Madeleine Ballard1,2, Carey Westgate1, Rebecca Alban3, Nandini Choudhury2,4, Rehan Adamjee5, Ryan Schwarz4,6, Julia Bishop7, Meg McLaughlin8, David Flood9, Karen Finnegan10, Ash Rogers11, Helen Olsen12, Ari Johnson13,14, Daniel Palazuelos6,15, Jennifer Schechter16. 1. Community Health Impact Coalition, New York, New York, USA. 2. Department of Global Health and Health System Design, Icahn School of Medicine at Mount Sinai, New York, New York, USA. 3. VillageReach, Seattle, Washington, USA. 4. Possible, New York, New York, USA. 5. VITAL Pakistan, Karachi, Pakistan. 6. Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. 7. One to One Africa, Cape Town, South Africa. 8. THINKMD, Burlington, Vermont, USA. 9. Wuqu' Kawoq, Santiago Sacatepéquez, Sacatepéquez, Guatemala. 10. PIVOT, Ranomafana, Madagascar. 11. Lwala Community Alliance, Rongo, Kenya. 12. Medic Mobile, San Francisco, California, USA. 13. Muso, Bamako, Mali. 14. Department of Medicine, Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA. 15. Partners In Health, Boston, Massachusetts, USA. 16. Integrate Health, Lome, Togo.
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.
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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