Dual Cadres.

LABOUR EXPLOITATION IN DUAL-CADRE SYSTEMS

COALITION RESEARCH.

Health care delivered by community health workers (CHWs) reduces morbidity and mortality with considerable equity and economic dividends. Despite growing consensus that CHWs, a predominantly female workforce, should receive a salary, many community health programmes take the form of a two-tiered or dual-cadre systems.

In dual-cadre systems a salaried cadre of CHWs work alongside an unsalaried cadre. These systems are common in low-income and middle-income countries (LMICs). Dual-cadre systems emerged in response to health worker shortages to provide additional coverage of health services. And although volunteering can be a powerful force for community organising and community betterment, without adequate safeguards, dual-cadre systems risk replicating the exploitative labour conditions of all-volunteer programmes.

At the Coalition we aimed to determine the presence, prevalence, and magnitude of exploitation in national dual-cadre CHW programmes, conducting a systematic review of available evidence from peer-reviewed databases and grey literature.

MORAL & TECHNICAL FAILURES.

We included 117 reports from 112 studies describing CHWs in dual-cadre programs across 19 countries. The majority of CHWs were female. And the majority of unsalaried CHWs lived below the poverty line.

Our research found considerable moral and technical failings in dual-cadre programmes. Finding that they are likely to replicate the exploitative dynamics of the all-volunteer programmes they often replace. 59% of unsalaried CHW cadres and 10% of salaried cadres experiencing labour exploitation.

Unsalaried cadres face pressure to work more than their agreed hours from community members and salaried colleagues who task-shift responsibilities. A third of unsalaried CHWs worked more than 20 hours per week, with 17% needing to work more than 40 hours per week to fulfil their assigned responsibilities.

Despite over half of unsalaried CHW cadres completing similar tasks to those performed by doctors and nurses, they reported non-payment, inadequate or inconsistent payment of incentives, and an overburdensome workload. Many reported their remuneration did not match the tasks they performed or the out-of-pocket expenses they incurred.

PSYCHOSOCIAL WELLBEING

Although some unsalaried CHWs mentioned being valued by community members, others face social rejection from family and community members who disapprove of their work.

At the family level, this was partly explained by CHWs not performing expected roles at home. At the community level, unsalaried CHWs were perceived as inferior because of having inadequate or little training. Social acceptance of unsalaried CHWs was further threatened by the community perception that CHWs were unable to help community members during a crisis, poor outcome of health conditions managed by CHWs, and social stigma relating to the diseases being managed by CHWs.

Moreover, dual-cadre programmes can cause additional psychosocial stress, since unsalaried CHWs might compare themselves with salaried CHWs and experience disappointment from unmet implicit needs to transition to paid roles.

A Community Health Worker seated at the entrance of a house with a mother and her three children

Wuqu Kawoq

A lady in a head scarf looking at a phone while holding a yellow notebook

Dimagi

WHAT NEXT?

URGENT ACTION NEEDED.

Unsalaried CHWs in dual-cadre programmes often face labour exploitation, potentially leading to inadequate health-care provision.

Labour laws must be upheld and the creation of professional CHW (proCHW) cadres with fair contracts prioritised. International funding should prioritise this. And CHWs must have input in policies that affect them.

To address labour exploitation of unsalaried CHWs in dual-cadre programmes:

governments and international funders must respect domestic and international labour law
international funding for programmes using unsalaried workers should be reported
health providers should assess CHWs’ workloads and measure actual time use
CHWs should be included in discussions about their labour conditions
volunteers should not be responsible for delivering essential health services

Read the full study in Lancet Global Health