CHWs (51) Performance-based incentives (4)

8 November, 2019

Dear Alice and All,

Thank you for your comments. You said that 'performance-based incentives can distort CHW's work because some tasks may be rewarded while others are not, and they can lead to forgery of outputs'. [Note from moderator (NPW): This is how I paraphrased Alice's points. Alice's original message is here: ]

My comment: you are right in raising the risk of ‘possibility of 'forgery of outputs’; but that is not a strong enough reason to not provide for and pay incentives over and above the basic salary. Basic salary in LMICs are almost always living wages for workers, including CHWs. If they are not paid incentives they seek to earn extra money elsewhere often doing such extra work during official working hours, or they indulge in corrupt practices like asking for cash before they even attend to patients or other visitors seeking public services.

Obviously they should not be taking bribes to do their work but they are tempted to do it (wrongly in my view but that is the reality). They claim to do it because that is the only way to pay their bills and take care of their families, including school fees and medical bills. At least if incentive is paid to augment their meagre wages, the bribery and corruption is limited and reduced to only those who are criminally minded anyway, but their numbers are usually a small minority. Those who administer an incentive programme must structure it to uncover forgery and other corrupt practices e.g. install internal verification and followed independent counter verification. It works in Nigeria State Health Improvement Programme (NSHIP) which is a World Bank Assisted programme run by Oxford Programme Management group (OPM) in primary health care in some pilot states. Those found to be guilty must be punished as a deterrent.

Joseph Ana.


@Health Resources International (HRI) WA.

National Implementing Organisation: 12-Pillar Clinical Governance

National Implementing Organisation: PACK Nigeria Programme for PHC

Publisher: Medical and Health Journals; Books and Periodicals.

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HIFA profile: Joseph Ana is the Lead Consultant and Trainer at the Africa Centre for Clinical Governance Research and Patient Safety in Calabar, Nigeria. In 2015 he won the NMA Award of Excellence for establishing 12-Pillar Clinical Governance, Quality and Safety initiative in Nigeria. He has been the pioneer Chairman of the Nigerian Medical Association (NMA) National Committee on Clinical Governance and Research since 2012. He is also Chairman of the Quality & Performance subcommittee of the Technical Working Group for the implementation of the Nigeria Health Act. He is a pioneer Trustee-Director of the NMF (Nigerian Medical Forum) which took the BMJ to West Africa in 1995. He is particularly interested in strengthening health systems for quality and safety in LMICs. He has written Five books on the 12-Pillar Clinical Governance for LMICs, including a TOOLS for Implementation. He established the Department of Clinical Governance, Servicom & e-health in the Cross River State Ministry of Health, Nigeria in 2007. Website: Joseph is a member of the HIFA Steering Group and the HIFA working group on Community Health Workers.

Email: jneana AT