Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation.
BACKGROUND
The recent publication of the WHO guideline on support to optimise community health worker (CHW) programmes illustrates the renewed attention for the need to strengthen the performance of CHWs. Performance partly depends on motivation, which in turn is influenced by incentives. This paper aims to critically analyse the use of incentives and their link with improving CHW motivation.


METHODS
We undertook a comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries. These studies had used a conceptual framework on factors influencing CHW performance, where motivational factors were defined as financial, material, non-material and intrinsic and had undertaken semi-structured interviews and focus group discussions with CHWs, supervisors, health managers and selected community members.


RESULTS
We found that (a mix of) incentives influence motivation in a similar and sometimes different way across contexts. The mode of CHW engagement (employed vs. volunteering) influenced how various forms of incentives affect each other as well as motivation. Motivation was negatively influenced by incentive-related "expectation gaps", including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of CHWs. Furthermore, we found that incentives could cause friction for the interface role of CHWs between communities and the health sector.


CONCLUSIONS
Whether CHWs are employed or engaged as volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the demotivation derived from the perceived low level of financial reward. Overall, introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Adequate expectation management regarding financial and material incentives is essential to prevent frustration about expectation gaps or "broken promises", which negatively affect motivation. Consistently receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives.
['Ormel|Hermen|H|0000-0003-1521-9462', 'Kok|Maryse|M|', 'Kane|Sumit|S|', 'Ahmed|Rukhsana|R|', 'Chikaphupha|Kingsley|K|', 'Rashid|Sabina Faiz|SF|', 'Gemechu|Daniel|D|', 'Otiso|Lilian|L|', 'Sidat|Mohsin|M|', 'Theobald|Sally|S|', 'Taegtmeyer|Miriam|M|', 'de Koning|Korrie|K|']
D000328:Adult D000349:Africa D001291:Attitude of Health Personnel D003150:Community Health Workers D005260:Female D017144:Focus Groups D006801:Humans D007407:Interviews as Topic D008297:Male D009042:Motivation D036301:Qualitative Research D012456:Salaries and Fringe Benefits D014838:Volunteers
Community health workers Incentives Motivation Low- and middle-income countries Remuneration