Framework of Motivations
for Community Health Workers

JOHN LEE, ARIJIT SARKAR

Broad analysis of existing CHW programs (Page 1 of 3)

In attempts to improve CHW programs, many organizations have identified key areas in which their programs often face trouble in ensuring sustainable and effective CHWs. Numerous studies have collected and organized these common areas of concern, each of them presenting possible ways in which to address these areas. Each study has high overlap with one another, indicating that many CHW programs deal with similar issues and problems (KARABI, ICTPH). The common areas identified through a vast body of literature are listed below:

1. Incentives

2. Training

3. Supervision / Support

4. Roles / Feedback

5. Career prospects

This list represents areas in which studies on existing CHW programs have found were common reasons for failure and which could be improved upon. Most areas are not oriented towards building specific motivations for workers; rather they deal with bolstering and restructuring programs in order to accommodate and work for CHWs. Therefore, in order to increase motivation, the program as a whole must be designed in a manner that addresses these areas. The list provides items that can be analyzed using Maslow’s Hierarchy of Needs, to assess whether programs adequately provide for the satisfaction of needs of CHWs, in order to cultivate intrinsic motivation. The goal of programs should be to support and allow for their workers to reach the self-actualization stage so that they will be effective and committed to the mission of their respective programs. However, having all workers reach self-actualization may be too optimistic; therefore, programs should try to satisfy all needs below self-actualization, and hope that self-actualization occurs.

Popular techniques for addressing the common areas of concern will be viewed in the perspective of each level of Maslow’s Need. Using the Needs Hierarchy allows one to scrutinize a program, identifying ways in which a technique or practice affects a worker’s motivation. An analysis of the most popular management practices for CHWs will provide better information about creating more effective management structures. This section will also act as a model to illustrate how management strategies for dealing with common problems of CHW programs can be applied to Maslow’s Hierarchy of Needs.

Physiological needs

Maslow describes physiological needs as the need for food, shelter, clothing, and other necessities of homeostasis. The most basic form in which to acquire all of these provisions is through money. One of the most controversial areas of CHW programs is whether to provide monetary incentives for CHWs to aid in satisfying physiological needs, thereby motivating them. Many CHW programs have taken different approaches to monetary incentives; some provide credit and reimbursements, while others provide the resources for small income-generating projects (UNICEF). There have also been mixed reviews of results from monetary incentives. Analyzing monetary incentives in respect of Maslow’s physiological needs may provide a more comprehensive perspective of the motivations behind this issue.

In many projects, monetary incentives have shown to significantly decrease attrition rates in the short term (KARABI). According to Maslow, when an individual’s physiological needs are fulfilled, they are free to pursue more social needs. One of the leading causes of attrition for CHWs has been that costs of volunteering; for example, the time taken off of work, transportation costs, and other miscellaneous costs (SHRC). These factors lead to physiological needs being unsatisfied. Because of this need’s prepotency, it inhibits workers from attaining higher levels of motivation. The case for monetary incentives is certainly strong. It fits well in Maslow’s Needs Hierarchy as an essential need to reach self-actualization. Why then has it become such a controversial issue?

To understand why monetary incentives may be deleterious to increasing motivation in CHWs, we must apply Maslow’s Hierarchy in respect of the nature of volunteering. As stated earlier, volunteering represents a self-sacrifice by the volunteer, usually forgoing some resources, such as money and time. The motivation for this sacrifice may vary from wanting to gain stature in the community to seeking some self-actualized goal. According to Marx, volunteering is a conscious movement away from an individual’s normal job or career to an area where they have the potential to succeed through self-sacrifice. As a result, providing monetary incentives may create a sense in the CHW that their work is no longer volunteering; rather, it has become a career. Past CHW programs have found that upon offering monetary incentives, CHWs often demanded more pay (KARABI). Other projects have found that monetary incentives lead to unionization, insurance, and other demands (Meganathan). Perhaps the most harmful of these effects was that it created inequity within CHW programs between differences in pay and non-paid workers (KARABI). Studies have shown that while financial incentives are beneficial in the short-term, they curtail efforts at long-term sustainability (KARABI). All of these effects lead to considerable degradation of programs, inhibiting long term sustainability and effectiveness.

One way in which to satisfy both Maslow’s Hierarchy and the nature of volunteering is to provide in-kind incentives. These incentives include food, insurance, childcare, transport, etc. Like monetary incentives, they help satisfy physiological needs of the volunteers. They can alleviate some of the tensions from an unsatisfied physiological need for CHWs. Unlike monetary incentives, they are not salaried pay and do not hold the same implications as a job. As items, they can be formulated to be “perks” of volunteering, rather than compensation for volunteering. This way, salaried worker and volunteer are distinguished; though management should be careful not to provide such incentives too often or too much, as it has been shown to reduce long-term motivation given in excess (KARABI).

In fulfilling the physiological needs of CHWs, management can strive to provide in-kind incentives that free workers to pursue deeper means of motivation in their health work. The most significant barrier to any kind of incentive, monetary or in-kind, is its unsustainable nature. Once an incentive has been given, it must be given continuously. Therefore, it is important to ensure that incentives can be given long-term within a CHW program. The main impetuses behind giving incentives are to relieve the burden of volunteering as much as possible, and accommodate for CHWs as much as possible. Because of the basic nature of this needs level, the other common problem areas of training, supervision, support, roles, feedback, and career prospects are not as relevant. They are more pertinent in the higher needs levels.

Table 2: Summary of physiological needs

Summary of physiological needs
Need	Major points
Physiological	Monetary incentives seemingly fit well into Maslow’s model in satisfying physiological needs Monetary incentives cancel the nature of volunteer work and create a job Monetary incentives may be a good alternative to fit both Maslow’s model and Marx’s theory of volunteers In-kind incentives may be a good alternative to fit both Maslow’s model and Marx’s theory of volunteers Importance of sustainability with any kind of incentive

Safety and security needs

With females comprising the main population of CHWs, physical safety can be a major issue. In a qualitative study done by the State Health Resource Centre (SHRC), they found that nearly 12% of workers faced harassment frequently. Consistent provocation could lead to serious declines in morality and security, making it impossible for CHWs to function effectively. Maslow would predict that CHWs that faced harassment would be unsatisfied in their safety needs and their motivation to work would diminish. Management must make the safety of CHWs a priority and actively work to reduce the risk of harassment.

One common problem area in programs has been the lack of supervision and support of CHWs. Studies have shown that poor supervision often leads to ineffective health workers (Edpuganti). When CHWs have strong communication and support they can more easily voice their concerns to supervisors. This would allow supervisors to act properly and help design programs that would reduce risk to CHWs. Supervisors could also incorporate lessons on how to avoid or deal with harassment into the training regiment for CHWs. This would give CHWs the tools and prior knowledge to deal with provocative situations more easily. By preparing volunteers to deal with tough situations, they would potentially feel more secure and supportive in handling some of the inherent risks for health work. With feelings of safety and security, they will be able to pursue higher means of motivation.

In creating the safety and security need, Maslow also included long-term issues such as job security, tenure, and insurance. Often times, physical violence may not comprise the largest risks to safety, rather, the inability to pay for healthcare, lack of education, and poor financial services may create more fear. Maslow noted that as society has elevated, many of the physiological risks when man was more like an animal have diminished; the need to hunt, fight, etc no longer encompasses safety. Therefore, in order to secure safety, one must address long-term issues so that an individual will satisfy their needs. Similar to an in-kind incentive, CHW programs could provide services and benefits to volunteers. These benefits could be free health insurance to CHW families, education for their children, financial consulting, and transportation. These incentives would not only practically increase feelings of security, but would increase feelings of support from management.

For any CHW program to succeed, the need for safety and security must be recognized as extremely important in having not only an effective program, but comfortable volunteers.

Table 3: Summary of safety needs

Summary of safety needs
Need	Major points
Safety	Harassment of CHWs a major issue Need better support and supervision to prevent harassment = Training on how to manage and avoid harassment Long-term security issues (Financial, health, education, etc) Importance of sustainability with any kind of incentive