Community health workers are often the first point of care for vulnerable and underserved populations in low- and middle-income countries. In 2018, the World Health Organization recommended that countries fairly remunerate CHWs. Three years since those recommendations were published, fair pay for CHWs remains rare.
Only 14% of CHWs in Africa are salaried, and the vast majority are volunteers with some or no compensation. From Bangladesh to Rwanda, the global community faces a moral dilemma — will we commit to decent work in community health, or will we continue to build health systems on the backs of an unpaid, largely female care workforce?
New research, facilitated by TrustLaw, the Thomson Reuters Foundation’s global pro bono legal program, finds that many common CHW payment models do not reflect WHO recommendations for compensation.
From performance-based incentives in Rwanda, to volunteer models in Ghana, to contracting models with limited oversight in Nigeria, CHWs remain underpaid — and often unpaid — in direct contradiction to evidence telling us to do otherwise. Certain approaches to CHW compensation are more promising than others — particularly, public sector or models with public sector wage floors.
Countries’ legal frameworks are not the only problem. For decades, donor-funded programs have signaled that delivering health care on the backs of predominantly female unpaid labor is an acceptable option.
It’s telling that South Africa, where the battle for CHW fair pay is still ongoing, is by some measures a success story — it’s one of the very few places across the African continent where CHWs have organized to demand fair pay and other basic benefits.
Signs of change are coming. In Kenya, where health services are managed at the subnational level, local governments are taking matters into their own hands. Now, counties are updating policies and budgets to support fair pay for CHWs who previously served as volunteers or relied on periodic stipends from NGO partners.
In Uganda, another country where volunteer CHWs, known as Village Health Team workers, or VHTs, have supported global health programs for decades, the Minister of Local Government recently announced a one-time payment to cover the additional duties VHTs performed during the COVID-19 pandemic. While a step in the right direction, Ugandan advocates and the international community have their work cut out to transform a one-time emergency payment into lasting policy change.
International donors also have a role to play. They can revise strategies, policies, and investments in order to eliminate the risk of exploiting unpaid labor to achieve agency and/or program objectives. The President’s Malaria Initiative has already taken steps to encourage payment of a fair salary to CHWs.
Additionally, in the United States Agency for International Development’s Implementation Plan for the U.S. COVID-19 Global Response and Recovery Framework, the agency acknowledges that “70 percent of whom [health workers] are women and many of whom are unpaid volunteers,” and commits to encouraging that they be compensated.
In this year of the health and care worker, the best way to move from appreciation to action on behalf of front-line responders — specifically CHWs — is to pay them a decent wage.
—As donors such as the U.S. President's Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis and Malaria, Gavi, the Vaccine Alliance, and others prepare new strategies for the post-COVID-19 context, we urge them to implement similar changes.
There are concerns that in a post-COVID-19 world, tight fiscal space and the debt rating downgrades of many LMICs means that now is no time to be pushing for expansion of the wage bill. This is a nice excuse for inaction on the part of the global community, and all the more reason why international donors and lenders — particularly the World Bank — should revisit policies that cripple countries’ ability to decently employ public sector workers.
We recognize the utility of volunteerism for achieving health gains quickly in recent decades. We also acknowledge the fulfillment that many people derive from volunteering to support causes close to their hearts. We draw the line, however, at nefarious, deep-seated issues that disenfranchise and deny fair pay to CHWs, who themselves are often members of the communities in which they work.
In this year of the health and care worker, the best way to move from appreciation to action on behalf of front-line responders — specifically CHWs — is to pay them a decent wage. Governments can reform legal frameworks and health sector budgets to ensure CHWs are accounted for as workers — not as volunteers.
Funders can prioritize CHW professionalization in revised strategies and loosen current policies that prohibit funds from being used for salary support. NGOs can refuse to implement, and researchers can refuse to evaluate programs that deny CHWs fair pay. It’s time to dismantle an inequitable system that depends on unpaid labor from socio-economically disadvantaged communities, and put in its place a system in which every CHW is guaranteed fair pay. We will continue the fight until we rid ourselves, once and for all, of the notion of “volunteer” CHWs.
Visit the Building Back Health series for more coverage on how we can build back health systems that are more effective, equitable, and preventive. You can join the conversation using the hashtag #BuildingBackBetter.
About the author
Contributors
The Community Health Impact Coalition exists to make professionalized community health workers a norm worldwide. Members of CHIC and co-authors of this piece are: Carey Carpenter Westgate, deputy director at CHIC; Mathilde Hutchings, director of partnerships at PIVOT Works, Inc.; Nandini Choudhury, adviser at Possible Health; Helen Olsen, monitoring and evaluation senior manager at Medic, and Madeleine Ballard, executive director at CHIC.
