Tables 1 and 2 summarize each country’s approach to CHW compensation based on several key criteria. Synthesized questionnaire responses are available in Additional File 2.
Table 1
CHW Compensation Models by Country
Country (Cadre) | Type of Compensation Model | Existing laws, regulations or policies governing CHW payment | Salary Floor / Minimum Wage | Provision for CHW volunteers | Legal Protection / Ability to Unionize | Complies with WHO CHW Guideline |
Brazil (CHW/ACS) | Public Sector | Yes | Yes | Yes (through NGOs) | Yes | Yes |
Ghana (CHVs) | Volunteer-based | No | No | Yes | No | No |
Nigeria (CHWs) | Private (with minimum wage floor) | No | Yes | Yes | Yes | Partial/In Progress |
Rwanda (CHWs) | Cooperatives with Performance Based Incentives | Yes | No | Yes | No | No |
South Africa (CHWs) | Hybrid: Public Sector & Private (sub-contracting) | Partial / In Progress | Partial / In Progress | Yes (through NGOs) | Yes | Partial/In Progress |
Table 2
Country (Cadre) | Payment Type | Payment Level | Payer | Benefits |
Brazil (CHW/ACS) | Salary | At/above minimum wage | State | Basic (varies by jurisdiction) |
Ghana (CHVs) | Volunteer | None | None | None |
Nigeria (CHWs) | Not defined | As long as a contract is in place, pay must be at/above minimum wage, but part-time workers exempted | Non-State | Dependent on individual contracts |
Rwanda (CHWs) | Performance- based incentives via cooperatives | Below minimum wage | State & Non-State | None |
South Africa (CHWs) | Salary (only state-employed CHWs) | Below minimum wage (though full-time CHWs are legally entitled to minimum wage) | State & Non-State | Basic (varies by province) |
Brazil employs a public sector model in which CHWs are defined as full-time (8 hours per day, 5 days per week) state employees and therefore qualify for a minimum wage that is updated annually.,, There is a provision for CHWs not employed by the state to act as volunteers. There are criteria and educational requirements for practicing as a CHW, and CHWs are generally afforded the same legal protections available to other classes in Brazil. This includes the right to form a union. This model complies with WHO recommendations pertaining to CHW compensation
Ghana employs a volunteer-based model. Ghana’s Community-based Health Planning and Services Policy (CHPS) published in March 2016 defines Community Health Volunteers as non-salaried. CHVs, unlike remunerated cadres like Community Health Nurses, are not considered workers and so do not benefit from a salary floor. They are also not subject to certification requirements, and are not afforded the legal protections available to other classes of workers. This model does not comply with WHO recommendations pertaining to CHW compensation.
Nigeria employs a private model, with a public-sector wage floor. CHWs are classified as Non-Workers under Nigerian law and their compensation - including benefits - is dependent on the terms of their contracts with various employers. It is, however, an offence for employers, to whom the Minimum Wage Act applies, to pay less than the specified minimum wage to their employees. Moreover, certain employment-related benefits, such as life insurance and pensions are regulated by Nigerian Law and apply to CHW employment. Volunteerism is allowed, provided that volunteer CHWs, as with all CHWs, register, obtain certification, and pay annual retention fees.19 CHWs are entitled to the same legal protections as other employees including the right to form unions. The current approach satisfies most of the criteria in WHO CHW Guideline on remuneration.
Rwanda employs a Performance-Based Financing Model centered on Cooperatives. As outlined in Rwanda’s national policies and strategic plans, community health workers are volunteers who receive some compensation according to a performance-based system and income-generating cooperative model.,, Payment is dependent upon the CHWs meeting the targets set for each assignment (i.e. submit report by the 5th of each month, Report completely filled in, etc.). This payment is made directly to cooperatives, which are then tasked with dividing 70% of the money towards income-generating activities, and 30% (plus any revenue) towards cooperative members. Because they are treated as volunteers, CHWs lack legal protections afforded to other workers, such as the right to form a union. This model does not comply with WHO recommendations as it is primarily based on performance, there is limited accountability in ensuring individual CHWs receive payment, and there are no contracts in place to provide for the mode of payment between the government and the CHW.
South Africa employs a Hybrid Public/Private Model. South Africa’s legal framework governing CHW payment is changing, rendering a rating of “partial / in progress” for several criteria. There is no legislation governing the payment of CHWs today. The National Department of Health’s 2018 Policy Framework and Strategy for Ward-Based Primary Healthcare and the 2011 provincial guidelines for primary healthcare, however, provide a strategic framework for the employment of CHWs by provincial and district departments of health. In light of the provisions of this policy framework, the Department of Health concluded an agreement with unions representing CHWs to standardize the remuneration of state-employed CHWs at the same level as the legislated minimum wage,. These developments apply only to CHWs employed by the state and who meet specific criteria. While certain provinces directly employ CHWs in their respective departments of health, others use NGOs as intermediaries and certain provinces make use of payroll management companies contracted by the health departments to employ CHWs. CHWs employed through intermediaries are not protected by the remuneration agreement concluded with the Department of Health and remain excluded from the protection of the National Minimum Wage Act of 2018. Given this, only the State employment of CHWs definitively complies with WHO recommendations.