Performance based incentives should be applied after thorough understanding of the dynamics between CHWs, the community and the health institutions. Many donor-driven programmes have skewed service delivery by CHWs to HIV, TB, reproductive health and malaria to the detriment of other health services such as eye health, prevention of deafness and neglected tropical diseases which offer less or no ‘allowance’. Some of the older and usually more trusted CHWs may also become frustrated when they are not rewarded according to their relatively high energy contribution which may be more thorough but covers less people/families than the superficial contribution of younger CHWs. The performance based incentive can also induce forgery of outputs. I was once shocked as I watched several CHWs forge family visits as they prepared to submit monthly reports. Even worse was their supervisor, a nurse who too did not want to submit data that indicated her team had not met its targets.
Performance based incentives should also be linked to indicators that cover common conditions even if these are not linked to high mortality such as NTDs, skin conditions, epilepsy, mental health to a pick but a few. The incentive should cover quality time spent with the family or community and not simply the numbers reached or condoms distributed or number enrolled on FP. Projectised service delivery should avoid putting pressure on CHWs to reach set targets because this could lead to forgeries.
HIFA profile: Alice Nganwa is Executive Director at WIND Consult Limited in Uganda. Professional interests: Promote equity in development that includes marginalized people and addresses less popular but important development issues such as prevention of road traffic crashes, domestic violence, occupational safety, school health, healthy ageing and minimizing alcoholism and other addictions. windconsultug AT gmail.com