Sources of community health worker motivation: a qualitative study in Morogoro Region, Tanzania

Human Resources for Health

Peter J Winch¹  David P Urassa³  Maurus Mpunga²  Joy J Chebet¹  Shannon A McMahon¹  Jesse A Greenspan¹ 

[1] Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA;Department of Labour Studies, Institute of Social Work, P.O. Box 3375, Dar es Salaam, Tanzania;Muhimbili University of Health and Allied Sciences, P.O Box 65015, Dar es Salaam, Tanzania

关键词: Tanzania;    Incentives;    Motivation;    Community health workers;   

Others  :  822262
DOI  :  10.1186/1478-4491-11-52

 received in 2013-04-08, accepted in 2013-09-14,  发布年份 2013

【 摘 要 】

Background

There is a renewed interest in community health workers (CHWs) in Tanzania, but also a concern that low motivation of CHWs may decrease the benefits of investments in CHW programs. This study aimed to explore sources of CHW motivation to inform programs in Tanzania and similar contexts.

Methods

We conducted semi-structured interviews with 20 CHWs in Morogoro Region, Tanzania. Interviews were digitally recorded, transcribed, and coded prior to translation and thematic analysis. The authors then conducted a literature review on CHW motivation and a framework that aligned with our findings was modified to guide the presentation of results.

Results

Sources of CHW motivation were identified at the individual, family, community, and organizational levels. At the individual level, CHWs are predisposed to volunteer work and apply knowledge gained to their own problems and those of their families and communities. Families and communities supplement other sources of motivation by providing moral, financial, and material support, including service fees, supplies, money for transportation, and help with farm work and CHW tasks. Resistance to CHW work exhibited by families and community members is limited. The organizational level (the government and its development partners) provides motivation in the form of stipends, potential employment, materials, training, and supervision, but inadequate remuneration and supplies discourage CHWs. Supervision can also be dis-incentivizing if perceived as a sign of poor performance.

Conclusions

Tanzanian CHWs who work despite not receiving a salary have an intrinsic desire to volunteer, and their motivation often derives from support received from their families when other sources of motivation are insufficient. Policy-makers and program managers should consider the burden that a lack of remuneration imposes on the families of CHWs. In addition, CHWs’ intrinsic desire to volunteer does not preclude a desire for external rewards. Rather, adequate and formal financial incentives and in-kind alternatives would allow already-motivated CHWs to increase their commitment to their work.

【 授权许可】

   
2013 Greenspan et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]World Health Organization: Declaration of Alma-Ata, International Conference on Primary Health Care: 6-12 Sept 1978; Alma-Ata, USSR.. Geneva: WHO; 1978.
• [2]Standing H, Chowdhury AM: Producing effective knowledge agents in a pluralistic environment: what future for community health workers? Soc Sci Med 2008, 66:2096-2107.
• [3]Lehmann U, Sanders D: Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. In Evidence and Information for Policy. Edited by Health DoHRf. Geneva: World Health Organization; 2007.
• [4]Dil Y, Strachan D, Cairncross S, Korkor AS, Hill Z: Motivations and challenges of community-based surveillance volunteers in the Northern Region of Ghana. J Community Health 2012, 37:1192-1198.
• [5]George A, Young M, Nefdt R, Basu R, Sylla M, Clarysse G, Bannicq MY, de Sousa A, Binkin N, Diaz T: Community health workers providing government community case management for child survival in Sub-Saharan Africa: who are they and what are they expected to do? Am J Trop Med Hyg 2012, 87(Suppl 5):85-91.
• [6]Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk BE, Odgaard-Jensen J, Johansen M, Aja GN, Zwarenstein M, Scheel IB: Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev 2010, 3:CD004015.
• [7]Lewin SA, Dick J, Pond P, Zwarenstein M, Aja G, van Wyk B, Bosch-Capblanch X, Patrick M: Lay health workers in primary and community health care. Cochrane Database Syst Rev 2005, 1:CD004015.
• [8]World Health Organization: The world health report 2006: working together for health. Geneva: WHO; 2006.
• [9]Haines A, Sanders D, Lehmann U, Rowe AK, Lawn JE, Jan S, Walker DG, Bhutta Z: Achieving child survival goals: potential contribution of community health workers. Lancet 2007, 369:2121-2131.
• [10]Maes K, Kalofonos I: Becoming and remaining community health workers: perspectives from Ethiopia and Mozambique. Soc Sci Med 2013, 87:52-59.
• [11]Franco LM, Bennett S, Kanfer R: Health sector reform and public sector health worker motivation: a conceptual framework. Soc Sci Med 2002, 54:1255-1266.
• [12]Afulani PA, Awoonor-Williams JK, Opoku EC, Asunka J: Using community health workers in community-based growth promotion: what stakeholders think. Health Educ Res 2012, 27:1005-1017.
• [13]Ewoigbokhan SE, Ches WR: Village health worker attrition and function levels in the ILE-IFE area of Nigeria. Int Q Community Health Educ 1993, 14:323-336.
• [14]Khan SH, Chowdhury AM, Karim F, Barua MK: Training and retaining Shasthyo Shebika: reasons for turnover of community health workers in Bangladesh. Health Care Superv 1998, 17:37-47.
• [15]Olang’o CO, Nyamongo IK, Aagaard-Hansen J: Staff attrition among community health workers in home-based care programmes for people living with HIV and AIDS in western Kenya. Health Policy 2010, 97:232-237.
• [16]Rahman SM, Ali NA, Jennings L, Seraji MH, Mannan I, Shah R, Al-Mahmud AB, Bari S, Hossain D, Das MK, Baqui AH, El Arifeen S, Winch PJ: Factors affecting recruitment and retention of community health workers in a newborn care intervention in Bangladesh. Hum Resour Health 2010, 8:12. BioMed Central Full Text
• [17]Bhattacharyya K, Winch PJ, LeBan K, Tien M: Community health worker incentives and disincentives: how they affect motivation, retention, and sustainability. Arlington, VA: BASICS/USAID; 2001.
• [18]Kironde S, Bajunirwe F: Lay workers in directly observed treatment (DOT) programmes for tuberculosis in high burden settings: should they be paid? A review of behavioural perspectives. Afr Health Sci 2002, 2:73-78.
• [19]Robinson SA, Larsen DE: The relative influence of the community and the health system on work performance: a case study of community health workers in Colombia. Soc Sci Med 1990, 30:1041-1048.
• [20]Glenton C, Scheel IB, Pradhan S, Lewin S, Hodgins S: Should we care what policy makers think? A response to Maes, Kohrt and Closser. Soc Sci Med 2010, 71:1379-1380.
• [21]Glenton C, Scheel IB, Pradhan S, Lewin S, Hodgins S, Shrestha V: The female community health volunteer programme in Nepal: decision makers’ perceptions of volunteerism, payment and other incentives. Soc Sci Med 2010, 70:1920-1927.
• [22]Maes K: Volunteerism or labor exploitation? Harnessing the volunteer spirit to sustain AIDS treatment programs in urban Ethiopia. Hum Organ 2012, 71:54-64.
• [23]Maes KC, Kohrt BA, Closser S: Culture, status and context in community health worker pay: pitfalls and opportunities for policy research. A commentary on Glenton et al. (2010). Soc Sci Med 2010, 71:1375-1378. discussion 1379–1380
• [24]Jerome G, Ivers LC: Community health workers in health systems strengthening: a qualitative evaluation from rural Haiti. AIDS 2010, 24(Suppl 1):S67-S72.
• [25]Hafeez A, Mohamud BK, Shiekh MR, Shah SA, Jooma R: Lady health workers programme in Pakistan: challenges, achievements and the way forward. J Pak Med Assoc 2011, 61:210-215.
• [26]Eichler R: Can “pay for performance” increase utilization by the poor and improve the quality of health services. In Background papers for the Working Group on Performance Based Incentives. Washington, DC: Center for Global Development; 2006.
• [27]Akintola O: What motivates people to volunteer? The case of volunteer AIDS caregivers in faith-based organizations in KwaZulu-Natal, South Africa. Health Policy Plan 2011, 26:53-62.
• [28]Alam K, Tasneem S, Oliveras E: Retention of female volunteer community health workers in Dhaka urban slums: a case–control study. Health Policy Plan 2012, 27:477-486.
• [29]Alfaro-Trujillo B, Valles-Medina AM, Vargas-Ojeda AC: Profiles, perceptions and motivations of Community Health Workers of NGOs in a border city of US-Mexico. J Community Health 2012, 37:583-590.
• [30]Jack BA, Kirton JA, Birakurataki J, Merriman A: The personal value of being a palliative care community volunteer worker in Uganda: a qualitative study. Palliat Med 2012, 26:753-759.
• [31]Javanparast S, Baum F, Labonte R, Sanders D: Community health workers’ perspectives on their contribution to rural health and well-being in Iran. Am J Public Health 2011, 101:2287-2292.
• [32]Kironde S, Klaasen S: What motivates lay volunteers in high burden but resource-limited tuberculosis control programmes? Perceptions from the Northern Cape province, South Africa. Int J Tuberc Lung Dis 2002, 6:104-110.
• [33]Lysack C, Krefting L: Community-based rehabilitation cadres: their motivation for volunteerism. Int J Rehabil Res 1993, 16:133-141.
• [34]Mkandawire WC, Muula AS: Motivation of community care givers in a peri-urban area of Blantyre, Malawi. Afr J Health Sci 2005, 12:21-25.
• [35]Ramirez-Valles J: “I was not invited to be a [CHW] … I asked to be one”: motives for community mobilization among women community health workers in Mexico. Health Educ Behav 2001, 28:150-165.
• [36]Ruano AL, Hernandez A, Dahlblom K, Hurtig AK, Sebastian MS: ‘It’s the sense of responsibility that keeps you going’: stories and experiences of participation from rural community health workers in Guatemala. Arch Publ Health 2012, 70:18. BioMed Central Full Text
• [37]Takasugi T, Lee ACK: Why do community health workers volunteer? A qualitative study in Kenya. Publ Health 2012, 126:839-845.
• [38]Thomas C, Newell JN, Baral SC, Byanjankar L: The contribution of volunteers to a successful community-orientated tuberculosis treatment centre in an urban setting in Nepal: a qualitative assessment of volunteers’ roles and motivations. J Health Organ Manag 2007, 21:554-572.
• [39]Walt G, Perera M, Heggenhougen K: Are large-scale volunteer community health worker programmes feasible? The case of Sri Lanka. Soc Sci Med 1989, 29:599-608.
• [40]Ministry of Health and Social Welfare (MoHSW) [Tanzania]: Health Sector Strategic Plan III-July 2009 - June 2015, Partnership for Delivering the MDGs. Dar es Salaam, Tanzania: MoHSW; 2009.
• [41]National Bureau of Statistics (NBS) [Tanzania] and ICF Macro: Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: NBS and ICF Macro; 2011.
• [42]Countdown Working Group on Health Policy and Health Systems: Assessment of the health system and policy environment as a critical complement to tracking intervention coverage for maternal, newborn, and child health. Lancet 2008, 371:1284-1293.
• [43]World Bank: World development report, 1980. Washington, DC: World Bank; 1980.
• [44]Creswell JW, Clark VLP: Designing and Conducting Mixed Methods Research. 2nd edition. Thousand Oaks, CA: SAGE Publications, Inc.; 2007.
• [45]Charmaz K: Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis. Thousand Oaks, CA: Sage Publications, Inc.; 2006.
• [46]Atlas.ti: Atlas.ti 7.0. Berlin: ATLAS.ti Scientific Software Development GmbH; 2012.
• [47]Kane SS, Gerretsen B, Scherpbier R, Dal Poz M, Dieleman M: A realist synthesis of randomised control trials involving use of community health workers for delivering child health interventions in low and middle income countries. BMC Health Serv Res 2010, 10:286. BioMed Central Full Text
• [48]Ahluwalia IB, Schmid T, Kouletio M, Kanenda O: An evaluation of a community-based approach to safe motherhood in northwestern Tanzania. Int J Gynaecol Obstet 2003, 82:231-240.
• [49]Jerman H, Jerman H, Jerman H: Between five lines: the development of ethnicity in Tanzania with special reference to western Bagamoyo district. Uppsala: Nordiska Afrikainstitutet (Scandinavian Institute of African Studies); 1997.
• [50]Nyerere JK: From the Arusha declaration: socialism and self reliance. In Freedom and Socialism: Uhuru na Ujamaa; A Selection from Writings and Speeches, 1965–1967. Volume 2. Dar es Salaam, Tanzania: Oxford University Press; 1968:231-250.
• [51]Raikes PL: Ujamaa and rural socialism. Rev Afr Polit Econ 1975, 2:33-52.
• [52]Frey BS, Jegen R: Motivation crowding theory. J Econ Surv 2001, 15:589-611.
• [53]Kebriaei A, Moteghedi MS: Job satisfaction among community health workers in Zahedan District, Islamic Republic of Iran. East Mediterr Health J 2009, 15:1156-1163.
• [54]The Earth Institute: One million community health workers: technical task force report. New York, NY: Columbia University; 2011.