Pay CHWs.

In each of the five countries profiled, a review of the regulatory framework governing CHW compensation was undertaken. Topics covered included: 

1. Legal requirements for CHW compensation
2. CHW compensation mechanisms
3. CHW legal protections and benefits

List of focus countries and CHW groups:

• Brazil
• Ghana
• Nigeria
• Rwanda
• South Africa

Relevant material about each framework was extracted from legal documents and organized to create a narrative overview of each CHW compensation system. Then, to assess the merits and shortcomings of each regulatory framework, the models were assessed for alignment with the 2018 WHO guideline. 

In particular, we assessed each model in regard to:

• If CHWs were afforded financial protection
• Ease of implementation within the respective health system
• Whether pay was commensurate with roles and responsibilities (hours, training, job demands)
• The extent to which pay was linked to performance (WHO advises against exclusive or predominantly performance-based incentives)

Here’s an overview of what we found for each country.

Brazil

Hours: 40 hours per week.

Training: To work as a CHW (“agente comunitário de saúde,” ACS) in Brazil, an individual must reside in the community in which they are operating and have completed high school education. Approximately 1200 hours of training is undertaken, including an initial training course with a minimum duration of 40 hours.

Job demands: Provide promotive, preventive, curative, and rehabilitative services.

Legal structure: Brazil employs CHWs under a public sector model. Staff are state employees and qualify for a minimum wage that is updated annually.

Compensation model: The Federal Constitution provides a national professional salary floor. CHWs working habitually in unhealthy conditions are entitled to risk pay on top of their base salary.

Protections and benefits: The same legal protections and benefits as other workers in the country.

Meets WHO guideline?: Yes. CHWs in Brazil receive a financial package that’s aligned with hours and job demands.

Ghana

Hours: CHWs in Ghana (community health volunteer, CHVs) are considered part time workers, yet are effectively on call 24 hours a day, every day.

Training: No certification requirements. Approximately 40 hours of informal training.

Job demands: Disease surveillance, health promotion, home management of minor ailments, referrals, transportation, and community mobilization.

Legal structure: CHWs in Ghana are employed via a volunteer based model in a designated non-salaried position.

Compensation model: Ghana’s 2016 Community-based Health Planning and Services Policy states that an appropriate incentives scheme is to be developed, yet no such scheme is currently in place.  

Protections and benefits: Not considered workers, so not afforded legal protections available to other classes of employees in the country.

Meets WHO guideline?: No. No remuneration package in place.

Nigeria

Hours: CHWs in Nigeria (community health extension workers; CHEWs) work full time; 40 hours per week.

Training: Registration and certification with the Community Health Practitioners Registration Board of Nigeria is required before practicing. Three years of training is undertaken.

Job demands: Curative services, referral, and health promotion.

 Legal structure: Nigeria uses a private model, with a public sector wage floor. Under Nigerian law, CHWs fall into a category classified as “Non-Workers” (employees who perform administrative or technical functions, as opposed to manual labor or clerical work) and compensation is dependent on the terms of contracts with employers. 

Compensation model: CHWs are paid in line with minimum wage. 

Protections and benefits: As non-workers, the benefits of CHWs in Nigeria are subject to the terms of contracts with their employers. Some employment-related benefits, such as life insurance and pensions are regulated by Nigerian Law and apply to CHW employment.

Meets WHO guideline?: Yes. CHWs receive a financial package that’s aligned with hours and job demands.

Rwanda

Hours: CHWs in Rwanda (Binômes) are part time, working an average of nine hours per week.

Training: Must have the ability to read and write, be aged between 20 and 50, willing to volunteer, living in and trusted by the local village, and selected by village members. An average of 480 hours training is undertaken.

Job demands: Diagnosis and treatment of illness (especially for children), screening and referral, and provision of contraceptives.

Legal structure: Rwanda employs a Performance-Based Financing Model centered on Cooperatives. CHWs are designated as volunteers who receive compensation according to a performance-based system and income-generating cooperative model

Compensation model: Payment relies on CHWs meeting targets set for each assignment (e.g., submit report by the 5th of each month, report completely filled in, etc.). Payment goes to cooperatives, which are then tasked with dividing the money between income-generating activities and cooperative members 

Protections and benefits: CHWs in Rwanda are volunteers, so not afforded the majority of legal protections and employment benefits that apply to other workers in the country.

Meets WHO guideline?: No. Remuneration is exclusively linked to performance. Two thirds of cooperatives did not make a profit, indicating funds may be insufficient compared to CHW job demands.

South Africa

Hours: Working hours of CHWs in South Africa are highly variable across the country, from anywhere between 20-40 hours per week.

Training: Variable, averaging 480 hours of training. 

Job demands: Prevention and promotion, adherence support for chronic lifelong conditions, screening, referral, and basic palliative care.

Legal structure: At the time the paper was written, South Africa employed a hybrid public/private model. Their National Department of Health’s 2018 Policy Framework and Strategy for Ward-Based Primary Healthcare and the 2011 Provincial Guidelines for Primary Health Care, provide a strategic framework for the employment of CHWs by provincial and district departments of health.  

Compensation model: The Department of Health concluded an agreement with unions representing CHWs to standardize state employed CHW remuneration at the same level as minimum wage. Some states use NGOs as intermediaries to employ CHWs and/or make use of payroll management companies contracted by health departments to employ CHWs. Compensation arrangements are highly variable across the country.

Protections and benefits: All CHWs should meet the legal definition of an employee under core labor legislation in South Africa and be afforded protection under the National Minimum Wage Act of 2018. However, this does not apply to CHWs employed by intermediaries.  

Meets WHO guideline?: Partial. High variability of remuneration for CHWs with similar job demands.

Finally, our paper identified three common factors that influence all CHW models of remuneration.

Volunteerism

All of the countries we assessed had provisions for engaging CHWs as volunteers, but only some mandated volunteerism in official policies and strategy documents.

Making provision for CHW volunteers isn’t ruled out by the institution of compensation models, but it can be difficult to distinguish between willing volunteers (e.g., who have an alternative source of employment) and those whose “choice” is influenced by economic insecurity.

CHW volunteers should have a workload that is commensurate with a volunteer position. They also should not be coerced into volunteering to access healthcare for themselves, family, or community members.

Non-State Actors

Governments aren’t the only determining factor in CHW compensation. The policies, approaches, and investments of key partners can make it easier or more difficult for governments to pay CHWs.

Bilateral, multilateral, and private philanthropic organizations who finance CHW programmes have a role to play in supporting processes and policies that promote fair pay and legal protections for CHWs.

Financing

Certain community health financing practices can hinder efforts to integrate a workforce of paid, proCHWs into a national health system.

Financing institutions should rethink harmful financing practices and replace them with practices that accelerate impact. 

First and foremost, financing should not encourage exploitation by preventing funds from being used on CHW salaries. It should also be aligned with national health strategy and goals, not attempt to short-circuit change, and be disbursed on time. For further discussion and analysis of CHW compensation models, check out the highlight reel from a roundtable discussion between Community Health Impact Coalition (CHIC), Financing Alliance for Health (FAH), CHW Advocates, and policymakers from Kenya and Uganda.