllis Awor
- Department of Community Health and Behavioural Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Cobos Muñoz
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Daniel Mäusezahl
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | - Jean Serge Ngaima
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Ugo Enebeli
- Department of Community Medicine, University of Port Harcourt, Choba, Rivers State, Nigeria
| | - Chinwoke Isiguzo
- School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Society for Family Health Nigeria, Abuja, Nigeria
| | - Humphreys Nsona
- IMCI, Malawi Ministry of Health, Lilongwe, Central Region, Malawi
| | - Ikechi Ogbonnaya
- Department of Health, Planning, Research & Statistics, Federal Ministry of Health, Abuja, Federal Capital Territory, Nigeria
| | - Pascal Ngoy
- PROSANI, USAID, Washington, District of Columbia, USA
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Sanadgol A, Doshmangir L, Majdzadeh R, Gordeev VS. Engagement of non-governmental organisations in moving towards universal health coverage: a scoping review. Global Health 2021; 17:129. [PMID: 34784948 PMCID: PMC8594189 DOI: 10.1186/s12992-021-00778-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 10/14/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Developing essential health services through non-governmental organisations (NGOs) is an important strategy for progressing towards Universal Health Coverage (UHC), especially in low- and middle-income countries. It is crucial to understand NGOs' role in reaching UHC and the best way to engage them. OBJECTIVE This study reviewed the role of NGOs and their engagement strategies in progress toward UHC. METHOD We systematically reviewed studies from five databases (PubMed, Web of Science (ISI), ProQuest, EMBASE and Scopus) that investigated NGOs interventions in public health-related activities. The quality of the selected studies was assessed using the mixed methods appraisal tool. PRISMA reporting guidelines were followed. FINDINGS Seventy-eight studies met the eligibility criteria. NGOs main activities related to service and population coverage and used different strategies to progress towards UHC. To ensure services coverage, NGOs provided adequate and competent human resources, necessary health equipment and facilities, and provided public health and health care services strategies. To achieve population coverage, they provided services to vulnerable groups through community participation. Most studies were conducted in middle-income countries. Overall, the quality of the reported evidence was good. The main funding sources of NGOs were self-financing and grants from the government, international organisations, and donors. CONCLUSION NGOs can play a significant role in the country's progress towards UHC along with the government and other key health players. The government should use strategies and interventions in supporting NGOs, accelerating their movement toward UHC.
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Affiliation(s)
- Arman Sanadgol
- Department of Health Policy & Management, Tabriz Health Services Management Research Center, School of Management&Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leila Doshmangir
- Department of Health Policy & Management, Tabriz Health Services Management Research Center, School of Management&Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran.
- Social Determinants of Health Research Center, Tabriz Univerisity of Medical Sciences, Tabriz, Iran.
| | - Reza Majdzadeh
- CenterCommunity Based Participatory Research Center and Knowledge Utilization Research Center, Tehran Univerisity of Medical Sciences, Tehran, Iran
| | - Vladimir Sergeevich Gordeev
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Munyangaju I, Langa MAS, Clemens SAC, Marchetti E. Evaluation of the partnership between international non-governmental organizations and the State in the health sector in Mozambique. Pan Afr Med J 2021; 39:91. [PMID: 34466193 PMCID: PMC8379398 DOI: 10.11604/pamj.2021.39.91.25970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 05/18/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Mozambique is one of the poorest nations in the world and its health budget is heavily dependent on external funding. Increasingly, donors prefer to direct their funds through international non-governmental organizations instead of direct donations to the State budget. In the current climate of increased emphasis on health system strengthening, a strong and stable partnership between government and international non-governmental organizations is pivotal for health system strengthening in Mozambique. Methods the study evaluates the current partnership through a standardized survey to healthcare workers employed by international non-governmental organizations in health (INGO, private) and the ministry of health (MOH, public). Results of the survey have been analyzed only descriptively and no statistical evaluations have been performed. Results out of the valid 109 responses obtained 55.1% were from MOH cadres and 45.0% from INGO cadres. Most have been in the health sector for more than 5 years. Most of the respondents recognize that INGOs assist the government in strengthening the health system (71.6%), see the internal brain drain to INGOs and salary scale difference as major problems (70.6% and 78.0%); 87.2% reported that the coordination between INGOs and government needs to be improved. MOH cadres perceived the migration of cadres to INGOs and the need for improving coordination as major issues more acutely than their INGO counterparts (80.0% vs. 59.2% and 88.3% vs. 85.7% respectively). INGOs were perceived to offer better quality health services by 51.4% of respondents (of these 69.4% were INGO respondents). The quality of health services was alike between INGOs and MOH for 33% of the respondents. Conclusion through the various efforts outlined the MOH and INGOs are moving towards an environment of mutual accountability, joint planning and coordination as well as harmonization of activities; but there are still challenges to be addressed. Prioritization and increased funding of the planning unit and planning and cooperation directorate as well as strategies for workforce retention are urgently needed.
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Affiliation(s)
- Isabelle Munyangaju
- Tinpswalo Association, Vicentian Association to Fight AIDS and Tuberculosis, Gaza, Mozambique
| | | | | | - Elisa Marchetti
- GlaxoSmithKline (GSK) Vaccines Institute for Global Health, Siena, Italy
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Olaniran A, Madaj B, Bar-Zeev S, Banke-Thomas A, van den Broek N. Factors influencing motivation and job satisfaction of community health workers in Africa and Asia-A multi-country study. Int J Health Plann Manage 2021; 37:112-132. [PMID: 34476842 DOI: 10.1002/hpm.3319] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 03/03/2021] [Accepted: 08/20/2021] [Indexed: 11/08/2022] Open
Abstract
As key stakeholders continue to affirm the relevance of community health workers (CHWs) in universal health coverage, there is a need for a commensurate focus on their motivation and job satisfaction especially in low- and middle-income countries (LMICs) where they play prominent roles. Despite the wealth of literature on motivation and job satisfaction, many studies draw on research conducted in high-income settings. This study explored factors influencing motivation and satisfaction among CHWs in LMICs. Thirty-two focus group discussions and 116 key informant interviews were conducted with CHWs, programme staff, health professionals and community leaders in Bangladesh, India, Kenya, Malawi and Nigeria. Data were analysed using thematic analysis. Overall, CHWs desired: (1) CHW programmes with manageable workload; work schedules that address concerns of female CHWs on work-life balance; clear career pathway; and a timely, regular and sustainable remuneration. However, no remuneration type guaranteed satisfaction because of an insatiable quest for additional financial reward. (2) Relationship with stakeholders that enhances their reputation. This was more important for unsalaried CHWs. (3) Opportunities to support community members. This was popular among all cadres as it resonated with their altruistic values. This study provides insights for developing a 'comprehensive motivation package' for CHWs.
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Affiliation(s)
- Abimbola Olaniran
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Barbara Madaj
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sarah Bar-Zeev
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Aduragbemi Banke-Thomas
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Nynke van den Broek
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Ormel H, Kok M, Kane S, Ahmed R, Chikaphupha K, Rashid SF, Gemechu D, Otiso L, Sidat M, Theobald S, Taegtmeyer M, de Koning K. Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation. HUMAN RESOURCES FOR HEALTH 2019; 17:59. [PMID: 31324192 PMCID: PMC6642499 DOI: 10.1186/s12960-019-0387-z] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 06/20/2019] [Indexed: 05/28/2023]
Abstract
BACKGROUND The recent publication of the WHO guideline on support to optimise community health worker (CHW) programmes illustrates the renewed attention for the need to strengthen the performance of CHWs. Performance partly depends on motivation, which in turn is influenced by incentives. This paper aims to critically analyse the use of incentives and their link with improving CHW motivation. METHODS We undertook a comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries. These studies had used a conceptual framework on factors influencing CHW performance, where motivational factors were defined as financial, material, non-material and intrinsic and had undertaken semi-structured interviews and focus group discussions with CHWs, supervisors, health managers and selected community members. RESULTS We found that (a mix of) incentives influence motivation in a similar and sometimes different way across contexts. The mode of CHW engagement (employed vs. volunteering) influenced how various forms of incentives affect each other as well as motivation. Motivation was negatively influenced by incentive-related "expectation gaps", including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of CHWs. Furthermore, we found that incentives could cause friction for the interface role of CHWs between communities and the health sector. CONCLUSIONS Whether CHWs are employed or engaged as volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the demotivation derived from the perceived low level of financial reward. Overall, introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Adequate expectation management regarding financial and material incentives is essential to prevent frustration about expectation gaps or "broken promises", which negatively affect motivation. Consistently receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives.
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Affiliation(s)
- Hermen Ormel
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
| | - Maryse Kok
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
| | - Sumit Kane
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
| | - Rukhsana Ahmed
- Eijkman Institute for Molecular Biology, Jalan Diponegoro 69, Jakarta, 10430 Indonesia
| | - Kingsley Chikaphupha
- Research for Equity and Community Health (REACH) Trust, P.O. Box 1597, Lilongwe, Malawi
| | - Sabina Faiz Rashid
- BRAC James P. Grant School of Public Health, BRAC University, Mohakhali, Dhaka Bangladesh
| | | | - Lilian Otiso
- LVCT Health, Research and Strategic Information Department, P.O. Box 19835-00202, Nairobi, Kenya
| | - Mohsin Sidat
- Department of Community Health, University Eduardo Mondlane, P.O. Box 257, Maputo, Mozambique
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Korrie de Koning
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
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Ozano K, Simkhada P, Thann K, Khatri R. Improving local health through community health workers in Cambodia: challenges and solutions. HUMAN RESOURCES FOR HEALTH 2018; 16:2. [PMID: 29304869 PMCID: PMC5756401 DOI: 10.1186/s12960-017-0262-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 12/11/2017] [Indexed: 05/12/2023]
Abstract
BACKGROUND Volunteer community health workers (CHWs) are an important link between the public health system and the community. The 'Community Participation Policy for Health' in Cambodia identifies CHWs as key to local health promotion and as a critical link between district health centres and the community. However, research on the challenges CHWs face and identifying what is required to optimise their performance is limited in the Cambodian context. This research explores the views of CHWs in rural Cambodia, on the challenges they face when implementing health initiatives. METHODS Qualitative methodology was used to capture the experiences of CHWs in Kratie and Mondulkiri provinces. Two participatory focus groups with CHWs in Mondulkiri and ten semi-structured interviews in Kratie were conducted. Results from both studies were used to identify common themes. Participants were CHWs, male and female, from rural Khmer and Muslim communities and linked with seven different district health centres. RESULTS Findings identify that CHWs regularly deliver health promotion to communities. However, systemic, personal and community engagement challenges hinder their ability to function effectively. These include minimal leadership and support from local government, irregular training which focuses on verticalised health programmes, inadequate resources, a lack of professional identity and challenges to achieving behaviour change of community members. In addition, the CHW programme is delivered in a fragmented way that is largely influenced by external aid objectives. When consulted, however, CHWs demonstrate their ability to develop realistic practical solutions to challenges and barriers. CONCLUSIONS The fragmented delivery of the CHW programme in Cambodia means that government ownership is minimal. This, coupled with the lack of defined core training programme or adequate resources, prevents CHWs from reaching their potential. CHWs have positive and realistic ideas on how to improve their role and, subsequently, the health of community members. CHWs presented with the opportunity to share learning and develop ideas in a supportive environment would benefit health initiatives.
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Affiliation(s)
- Kim Ozano
- Public Health Institute, Liverpool John Moores University, Henry Cotton Campus, 15-21 Webster Street, Liverpool, L3 2ET UK
| | - Padam Simkhada
- Public Health Institute, Liverpool John Moores University, Henry Cotton Building, 15-21 Webster Street, Liverpool, L3 2ET UK
| | - Khem Thann
- Louvain Cooperation, #17, Street 282, BKK I, Chamkarmorn, P.O. Box 1e12, Phnom Penh, Cambodia
| | - Rose Khatri
- Public Health Institute, Liverpool John Moores University, Henry Cotton Building, 15-21 Webster Street, Liverpool, L3 2ET UK
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Boulanger RF, Hunt MR, Benatar SR. Where Caring Is Sharing: Evolving Ethical Considerations in Tuberculosis Prevention Among Healthcare Workers. Clin Infect Dis 2017; 62 Suppl 3:S268-74. [PMID: 27118857 DOI: 10.1093/cid/ciw013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
In many settings, the dedication of healthcare workers (HCWs) to the treatment of tuberculosis exposes them to serious risks. Current ethical considerations related to tuberculosis prevention in HCWs involve the threat posed by comorbidities, issues of power and space, the implications of intersectoral collaborations, (de)professionalization, just remuneration, the duty to care, and involvement in research. Emerging ethical considerations include mandatory vaccination and the use of geolocalization services and information technologies. The following exploration of these various ethical considerations demonstrates that the language of ethics can fruitfully be deployed to shed new light on policies that have repercussions on the lives of HCWs in underresourced settings. The language of ethics can help responsible parties get a clearer sense of what they owe HCWs, particularly when these individuals are poorly compensated, and it shows that it is essential that HCWs' contribution be acknowledged through a shared commitment to alleviate ethically problematic aspects of the environments within which they provide care. For this reason, there is a strong case for the community of bioethicists to continue to take greater interest both in the micro-level (eg, patient-provider interactions) and macro-level (eg, injustices that occur as a result of the world order) issues that put HCWs working in areas with high tuberculosis prevalence in ethically untenable positions. Ultimately, appropriate responses to the various ethical considerations explored here must vary based on the setting, but, as this article shows, they require thoughtful reflection and courageous action on the part of governments, policy makers, and managers responsible for national responses to the tuberculosis epidemic.
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Affiliation(s)
- Renaud F Boulanger
- Advisory Committee on Research Ethics, International Development Research Centre, Ottawa, Ontario Biomedical Ethics Unit, McGill University Centre for Interdisciplinary Research in Rehabilitation
| | - Matthew R Hunt
- Centre for Interdisciplinary Research in Rehabilitation School of Physical and Occupational Therapy, McGill University, Montreal, Québec
| | - Solomon R Benatar
- Joint Centre for Bioethics, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada Bioethics Centre, Faculty of Health Sciences, University of Cape Town, South Africa
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Sarin E, Lunsford SS. How female community health workers navigate work challenges and why there are still gaps in their performance: a look at female community health workers in maternal and child health in two Indian districts through a reciprocal determinism framework. HUMAN RESOURCES FOR HEALTH 2017; 15:44. [PMID: 28666447 PMCID: PMC5493888 DOI: 10.1186/s12960-017-0222-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 06/25/2017] [Indexed: 05/16/2023]
Abstract
BACKGROUND Accredited Social Health Activists (ASHAs) are community health workers tasked to deliver health prevention in communities and link them with the health care sector. This paper examines the social, cultural, and institutional influences that either facilitate or impede ASHAs' abilities to deliver services effectively through the lens of the reciprocal determinism framework of social cognitive theory. METHODS We conducted 98 semi-structured, in-depth interviews with ASHAs (n = 49) and their family members (n = 49) in Gurdaspur and Mewat districts. Data were analyzed by comparing and contrasting codes leading to the identification of patterns which were explained with the help of a theoretical framework. RESULTS We found that while the work of ASHAs led to some positive health changes in the community, thus providing them with a sense of self-worth and motivation, community norms and beliefs as well as health system attitudes and practices limited their capacity as community health workers. CONCLUSION We outline potential mechanisms for improving ASHA capacity such as improved sensitization about religious, cultural, and gender norms; enhanced communication skills; and sensitization and advocating their work with health and state officials.
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Affiliation(s)
- Enisha Sarin
- University Research Co., LLC, B7, 1st floor, Suncity, sector 54, Gurgaon, Haryana 122001 India
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11
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Akintola O, Chikoko G. Factors influencing motivation and job satisfaction among supervisors of community health workers in marginalized communities in South Africa. HUMAN RESOURCES FOR HEALTH 2016; 14:54. [PMID: 27601052 PMCID: PMC5013625 DOI: 10.1186/s12960-016-0151-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 08/25/2016] [Indexed: 05/19/2023]
Abstract
BACKGROUND Management and supervision of community health workers are factors that are critical to the success of community health worker programmes. Yet few studies have explored the perspectives of supervisors in these programmes. This study explored factors influencing motivations of supervisors in community health worker programmes. METHODS We conducted qualitative interviews with 26 programme staff providing supervision to community health workers in eight community-based organizations in marginalized communities in the greater Durban area of South Africa from July 2010 to September 2011. RESULTS Findings show that all the supervisors had previous experience working in the health or social services sectors and most started out as unpaid community health workers. Most of the participants were poor women from marginalized communities. Supervisors' activities include the management and supply of material resources, mentoring and training of community health workers, record keeping and report writing. Supervisors were motivated by intrinsic factors like making a difference and community appreciation and non-monetary incentives such as promotion to supervisory positions; acquisition of management skills; participation in capacity building and the development of programmes; and support for educational advancement like salary, bonuses and medical benefits. Hygiene factors that serve to prevent dissatisfaction are salaries and financial, medical and educational benefits attached to the supervisory position. Demotivating factors identified are patients' non-adherence to health advice and alienation from decision-making. Dissatisfiers include working in crime-prevalent communities, remuneration for community health workers (CHWs), problems with material and logistical resources, job insecurity, work-related stressors and navigating the interface between CHWs and management. While participants were dissatisfied with their low remuneration, they were not demotivated but continued to be motivated by intrinsic factors. Our findings suggest that CHWs' quest for remuneration and a career path continues even after they assume supervisory positions. Supervisors continue to be motivated to work in mid-level positions within the health and social services sectors. CONCLUSIONS Global efforts to develop and increase the sustainability of CHW programmes will benefit immensely from insights gained from an exploration of supervisors' perspectives. Further, national CHW programmes should be conceptualized with the dual purpose of building the capacity of CHWs to strengthen health systems and reducing unemployment especially in marginalized communities with high unemployment and low-skilled labour force.
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Affiliation(s)
- Olagoke Akintola
- School of Applied Human Sciences, University of KwaZulu-Natal, Mazisi Kunene Road, Glenwood, Durban 4041 South Africa
- School of Human and Social Development, Nipissing University, 100 College Drive, ON P1B 8L7 North Bay, Canada
| | - Gamuchirai Chikoko
- School of Applied Human Sciences, University of KwaZulu-Natal, Mazisi Kunene Road, Glenwood, Durban 4041 South Africa
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Sarin E, Lunsford SS, Sooden A, Rai S, Livesley N. The Mixed Nature of Incentives for Community Health Workers: Lessons from a Qualitative Study in Two Districts in India. Front Public Health 2016; 4:38. [PMID: 27014675 PMCID: PMC4789362 DOI: 10.3389/fpubh.2016.00038] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/28/2016] [Indexed: 11/26/2022] Open
Abstract
Incentives play an important role in motivating community health workers (CHWs). In India, accredited social health activists (ASHAs) are female CHWs who provide a range of services, including those specific to reproductive, maternal, neonatal, child, and adolescent health. Qualitative interviews were conducted with 49 ASHAs and one of their family members (husband, mother-in-law, sister-in-law, or son) from Gurdaspur and Mewat districts to explore the role of family, community, and health system in supporting ASHAs in their work. Thematic analysis revealed that incentives were both empowering and a source of distress for ASHAs and their families. Earning income and contributing to the household’s financial wellbeing inspired a sense of financial independence and self-confidence for ASHAs, especially with respect to relations with their husbands and parents-in-law. In spite of the empowering effects of the incentives, they were a cause of distress. Low incentive rates relative to the level of effort required to complete ASHA responsibilities, compounded by irregular and incomplete payment, put pressure on families. ASHAs dedicated much of their time and own resources to perform their duties, drawing them away from their household responsibilities. Communication around incentives from supervisors may have led ASHAs to prioritize and promote those services that yielded higher incentives, as opposed to focusing on the most appropriate services for the client. ASHAs and their families maintained hope that their positions would eventually bring in a regular salary, which contributed to retention of ASHAs. Incentives, therefore, are both motivating and inspiring as well as a cause dissatisfaction among ASHAs and their families. Recommendations include revising the incentive scheme to be responsive to the time and effort required to complete tasks and the out-of-pocket costs incurred while working as an ASHA; improve communication to ASHAs on incentives and responsibilities; and ensure timely and complete payment of incentives to ASHAs. The findings from this study contribute to the existing literature on incentivized CHW programs and help throw added light on the role incentives play in family dynamics which affects performance of CHW.
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Affiliation(s)
- Enisha Sarin
- University Research Co., LLC , New Delhi , India
| | | | - Ankur Sooden
- University Research Co., LLC , New Delhi , India
| | - Sanjay Rai
- University Research Co., LLC , New Delhi , India
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Kasteng F, Settumba S, Källander K, Vassall A. Valuing the work of unpaid community health workers and exploring the incentives to volunteering in rural Africa. Health Policy Plan 2016; 31:205-16. [PMID: 26001813 PMCID: PMC4748129 DOI: 10.1093/heapol/czv042] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2015] [Indexed: 11/12/2022] Open
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.
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Affiliation(s)
- Frida Kasteng
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Health Economics and Systems Analysis Group, London, UK,
| | | | - Karin Källander
- Malaria Consortium, London, UK, Department of Public Health Sciences, Karolinska Institutet, Health Systems and Policy group, Stockholm, Sweden, Department of Epidemiology and Biostatistics, Makerere University College of Health Sciences, Kampala, Uganda, and
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Social and Mathematical Epidemiology Group, London, UK
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