We developed a framework to examine the HRM of CHWs in fragile settings (Figure 1). This draws upon the CHW performance framework by Kok et al. [21] and the HRM approach defined by Armstrong [31] 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
HR outcomes
From the national decision makers and district managers, we found that 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, district managers reported that in Bunia district, there were 480 CHWs, of whom 288 (60%) were female, and in Aru district out of 840 CHWs, 403 were female (48%). From the interviews with decision makers and managers 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 by the decision makers, managers and CHWs probably as the community health policies have only recently been implemented.
Attraction: wanting to serve their community
In Sierra Leone, most CHWs reported that they provided community health services before joining the new CHW programme, such as through 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, decision makers and managers reported that 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
The Community Health Policies in Liberia and DRC include literacy as a requirement for being a CHW [9,10]. In Sierra Leone, the CHW policy states that “literacy and basic numeracy is highly valued and preferable, but is not strictly required, especially in the case of female candidates” [9, p21]. Decision makers and managers in DRC and Liberia reported that it was challenging to find people with reading and writing skills who wanted this role. Decision makers and managers in Sierra Leone reported that some CHWs were unable to read or write which created problems with training, drug administration and reporting. Decision makers and managers in all settings and the CHWs in Sierra Leone, explained that conflict disrupted education and this influenced the literacy and numeracy for some community members. Decision makers and managers in all settings recommended that basic literacy training is needed.
In Sierra Leone and Liberia, the policies state a preference for women, while in DRC, there are equal opportunities for men and women in the selection process [9,10]. 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. Interviews with managers and decision makers in Sierra Leone and Liberia explained that 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. 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, the managers explained that 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, the policies state that the CHW role is to connect communities and the health system, providing basic health care services, health promotion, health surveillance and mobilising communities [9,10]. The policies in all settings map out the training requirements for the CHWs (table 5).
Table 5: Training of CHWs
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Sierra Leone
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Liberia
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DRC
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Initial training
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Standardised package that includes three modules:
1. community health basics (e.g. communication, community entry, household registration, surveillance, health education, preventive care for children, identification of pregnant women); 2. Integrated community case
management ‘plus’ (e.g. assessment, referral, treatment and counselling, follow up care for sick child or child with malnutrition; assess and treat adults with malaria; 3. Reproductive, maternal, newborn, and
child health (e.g. RMNCH continuum of care, family spacing, pregnancy visits, newborn visits, child visits).
6-8 days training for each module, face to face, with additional 1-2 days practical.
No record of training evaluation.
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Integrated and standardised training package includes modules on: promotive, preventive and curative services, logistics, monitoring and surveillance. Each module is a month long
with a one-week face to face training delivered alongside implementation of services/practical experience.
They must pass proficiency tests and supervision to progress to the next training module and function as a CHW.
No record of training evaluation.
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Site CHWs: 7 days training on treatment of common illnesses of children in the community such as simple malaria, diarrhoea, acute respiratory infections, and malnutrition.
Promotion CHWs: 7 days training on health education and communication.
Disease-programme CHWs: receive training specific to the programme.
No description of mode of training or evaluation.
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Refresher
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Annual refresher training – no details in policy.
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Twice a year training based on findings from supervision visits, and training needs assessments.
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CHWs should receive refresher training, but no mention of frequency, duration or content.
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In Sierra Leone and Liberia, initial training was done in modules over 1 year or 4 months, with each module focusing on different topics. Most managers and CHWs in both settings 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 reported that 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 reported to be more ad hoc. Managers explained that it was usually organised by the district health authorities when new CHWs were selected, or when there were national health campaigns. Managers reported that 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 as reported in the policy documents (table 6). There are some successes with this supervision but also significant challenges.
Table 6: key actors involved in supervision of CHWs in Sierra Leone, Liberia and DRC
Sierra Leone
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Liberia
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DRC
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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.
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CHSS: provides field-based supervision to 10 CHWs working in remote catchment communities, collates reports from CHWs and takes to the facility.
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Chair of CHW group: organises monthly meetings, reports to the head nurse, who then reports to the District Health Office.
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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.
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Facility Manager: checks CHWs reports and clarify any issues, and report to the district health team.
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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.
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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. This motivated them to visit households, to follow the guidance given during training and to contact the supervisors when there were problems that they could not solve. As one CHW explained:
“Every week the peer supervisor visits. It wakes me up to do my work.” (CHW, male, Sierra Leone)
Some CHWs in Sierra Leone valued the meetings at the local health facilities where they could discuss issues and collectively solve problems:
“Well the meeting is good, it brings cordiality and makes the work easier because any issue you do not understand you can bring it up and they explain it to you.” (CHW, male, Sierra Leone).
In DRC, facility managers reported linking their supervision visits to other activities and providing training and advice. They thought the supervision worked well in identifying where the CHWs were working well and any issues, and this supported the CHWs to provide services.
".. 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).
There were several challenges with supervision. 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 by managers in all settings 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, a few CHWs reported that 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 managers 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, the community health policies state that CHWs should be given allowances. In in Sierra Leone CHWS should receive 100,000 Leones plus 50,000 to 80,000 Leones for transport and other logistics per month (equivalent of US$18-24). The monthly salary for a nurse is approximately US$400. InLiberia each CHW should be given US$70 per month which is based on provision of a package of health care at the household level through a minimum of four hours work per day. The monthly salary for a nurse is approximately US$350. The policy also states that they may also receive other forms of motivation, such as transportation, gifts in-kind, employment and advancement opportunities, involvement in national campaigns, and recognition events.
Most CHWs in Sierra Leone perceived the allowance to be too small to support themselves and their family and in relation to the amount of work they do.
“We want them to increase our salary - pay us monthly and increase on the amount. Monthly payment is the best as we have personal commitments that require financial inputs and the amount is small, we want them to look into it critically ….and also they should take into consideration that the job is an everyday job and it involves us working with our community, it is very tedious and we even work at night when there are emergencies.” (CHW, female, Sierra Leone)
In both settings there were significant delays in CHWs receiving their allowances. In Sierra Leone, at the time of data analysis, district managers reported that CHWs had not received their allowance due to delays in setting up mobile phones and accounts to receive money. CHWS reported that they 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, managers reported that bureaucracy between the donor and the Ministry of Health has led to payment delays.
In DRC, CHWs are voluntary roles without remuneration. However, managers reported that the CHWs receive some financial compensation if they work for specific programmes, go on training, or from sales of health products such as bed nets. This money is irregular, and the amount varies per month, depending on their sales, the training and work opportunities and how much the programmes provide. They often have to use their own resources to visit households or attend meetings at facilities. Managers explained that 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. Managers suggested that regular payment would motivate CHWs to work and reduce attrition.
"...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 to treat uncomplicated malaria, acute respiratory infection and diarrhoea. In all three countries, managers and CHWs (Sierra Leone only) reported that challenges in the drug supply chain have led to delays in CHWs receiving medicines on time to treat patients, meaning their role has become predominantly to make referrals. In both Sierra Leone and Liberia, CHWs report to their supervisors when they run out of drugs or supplies, and then collect them from the local facility. Despite a proportion of drugs at the facility being allocated to CHWs, most drugs were used at facility level. In addition, Sierra Leonean 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)
CHWs and peer supervisors in Sierra Leone suggested that some drugs should be kept with the peer supervisors so that they can quickly “top up” the CHWs supply. In Liberia, managers recommended more rigorous and transparent process for allocation of drugs to CHWs is needed.
Despite promises of equipment and materials such as test kits for malaria, uniform, badge, torches, drugs boxes, thermometers, stationery and bicycles, CHWs in Sierra Leone and managers in all settings reported that most CHWs have not received these items. These are critical to CHW roles in promoting health and recognising and treating illnesses, making visits at night or in rainy weather and community recognition and trust.
“CHWs need kits and identification card - some people will not speak to them or accept them without ID card, kits, rain boots, rain coats(Community Manager, male, Sierra Leone)
Performance management – the challenges of rewarding and sanctioning volunteers
In the three countries, there is no written guidance or indicators on how to manage or measure CHW performance. In practice, the facility managers reported that they assess CHW performance through their monthly reports of activities. In Sierra Leone, a health facility manager and peer supervisor gave each CHW a score based on the numbers and quality of household registrations and completed registers. Managers also reported that communities through the health facility committees play a role in monitoring CHW activities in Liberia, Sierra Leone and DRC. The committees review CHW reports, attend facility meetings and provide feedback from community members on the CHWs work. One manager in Sierra Leone explained how the committee identified a poorly performing CHW and worked with the managers to solve the problem:
"They told me they cannot go to the man because he is always drunk so we have to change that CHW” (District manager, male, Sierra Leone).
Managers, in these resource poor settings, developed innovative ways to reward well performing CHWs but found it difficult to sanction poorly performing ones (table 7).
Table 7: Rewarding and sanctioning CHWs
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Strategies
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Challenges
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Rewarding CHWs
“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).
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Selecting active CHWs for programme activities where they will be given a financial incentive
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Not enough rewards and recognition
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Sharing food or small financial incentives during meetings
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Create annual awards, certificates and radio announcement
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Providing verbal praise
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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.
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Assuring CHWs that they have the community’s and God’s recognition
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Sanctioning CHWs
"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).
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More closely monitoring the CHWs and providing encouragement
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Difficult to dismiss poorly performing CHWs
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Providing additional training and support
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Time and resource consuming to replace CHWs
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Talking with the community to try to resolve performance problems
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Occasionally, threatening not to submit the CHW report to the facility which would prevent them receiving their allowance.
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The managers in Liberia, DRC and Sierra Leone, recognised the limitations of these rewards but perceived them to be valuable in supporting CHWs. As two managers explained:
"As for rewards, we do not do something special, as we do not have money. But, whenever there is a meeting, we prepare food, and we eat together, and get to know each other much better." (Facility manager, female, DRC)
“I didn't give them any reward, but the means…when a programme came, I didn't just let one keep working and working I started to rotate them when different programmes came and that allowed them to re-engage.” (Facility manager, male, Liberia).
CHWs in Sierra Leone reported that the praise and recognition of the community is important in motivating them to continue their work. They wanted this recognition to be translated into more practical measures such as help with farm work and exemption from community tasks:
"The community people sometimes give me words of moral boost and sometimes give me food items like fish, cassava” (CHW, male, Sierra Leone)
"To make my job easier the community should at least assist me not financially but like if I want to make a cassava garden, they help me out, but they had not started doing that. (CHW, male, Sierra Leone).