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Review
. 2021 Feb 15:11:04010.
doi: 10.7189/jogh.11.04010.

Compensation models for community health workers: Comparison of legal frameworks across five countries

Madeleine Ballard  1   2 , Carey Westgate  1 , Rebecca Alban  3 , Nandini Choudhury  2   4 , Rehan Adamjee  5 , Ryan Schwarz  4   6 , Julia Bishop  7 , Meg McLaughlin  8 , David Flood  9 , Karen Finnegan  10 , Ash Rogers  11 , Helen Olsen  12 , Ari Johnson  13   14 , Daniel Palazuelos  6   15 , Jennifer Schechter  16
Affiliations
Review

Compensation models for community health workers: Comparison of legal frameworks across five countries

Madeleine Ballard et al. J Glob Health. .

Abstract

Background: Despite the life-saving work they perform, community health workers (CHWs) have long been subject to global debate about their remuneration. There is now, however, an emerging consensus that CHWs should be paid. As the discussion evolves from whether to financially remunerate CHWs to how to do so, there is an urgent need to better understand the types of CHW payment models and their implications.

Methods: This study examines the legal framework on CHW compensation in five countries: Brazil, Ghana, Nigeria, Rwanda, and South Africa. In order to map the characteristics of each approach, a review of the regulatory framework governing CHW compensation in each country was undertaken. Law firms in each of the five countries were engaged to support the identification and interpretation of relevant legal documents. To guide the search and aid in the creation of uniform country profiles, a standardized set of questions was developed, covering: (i) legal requirements for CHW compensation, (ii) CHW compensation mechanisms, and (iii) CHW legal protections and benefits.

Results: The five countries profiled represent possible archetypes for CHW compensation: Brazil (public), Ghana (volunteer-based), Nigeria (private), Rwanda (cooperatives with performance based incentives) and South Africa (hybrid public/private). Advantages and disadvantages of each model with respect to (i) CHWs, in terms of financial protection, and (ii) the health system, in terms of ease of implementation, are outlined.

Conclusions: While a strong legal framework does not necessarily translate into high-quality implementation of compensation practices, it is the first necessary step. Certain approaches to CHW compensation - particularly public-sector or models with public sector wage floors - best institutionalize recommended CHW protections. Political will and long-term financing often remain challenges; removing ecosystem barriers - such as multilateral and bilateral restrictions on the payment of salaries - can help governments institutionalize CHW payment.

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Conflict of interest statement

Competing interests: The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author), and declare no conflicts of interest.

References

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