Incentives for Community Health Workers in Fragile and Conflict-Affected Settings: A Narrative Review

Abstract

Background: There is ample evidence advising the implementation of community health workers (CHWs) programmes in addressing the shortage of human resources for health in low and middle income countries and Fragile and Conflict-Affected Settings (FCAS), as they are positioned to provide primary health services to populations in need. However, there is limited understanding of the appropriate incentives available to Community Health Workers (CHWs) to enhance their performance and retention. This study seeks to identify what incentives are available to CHWs in FCAS and how the incentives influence their performance and retention. Methods: This study is a narrative review of existing incentives for CHWs, specifically in FCAS. Based on a conceptual framework on how incentives affect performance and retention, a search strategy was developed to search electronic databases, relevant journals, and grey literature for the existing literature. A total of 1127 papers were retrieved and initially screened for focus on CHWs, FCAS and incentives, resulting in a final selection of 23 papers for this review. Data from these papers were extracted based on concepts and themes from the conceptual framework and analysed using a thematic approach. Results: The findings from the selected papers for review show that there is a growing interest in incentives for CHWs in FCAS. Also, most CHW programmes provide a mix of financial incentives like salaries, per-diems and transport allowance, and non-financial incentives like supervision, training and community support and recognition. The performance of the CHWs is generally reported to be positively influenced by the available incentives, though the mechanism is not clearly understood. The retention of CHWs in FCAS appears to be positively influenced by the available incentives, though few of the selected studies reported this. Conclusion: This study provides the first overview of incentives for CHWs in FCAS, and it highlights that the best approach to incentivising CHWs in FCAS is providing a mix of both financial and non-financial incentives to improve their performance and retention. However, further research is needed to advise the design of CHW programmes, and it is imperative to consider the context of fragility as it profoundly influences the type of incentives available to CHWs and in turn how these incentives will influence the performance and retention of CHWs in contexts of fragility, as well as the sustainability of CHW programmes in these settings.