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We must move beyond the ‘pay vs. no pay’ debate for community health workers

By Stephanie Topp
on October 2, 2015

After several years of consultation, the SDG agenda was launched last week with much fanfare in New York.  Amongst the various health-related targets established by the forthcoming Sustainable Development Goals (SDGs) target 3.c aims to: substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in the least-developed countries and developing small-island states. This target speaks to the ‘chronic emergency’ many low- and middle-income countries (LMIC) face both in terms of the quantity and performance of human resources for health.  Importantly, meeting this target will be a prerequisite to attaining SDG target, 3.8 which aims (amongst other things) to: achieve universal health coverage [via] financial risk protection and access to quality essential health care services […]. 

The financing and sustainability of a strengthened health workforce is one of, if not the key component(s) underpinning our ability to achieve universal health coverage (UHC).  But the wording of Target 3.c, with its reference to the need for recruitment and development and training and retention, hints at the complexity of an issue that must be central to global health and health systems debates in the coming months and years.  Increasingly, the human resource crises in LMIC are being recognized as not simply a crisis of numbers but also a crisis of human resource management.  Although strengthening local training capacity and increasing the output of health professionals is desirable, the experiences of various countries have demonstrated that it is not possible to ‘train’ our way out of this problem.  Even assuming they stay in the system, having more doctors, nurses or even stipendiary or volunteer community health workers available is simply no guarantee of universal access to good quality and essential health care services – as issues of distribution, motivation and retention all come into play.

While more doctors and nurses are undoubtedly needed, experiences from across different regions and countries have repeatedly demonstrated the challenges of retaining clinical health workers in service of the most vulnerable populations – including both rural and urban poor.  Meanwhile, health systems and global health programs continue to rely on lay or community health workers to deliver various primary-level services in various permutations of community- or clinic-based care.

Clearly, given the scope of the human resource short-fall and the issues of distribution in many LMICs, it is time to place community health workers (or lay health workers or auxiliary workers) at the centre of discussions around how UHC can be achieved.  And as part of that debate, the thorny – even ideological – issue of volunteerism versus formal employment of these lower cadres must be tackled.  On one side of this debate it has been argued that there is an economic imperative to maintain non-paid health workers as the only way to ensure basic service coverage in geographically remote or otherwise marginalized communities.  The potential for formal payments and/or employment to pervert intrinsic pro-social motivations among such workers has been raised along with the need for non-monetary incentives.  Problematically, however, a number of studies have also demonstrated that along with genuine ‘help-giving’ motivations, health volunteers often experience severe economic need that contributes to high levels of physical and mental stress that undermine performance and retention. Some have even suggested that our widespread reliance on volunteerism to provide health services to marginalized people is reflective of societies habituated to inequality.

Where does that leave us? As we think about how to gain traction for increased funding or negotiate complex policy reform targeting the HRH-oriented SDG target, we must move beyond the dichotomy of ‘pay vs. no pay’ in relation to community health workers.  A more helpful starting point is the desired outcome – UHC – and a better more thoughtful assessment of the way inconsistencies in recruitment, posting and retention policies impact on (both professional and community) health workers’ motivation and capacity to deliver on that outcome.  Assessment and reform of health systems to ensure congruence between the system-wide goal (UHC encompassing financial protection and service coverage) and health workers’ goals (both intrinsic and economic) is required.  This is a more nuanced lens through which to discuss the central role that CHWs will have to play if we are to achieve ‘universal’ care.  It is an approach that allows for different meanings and significance attributed to “volunteerism” in different settings. But it also moves us away from the pervasive and dangerous assumption that the most vulnerable members of our health workforce should, and are able to provide, continuous service with only minimal or no support.

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