TY - JOUR
T1 - Understanding community health worker incentive preferences in Uganda using a discrete choice experiment
AU - Agarwal, Smisha
AU - Abuya, Timothy
AU - Kintu, Richard
AU - Mwanga, Daniel
AU - Obadha, Melvin
AU - Pandya, Shivani
AU - Warren, Charlotte E.
N1 - Funding Information:
Community health workers (CHWs) play an important role in addressing critical inequities in health care access and support the linkage of communities to health care services. They are often the first point of contact communities have with health systems [1]. In 2001, Uganda introduced their community health workforce, known as Village Health Teams (VHTs). VHTs are responsible for health promotion, health education, community mobilization for health service utilization, community case management and follow up, and the distribution of health commodities to support advancement of maternal and child health, as well as, more broadly, primary health care [2]. As of 2015, over 179 000 VHTs have been trained since the program’s inception, and operate in all 112 districts in Uganda [2,3]. The VHT program is supported by Uganda’s Ministry of Health (MoH), as well as a number of non-governmental development organizations (eg, United Nations agencies, Pathfinder International, AMREF) financially and logistically [2]. Non-governmental organizations (NGOs) also have their own CHWs, often known as community health promoters (CHPs), that provide support, education, and services to the community.
Funding Information:
Acknowledgements: The authors thank the Republic of Uganda’s Ministry of Health and Pathfinder International for their support in the design and implementation of this study. The authors specifically thank Dr Richard Kabanda, Ag. Commissioner for health promotion, education and communication, MoH, Uganda, for his insights on the study questionnaire and approach. The authors would also like to thank the VHTs, CHPs, their supervisors, and representatives from the government, non-governmental organizations (AMREF, BRAC, Living Goods), and Makerere University School of Public Health for providing their time and input for a more contextualized understanding of CHW needs in Uganda. Funding: This report was supported by a grant of the Bill & Melinda Gates Foundation. The funders had no role in the design and implementation of the study. Authorship contributions: SA and RK conceptualized the study. SA, RK, and CEW developed study protocol. TA and DM led the field data collection approach. SA and MO conducted the analyses for this study. CEW is the overall PI for this multi-country study. SA and SP wrote and finalized this paper, with MO, TA, DM, and CEW providing revisions and feedback. All named authors had a role in the design, implementation, or analysis of this study. Competing interests: The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author), and declare no conflicts of interests. Additional material Online Supplementary Document 1 World Health Organization, WHO, World Health Organization. WHO Guideline on health policy and system support to op-timize community health worker programmes. Geneva, Switzerland; 2018. 2 Government of Uganda, Bureau of Statistics. Uganda Demographic and Health Survey 2016. 2016. Available: www.DHSpro-gram.com. Accessed: 1 November 2020. 3 Haines A, Sanders D, Lehmann U, Rowe AK, Lawn JE, Jan S, et al. Achieving child survival goals: potential contribution of community health workers. Lancet. 2007;369:2121-31. Medline:17586307 doi:10.1016/S0140-6736(07)60325-0 4 Republic of Uganda Ministry of Health, United Nations, IDEAL Development Consults Limited, Pathfinder International. Na-tional Village Health Teams (VHT). Assessment in Uganda. 2015;(March):339. 5 Mays DC, O’Neil EJ, Mworozi EA, Lough BJ, Tabb ZJ, Whitlock AE, et al. Supporting and retaining Village Health Teams: An assessment of a community health worker program in two Ugandan districts. Int J Equity Health. 2017;16:129. Med-line:28728553 doi:10.1186/s12939-017-0619-6 6 Nkonki L, Cliff J, Sanders D. Lay health worker attrition: important but often ignored. Bull Word Health Org. 2011;89:919-23. Medline:22271950 doi:10.2471/BLT.11.087825
Publisher Copyright:
© 2021 The Author(s)
PY - 2021
Y1 - 2021
N2 - Background Community health workers (CHWs) play a critical role in supporting health systems, and in improving the availability and accessibility to health care. However, CHW programs globally continue to face challenges with poor performance and high levels of CHW attrition. CHW programs are often underfunded and poorly planned, which can lead to loss of motivation by CHWs. The study aims to determine preferences of CHWs for job incentives with the goal of furthering their motivation and success. Methods Relevant incentive attributes were identified through focus group discussions and in-depth interviews with CHWs, non-governmental organization CHWs, CHW supervisors, and policy-level stakeholders. Based on seven attributes (eg, training, workload, stipend) we developed a discrete choice experiment (DCE) that was administered to 399 CHWs across eight districts in Uganda. We used conditional and mixed multinomial logit models to estimate the utility of each job attribute. We calculated the marginal willingness to accept as the trade-off the CHWs were willing to make for a change in salary. Results CHWs preferred higher salaries, though salary was not the most important attribute. There was a preference for reliable transportation, such as a bicycle 2.67), motorcycle (β = 1.81, 95% CI = 1.27, 2.34) or allowance (β = 1.37, 95% CI = 0.65, 2.10) to no transport. Formal identification identity badges (β = 1.61, 95% CI = 0.72, 2.49), branded uniforms (β = 1.04, 95% CI = 0.45, 1.63) and protective branded gear (β = 0.76, 95% CI = 0.32, 1.21) were preferred compared to no identification. CHWs also preferred more regular refresher trainings, the use of mobile phones as job-aids and a lesser workload. The relative importance estimates suggested that transport was the most important attribute, followed by identification, refresher training, salary, workload, recognition, and availability of tools. CHWs were willing to accept a decrease in salary of USH 31 240 (US$8.5) for identity badges, and a decrease of USH85 300 (US$23) for branded uniforms to no identification. Conclusions This study utilized CHW and policymaker perspectives to identify realistic and pragmatic incentives to improve CHW working conditions, which is instrumental in improving their retention. Non-monetary incentives (eg, identification, transportation) are crucial motivators for CHWs and should be considered as part of the compensation package to facilitate improved performance of CHW programs.
AB - Background Community health workers (CHWs) play a critical role in supporting health systems, and in improving the availability and accessibility to health care. However, CHW programs globally continue to face challenges with poor performance and high levels of CHW attrition. CHW programs are often underfunded and poorly planned, which can lead to loss of motivation by CHWs. The study aims to determine preferences of CHWs for job incentives with the goal of furthering their motivation and success. Methods Relevant incentive attributes were identified through focus group discussions and in-depth interviews with CHWs, non-governmental organization CHWs, CHW supervisors, and policy-level stakeholders. Based on seven attributes (eg, training, workload, stipend) we developed a discrete choice experiment (DCE) that was administered to 399 CHWs across eight districts in Uganda. We used conditional and mixed multinomial logit models to estimate the utility of each job attribute. We calculated the marginal willingness to accept as the trade-off the CHWs were willing to make for a change in salary. Results CHWs preferred higher salaries, though salary was not the most important attribute. There was a preference for reliable transportation, such as a bicycle 2.67), motorcycle (β = 1.81, 95% CI = 1.27, 2.34) or allowance (β = 1.37, 95% CI = 0.65, 2.10) to no transport. Formal identification identity badges (β = 1.61, 95% CI = 0.72, 2.49), branded uniforms (β = 1.04, 95% CI = 0.45, 1.63) and protective branded gear (β = 0.76, 95% CI = 0.32, 1.21) were preferred compared to no identification. CHWs also preferred more regular refresher trainings, the use of mobile phones as job-aids and a lesser workload. The relative importance estimates suggested that transport was the most important attribute, followed by identification, refresher training, salary, workload, recognition, and availability of tools. CHWs were willing to accept a decrease in salary of USH 31 240 (US$8.5) for identity badges, and a decrease of USH85 300 (US$23) for branded uniforms to no identification. Conclusions This study utilized CHW and policymaker perspectives to identify realistic and pragmatic incentives to improve CHW working conditions, which is instrumental in improving their retention. Non-monetary incentives (eg, identification, transportation) are crucial motivators for CHWs and should be considered as part of the compensation package to facilitate improved performance of CHW programs.
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U2 - 10.7189/jogh.11.07005
DO - 10.7189/jogh.11.07005
M3 - Article
C2 - 33763219
AN - SCOPUS:85103508473
VL - 11
SP - 1
EP - 11
JO - Journal of Global Health
JF - Journal of Global Health
SN - 2047-2978
ER -