Course 5: Voluntary Health Workers and Social Mobilization

Introduction

In the 1970s and 1980s, many developing countries began extending coverage of health services to underserved rural areas. One of the most economical ways this could be done was by training local people, collectively called Voluntary Community Health Workers (VCHWs), to volunteer and offer basic preventative and curative care services.(1) According to the World Health Organization, Community Health Workers “are men and women chosen by the community, and trained to deal with the health problems of individuals and the community, and to work in close relationship with the health services. They should have had a level of primary education that enables them to read, write and do simple mathematical calculations.” (2) Community Health Workers are important because they promote health and mobilize communities who have lacked access to health care. They also help to identify community problems, and can respond creatively to local needs and within a local context.

The Role of Voluntary Health Workers

VCHWs are effective resources for spreading awareness about health issues and improving health outcomes.  The majority of the volunteers tend to be young, single, well-educated, and female. Though the roles of VCHWs vary depending on the needs of specific communities, in general, their work consists of activities aimed at teaching the community about improved health practices, as well as the promotion of latrine construction and hygiene. VCHWs are usually elected or nominated by the community on the basis of their literacy, communication skills, credibility and previous experiences.  After the selection process, VCHWs frequently receive training on maternal and child health, hygiene, sanitation and malaria prevention. VCHWs transmit key health messages to families through house-to-house visits, by going to water collection points, church meetings, and women’s association meetings. They often use a family health booklet to convey important messages about vaccination, birth preparedness, newborn care, HIV prevention, child nutrition, and family planning among other topics. “While their efforts were often characterized by initial resistance followed by gradual acceptance, all of the respondents were very positive about their work.” (3)

Incentives

Many VCHWs identified the gratifying nature of serving others, and the responsibility given to them as their personal motivations for serving in a volunteer capacity. In addition to improving the health of their communities, VCHWs valued their new-found knowledge, which they believed would help them to improve the health of their own families. For example, a 34-year-old married woman from Amhara, Ethiopia, who served as a VCHW explained, “I have benefited a lot from spacing my births. Before I received this education, I had my second child only two years and a half after my first one. After my training, I went to Bichena to get a long-term contraceptive and only had my next child after seven years. Now, I do not want to have more than the four children I already have. I want to raise them hygienically, providing them with good clothes and shoes, so that they will learn well and become successful.” (4)

Though the workers are not financially compensated, non-financial incentives and benefits are important for creating sustainable VCHW programs. Increased community recognition and acceptance of the work of VCHWs was found to further motivate them. Many VCHWs expressed that receiving ongoing mentoring and support, as well as certification for what they have done, would motivate them to work even harder. One worker explained the satisfaction and recognition she obtained from receiving a certificate. As she explains, this has “facilitated my work because it was given to me in the presence of the community. It is therefore very pleasing. The community is very receptive to us when we make house visits.”(5) Similarly, workers believe that evaluations or performance reviews serve as good incentives for them to work harder. Because many VCHW programs have high levels of attrition, it is important to have an infrastructure of non-financial incentives in order to keep the program sustainable. As an Ethiopian study on VCHWs concluded, “small-scale voluntary schemes are likely to be more successful where the most important ingredients of support and supervision are consistent, regular, and there are built-in incentives or rewards (not necessarily financial) in the programme.” (6)

Case Study: Sri Lanka

The Sri Lankan government developed its own volunteer program in the 1970s, which was affiliated with the Health Education Bureau, and consisted mostly of public health midwives. Though attrition rates for this program were high, 65% of the women had 3 or more years of experience as volunteers, suggesting the presence of a core of regular volunteers who sustained the program. In the mid 1980s, the Ministry of Health recognized the potential impact of the Health Workers and began developing incentives for them. The Ministry decided that health volunteers would have preferential access to training courses and jobs in the Health Department, thereby making volunteering a potential path to future employment.  Of the volunteer health workers surveyed, 60% stated that their main reason for volunteering was that they hoped it would lead to employment, while over one third put community service and the satisfaction of helping others as their main motivation for volunteering.  As one volunteer explains, “officials come from outside and go away. We live here and see the hardships people undergo. They have to go 4-5 miles with a sick person sometimes. It is a great merit to relieve pain.” (7) Another important incentive and predictor of program success was how valued each worker was in their respective communities.

Barriers to Effective Voluntary Health Worker Program in Sri Lanka

In Sri Lanka, many health volunteers were initially not listened to or respected. However, patronage by health workers was seen to increase their credibility. Thus, in this case, a successful volunteer program depended upon the amount of contact the volunteers had with official health workers. Another obstacle was the difficulty of persuading people to follow allopathic practices, instead of their traditional folk practices. “Volunteers found themselves caught between the community members’ custom of using certain herbs and leaves for wounds, skin rashes, worms and scabies and the often negative attitudes of the professional health staff to these methods.” (8) In spite of these barriers, the health workers felt that the program was beneficial. In the end, 75% of the volunteers felt that they had gained personally, and they were more aware of health, had obtained new knowledge, and learned how to work as part of a healthcare team. (9)

Case Study: Nepal

Though many volunteer programs have high attrition levels, the Female Community Health Volunteer (FCHV) Programme in Nepal loses fewer than 5% of its volunteers annually. The program began in the late 1980s and includes almost 50,000 volunteers. It covers most of the country, except urban municipalities. The volunteers are women who receive 18 days of training and are preferably selected by their communities. “Spending on average only about 5 h a week on their voluntary work, the FCHVs have contributed to high coverage of important primary health care programmes and are seen as key contributors to the childhood mortality and morbidity decreases achieved over the last two decades.” (10) The women also play an important role in distributing vitamins and in immunization coverage. For example, antenatal iron use has increased to 59%, whereas in 2001 when the FCHVs were not involved, only 23% of pregnant women used antenatal iron. FCHVs do not receive salaries, but they receive stipends for training and access to micro-credit funds.

The health improvements which occur as a result of the program are not limited to the people that the FCHVs serve. The FCHVs themselves also report great benefits from participating in the program. “Stakeholders regarded the FCHV Programme as a success, arguing that it has had an impact not only on child health but also on the social status of the FCHVs: Twenty years ago these shy women [the FCHVs] came to the health institutions (and didn’t ask questions), and now they are so knowledgeable, [they now say,] ‘No, no, no, don’t do this thing! It will harm you!’ So the development itself is much larger than the health service itself. We see it from that perspective also. It is not only health and health promotion. It is more a development of the community.” (11)

Sources of Motivation

The most frequent source of motivation from their volunteering was the social recognition that the FCHVs received from their communities. The concept of dharma, a Sanskrit term that refers to a person’s religious and moral duties, also played a role. The women viewed volunteering as a route to dharma and social respect. Thus, in this case, salaries would have undermined the program by threatening the women’s volunteer spirit. A FCHV program evaluator explained that “If an FCHV tries to sell her services for monetary gain, then our whole philosophy of moral and getting a seat in heaven and serving the people will be killed. We are not thinking that ‘you do this, you get that’. That sort of thing doesn’t work. It has to be a very sustainable type of thing. It has to be tied to Nepali moral and values.”(12) This example serves to demonstrate the importance of local context and collaboration in program development.

“The FCHV Programme illustrates that it is possible to deliver important health interventions through a nationwide volunteer programme on a sustained basis. Our respondents suggest that non-financial incentives may not only be sufficient within certain contexts, but that regular salaries could threaten programme sustainability.” (13) In general, incentives must be matched with the health workers' expectations. For example, in Nepal, visible symbols such as ID cards and FCHV celebrations encourage social recognition.  While salaries clearly collide with expectations, other incentives are appropriate and often necessary. “Non-monetary incentives are critical to the success of any CHW programme. CHWs need to feel that they are a part of the health system through supportive supervision and appropriate training. Relatively small things, such as an identification badge, can provide a sense of pride in their work and increased status in their communities.”(14)

Conclusion

Voluntary health workers, if managed effectively, have the potential to improve the health outcomes of many rural underserved areas and contribute to community development. In general, volunteer health workers expressed that their primary motivation to volunteer was to serve others, help their communities, and to improve their job prospects. There is still much debate as to whether health workers should receive financial compensation or not. However, it is evident that in order to sustain long term volunteer programs, it is necessary to at least implement non-financial incentives which match local expectations.

Footnotes

(1) Walt, G., Perera, M., & Heggenhougen, K. (1989). "Are Large-Scale Volunteer Community Health Worker Programmes Feasible? The Case of Sri Lanka." Social Science Medicine. 29.5: 599-608.

(2) UNICEF. (2004). “What Works for Children in South Asia. Community Health Workers.” https://chwcentral.org/resources/what-works-for-children-in-south-asia-community-health-workers/.

(3) Ibid.

(4) Ibid.

(5) Ibid.

(6) Walt, G., Perera, M., & Heggenhougen, K. (1989). "Are Large-Scale Volunteer Community Health Worker Programmes Feasible? The Case of Sri Lanka." Social Science Medicine. 29.5: 599-608.

(7) Ibid.

(8) Ibid.

(9) Ibid.

(10) Glenton, C., et. al. (2010). “The female community health volunteer programme in Nepal: Decision makers’ perceptions of volunteerism, payment, and other incentives.” Social Science & Medicine. 70: 1920-1927.

(11) Ibid.

(12) Ibid.

(13) Ibid.

(14) Lehmann, U., & Sanders, D. (2007). Community health workers: what do we know about them. The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. Geneva: World Health Organization, 1-42.