We developed a framework to examine the HRM of CHWs in fragile settings (Fig. 1). This draws upon the CHW performance framework by Kok et al.  and the HRM approach defined by Armstrong  as “a strategic approach to acquiring, developing, managing, motivating and gaining the commitment of … the people who work in [the organisation] and for it” [page 33]. The HRM processes of attraction and selection, training and development, supervision, provision of supplies and performance management are influenced by the hardware (e.g. policies, guidelines, structures) and software (e.g. values and norms of the actors, relationships between the actors) of the community and health system, and the broader context in which they exist. These influence the HR outcomes such as numbers and characteristics of CHWs and reported attrition. This framework provides the structure for reporting the results.
Figure 1: Framework to examine the human resource management of CHWs in fragile and conflict affected settings
There were fewer female CHWs in Sierra Leone and Liberia. In Sierra Leone, 14935 CHWs were trained across the country: 10652 males (71%) and 3283 females (29%). In Grand Bassa County, Liberia there were 91 male (90%) and only ten female CHWs (10%). In DRC, Bunia district, there were 480 CHWs, of whom 288 (60%) were female, and in Aru district out of 840 CHWs, 403 were female (48%). In DRC, high attrition rates were reported, especially among younger and male CHWs who leave when they find better job opportunities. In Liberia and Sierra Leone, attrition issues were not reported, probably as the community health policies have only recently been implemented.
Attraction: wanting to serve their community
In Sierra Leone, most CHWs provided community health services before joining the new CHW programme, such as being a traditional birth attendant or contact tracer during the Ebola outbreak. They wanted to continue to serve their communities and save the lives of pregnant women and children. In DRC and Liberia, CHWs were attracted to the role in the expectation of remuneration and wanting to serve their community.
Selection: the tricky issues of literacy and gender
CHW literacy was a requirement in DRC and Liberia only. Fragility disrupts education of community members affecting literacy levels required for the CHW role. In Sierra Leone, some CHWs were unable to read or write which created problems with training, drug administration and reporting. Managers recommended that basic literacy training is needed. In DRC and Liberia, it was challenging to find people with reading and writing skills who wanted this role.
In Sierra Leone and Liberia, the policy states a preference for women, while in DRC, there are equal opportunities for men and women in the selection process. However, in all contexts policy ideals were mediated in practice by gendered community norms. In both Sierra Leone and Liberia, there were more male CHWs. Community-based selection processes, women’s limited voice and presence in community affairs, along with a culture of selecting men for paid work emerged as reasons for more male CHWs in Sierra Leone and Liberia. As one manager explained:
“When it comes to community affairs, only men show up, women don’t, they don’t even talk. Should they show up, then the community members would have selected them.” (District manager, male, Sierra Leone).
In DRC, there were more female CHWs where there were women’s associations. These associations advocate for women and influence husbands’ and relatives’ permission for women to join the programme. "Here in our health district, where you find nearly half of community health workers are female, there are women associations, but where there are no women associations, you find that there are more male community health workers." (District manager, male, DRC)
Training and development – opportunities for learning and supporting each other
In all three settings, CHWs connect communities and the health system, providing basic health care services, health promotion, health surveillance and mobilising communities. In Sierra Leone and Liberia, initial training was done in modules over 1 year or 4 months, with each module focusing on different topics, for example household registration and surveillance, reproductive health, and diagnosis and treatment of common illnesses. Most key informants and CHWs described the training positively, specifically: the mix of classroom training and practical community experience, the provision of a manual, learning how to visit households, communication skills and developing a sense of a cohort amongst the CHWs. One participant in Liberia described: “In the evening, they will sit in group, ask one another questions… when we were in the training today, what you didn’t understand? - The person will explain, they all put their minds together.” (Facility manager, female, Liberia)
In Sierra Leone, CHWs with limited literacy found it difficult to use the manual, make notes and review what was learned during the sessions. In Liberia, managers wanted to be more involved in the training so that they could understand what was expected of the new health cadres.
In DRC, training was more ad hoc. It was organised by the district health authorities when new CHWs were selected, or when there were national health campaigns. Female CHWs were less likely to attend training because of their gendered responsibilities within families.
Supervision – complex and challenging
Supervision of CHWs is a complex process and is the responsibility of a variety of different actors within the health system (Table 4). There are some successes with this supervision but also significant challenges.
key actors involved in supervision of CHWs in Sierra Leone, Liberia and DRC
Peer supervisor (CHWs with additional training): monthly visits to observe the CHWs work, check drug supplies and reports,
coordinates monthly meeting of CHWs at Peripheral Health Unit.
CHSS: provides field-based supervision to 10 CHWs working in remote catchment communities, collates reports from CHWs and takes to the facility.
Chair of CHW group: organises monthly meetings, reports to the head nurse, who then reports to the District Health Office.
Peripheral health unit manager:
regular visits to each CHW, attend monthly CHW meeting, provides advice and training to CHW, distribute drugs and supplies, compiles CHWs reports and sends to District CHW focal person.
Facility Manager: checks CHWs reports and clarify any issues, and report to the district health team.
Facility head nurse: regular visits to observe CHW work and records, provide training when needed such as implementing a specific programme or when a health problem increases.
District CHW focal person: provides training, visits the CHWs and the peer supervisors, collates reports from facilities and compiles district report for District Health Office and National Hub.
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In Sierra Leone, many CHWs were positive about the peer supervisors, reporting frequent contact and help with completing reports. In DRC, head nurses reported linking their supervision visits to other activities and providing training and advice: ".. for the supervision, we go on the ground, we see what they are doing … at the facilities level, there are other orientations, we give them, for example organising census within the health catchment area." (Facility manager, female, DRC).
Peer supervisors and the District CHW focal persons in Sierra Leone and the CHSS in Liberia reported no bicycles or transport allowance as a significant barrier to their work. They often travelled long distances, sometimes at their own cost. One CHSS explained the challenges she faced:
“I have to walk on seven hours distance to go for supervision, and then I have to supervise the CHAs on two hours. Before I come back, darkness will catch me and I will sleep there. No compensation. I spend more time in the field, so they should see about compensating me for accommodation and feeding. These things can really affect performance”. (Community manager, female, Liberia).
Workload was also cited as a key reason for supervision structures not working effectively. As one key informant in Liberia explained: ‘In the policy it says that CHSS will visit the CHA twice a month. The reality is that, some of them have not been able to reach to the CHA to supervise them even once a month. This is because the CHSS must work 20% of their time in the clinic, but the clinic work takes up most of their time.’ (National decision maker, male, Liberia).
In Sierra Leone, the relationship between CHWs and health facility staff is strained in some areas: CHWs feel ignored, are not given drugs or supplies, and are not selected for other community activities despite this being a good income source. One CHW reported being threatened by a manager: “He also told us that if he had known earlier, he would have removed our names from the programme because we’re not cooperative - we don’t give him any money from the incentive we are receiving.” (CHW, Sierra Leone, female). Some key informants explained that some health facility staff see CHWs as taking their work (which provides income that supplements their sporadic salary) and being given drugs that are in short supply.
Remuneration – delays and repercussions for retention and performance
In Sierra Leone and Liberia CHWs should be given allowances: in Sierra Leone 100,000 Leones plus 50,000 to 80,000 Leones for transport and other logistics per month (equivalent of US$18–24); and in Liberia 70USD is provided per month based on provision of a package of health care at the household level through a minimum of four hours work per day.
In both settings there were significant delays in CHWs receiving their allowances. In Sierra Leone, at the time of data analysis, CHWs had not received their allowance due to delays in setting up mobile phones and accounts to receive money. As a result, CHWs used their own money to travel around their community, attend meetings and training. Community members do not help CHWs with their farm work and so CHWs have less time to do health work. In Liberia, bureaucracy between the donor and the Ministry of Health led to payment delays.
In DRC, CHWs are voluntary roles without remuneration. However, they receive some financial compensation if they work for specific programmes, go on training, or from sales of health products such as bed nets. Despite being told about the voluntary nature of their work during the selection process, CHWs still expect to receive financial incentives. As this expectation is not met, they look for other work.
"...as they have to work voluntarily in context where finding a paying job is not easy. So, at the same they have to work for their survival and also for community. In a poverty context, their work is not easy". (District manager, male, DRC)
Provision of supplies - promised but not always received
In Sierra Leone and Liberia, the community health policies emphasise the provision of adequate and quality assured medicines and supplies. In all three countries, challenges in the drug supply chain have led to a delay in CHWs receiving medicines on time to treat patients, meaning their role has become predominantly to make referrals. In both Sierra Leone and Liberia, all supplies pass through the facility before reaching the community. However, most drugs were used at facility level, despite a percentage being allocated to CHWs. In addition, Sierra Leone CHWs reported spending their own money to travel to the health facility only to find either the drugs or the staff not there.
“The distance we cover from our own community to the PHU, we go for drugs and drugs are not available, they will inform us that they haven’t received supply.” (CHW, male, Sierra Leone)
Despite promises of equipment and materials such as uniform, torches, drugs boxes, stationery and bicycles, most CHWs have not received these items. These are critical to CHW roles and community recognition and trust. In Sierra Leone the lack of drugs led to mistrust between some communities and CHWs:
“Difficult when my child is sick and I need to look after her, and they come with a sick child. I’ll take care of the sick child before dealing with my own problem because if you do not take care of the sick child first, their parent will say they brought their sick child to that CHW and she left the sick child to attend to her own child.” (CHW, female, Sierra Leone)
Performance management – the challenges of rewarding and sanctioning volunteers
In the three countries, there is no written guidance on how to manage CHW performance. Managers found innovative ways to reward well performing CHWs but found it difficult to sanction poorly performing ones (Table 5).
Rewarding and sanctioning CHWs
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“We think that the high performing CHWs should be recognised and awarded. This will make a big difference to how they feel appreciated”.
(National decision maker, male, Liberia).
Selecting active CHWs for programme activities where they will be given a financial incentive
Not enough rewards and recognition
Sharing food or small financial incentives during meetings
Create annual awards, certificates and radio announcement
Providing verbal praise
Community recognition needs to be stronger in some areas: community members need to support CHWs with their farm work so that they can focus on their health work.
Assuring CHWs that they have the community’s and God’s recognition
"You know, it is not easy in our context to manage someone who works voluntarily, and does not benefit from financial incentives. It is just too difficult to objectively manage them". (Facility manager, female, DRC).
More closely monitoring the CHWs and providing encouragement
Difficult to dismiss poorly performing CHWs
Providing additional training and support
Time and resource consuming to replace CHWs
Talking with the community to try to resolve performance problems
Occasionally, threatening not to submit the CHW report to the facility which would prevent them receiving their allowance.