Task Shifting - Global Recommendations and Guidelines - unaids

Recommendations on ensuring sustainability
Summary of findings
Community health workers have the potential to make a significant contribution to increasing
access to HIV services under the task shifting approach. Part-time volunteers have an important
role to play by offering a limited scope of supplementary support services among their local
community. However, if community health workers are to be properly integrated into health
systems, and are trained to provide essential services, then their commitment must be sustained
through a variety of measures including adequate wages and/or other appropriate and
commensurate incentives.
Early community health worker programmes assumed a pool of willing volunteers but, in time,
lack of payment proved to be a major cause of workforce attrition 64 66 97 . There is virtually no
evidence that volunteerism can be sustained for long periods 197 . Most of the evidence reflects low
activity rates and high drop-out leading to the ultimate collapse of community health worker
programmes where payment, or other appropriate and commensurate incentives, are not
adequate 197 198 . For example, in South Africa the lack of payment for community health workers
resulted in a high rate of attrition and threatened the effectiveness of the community-based
tuberculosis programmes. 199 . One study of community health worker programmes in Sri Lanka
concludes that large-scale volunteer programmes will be characterized by high attrition and low
activity rates and will only be sustainable under particular enabling conditions 198 .
The question of what represents adequate remuneration remains controversial and there is a
paucity of evidence to indicate what combinations of incentives, including financial and nonfinancial
incentives, are sufficient to motivate and retain community health workers. Some
evidence exists to show that the relationship between community health workers and the
community they serve is important and that feedback and rewards from the community have an
influence on work performance 200 . Nevertheless, the burden of evidence indicates that stipends,
travel allowances and other non-financial incentives are not enough to ensure the livelihood of
health workers and that the absence of adequate wages will threaten the effectiveness and longterm
sustainability of community health worker programmes 65 199 201 .
The existing evidence, particularly for resource-constrained countries, overwhelmingly suggests
that community health worker programmes are not necessarily less expensive but that they
remain a good investment 197 . However, meeting the need for sustainable financing for community
health worker positions is a challenge, especially for resource-constrained countries. See further
discussion in Recommendation 15.
Advantages:
• Adequate wages for community health workers help retain human resources for health,
especially in rural areas and among marginal communities.
• Wages for community health workers may contribute to broader human development and
poverty reduction strategies.
Uncertainties:
• Securing long-term sustainable financing for the health sector is a challenge.
Selected examples of experience/additional resources:
One of the largest and most successful community health worker programmes can be found in
Brazil, where the Brazilian Family Health Programme has been successful in institutionalizing and
mainstreaming community participation. Community health workers have been integrated into
health services and are paid wages 202 203 .
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In Ethiopia and Malawi community health workers have been trained and deployed to support a
nationwide increase in access to HIV and other health services. These cadres have been fully
integrated into the national system for service delivery as regular employees. They receive
payment from the government and these costs are included in the national health budgets of
both countries Annex a .