Understanding Factors That Support Community Health Worker Motivation, Job Satisfaction, and Performance in Three Ugandan Districts: Opportunities for Strengthening Uganda's Community Health Worker Program

A systematic review of the types, workload, and supervision mechanism of community health workers: lessons learned for Indonesia

BACKGROUND

Community health workers (CHWs) have demonstrated capability to improve various health indicators, however, many programmes require support in meeting their objectives due to subpar performance and a high rate of CHW attrition. This systematic review investigated the types of CHWs, their workloads, and supervision practices that contribute to their performance in different countries.

METHODS

The search was carried out in November 2022 in Medline, Embase, and Neliti for studies published in Indonesian or English between 1986 and 2022 that reported public health services delivered by CHWs who live and serve the community where they live but are not considered health professionals. The findings were synthesised using a thematic analysis to assess key factors influencing the performance of CHWs.

RESULTS

Sixty eligible articles were included in this review. CHWs were responsible for more than two diseases (n = 35) and up to fifteen, with more than eighteen activities. Their roles covered the human life cycle, from preparation for pregnancy, care for newborns, health for children, adolescents, and productive age to elderly individuals. They were also involved in improving environmental health, community empowerment, and other social issues hindering access to health services. They carried out promotive, preventive, and curative interventions. The CHW-population ratio varied from eight to tens of thousands of people. Some CHWs did not have a clear supervision system. Challenges that were often faced by CHWs included inappropriate incentives, inadequate facilities, insufficient mentoring, and supervision, many roles, and a broad catchment area. Many studies revealed that CHWs felt overburdened and stressed. They needed help to balance their significant work and domestic tasks.

CONCLUSIONS

Effective planning that considered the scope of work of CHWs in proportion to their responsibilities and the provision of necessary facilities were crucial factors in improving the performance of CHWs. Supportive supervision and peer-supervision methods are promising, however, any CHW supervision required a detailed protocol. This systematic review emphasised the opportunity for CHW management system improvement in Indonesia.

Principles for task shifting hypertension and diabetes screening and referral: a qualitative study exploring patient, community health worker and healthcare professional perceptions in rural Uganda

BACKGROUND

A shortage of healthcare workers in low- and middle-income countries (LMICs) combined with a rising burden of non-communicable diseases (NCDs) like hypertension and diabetes mellitus has resulted in increasing gaps in care delivery for NCDs. As community health workers (CHWs) often play an established role in LMIC healthcare systems, these programs could be leveraged to strengthen healthcare access. The objective of this study was to explore perceptions of task shifting screening and referral for hypertension and diabetes to CHWs in rural Uganda.

METHODS

This qualitative, exploratory study was conducted in August 2021 among patients, CHWs and healthcare professionals. Through 24 in-depth interviews and ten focus group discussions, we investigated perceptions of task shifting to CHWs in the screening and referral of NCDs in Nakaseke, rural Uganda. This study employed a holistic approach targeting stakeholders involved in the implementation of task shifting programs. All interviews were audio-recorded, transcribed verbatim, and analyzed thematically guided by the framework method.

RESULTS

Analysis identified elements likely to be required for successful program implementation in this context. Fundamental drivers of CHW programs included structured supervision, patients' access to care through CHWs, community involvement, remuneration and facilitation, as well as building CHW knowledge and skills through training. Additional enablers comprised specific CHW characteristics such as confidence, commitment and motivation, as well as social relations and empathy. Lastly, socioemotional aspects such as trust, virtuous behavior, recognition in the community, and the presence of mutual respect were reported to be critical to the success of task shifting programs.

CONCLUSION

CHWs are perceived as a useful resource when task shifting NCD screening and referral for hypertension and diabetes from facility-based healthcare workers. Before implementation of a task shifting program, it is essential to consider the multiple layers of needs portrayed in this study. This ensures a successful program that overcomes community concerns and may serve as guidance to implement task shifting in similar settings.

The Effects of Monetary Incentives on Physicians' Effort and Patient Satisfaction: Understanding the Links between Monetary Incentives and Physicians' Effort

How monetary incentives promote physicians' job performance in terms of patient satisfaction has been widely discussed. The incentive dilemma debate concerns whether monetary incentives reduce physicians' intrinsic motivation at work and even lead to moral hazard. This study investigated monetary incentive policies in a hospital and analyzed how monetary incentives affect performance and behavior. By means of income composition grouping, a treatment group and control group were established, and the identification of the effect on performance was implemented using the difference-in-difference (DiD) method. The mechanism analysis was implemented using the event-study approach (ESA) and path analysis. The study found that (1) monetary incentives promote physicians to improve patient satisfaction, and the average effect is a two-point increment (p < 0.0001); (2) the effects are short-term; and (3) in contrast to many criticisms, the improvement in patient satisfaction was mainly from the effort in working during the monetary incentive policy. The results of this study contribute empirical evidence regarding the effects of monetary incentives and their mechanism and can help hospital management formulate incentive plans.