The Peceived impact on rewards and recognition on employee performance at The Mvula Trust
Optimising the benefits of community health workers’ unique position between communities and the health sector: A comparative analysis of factors shaping relationships in four countries
Community health workers (CHWs) have a unique position between communities and the health sector. The strength of CHWs’ relationships with both sides influences their motivation and performance. This qualitative comparative study aimed at understanding similarities and differences in how relationships between CHWs, communities and the health sector were shaped in different Sub-Saharan African settings. The study demonstrates a complex interplay of influences on trust and CHWs’ relationships with their communities and actors in the health sector. Mechanisms influencing relationships were feelings of (dis)connectedness, (un)familiarity and serving the same goals, and perceptions of received support, respect, competence, honesty, fairness and recognition. Sometimes, constrained relationships between CHWs and the health sector resulted in weaker relationships between CHWs and communities. The broader context (such as the socio-economic situation) and programme context (related to, for example, task-shifting, volunteering and supervision) in which these mechanisms took place were identified. Policy-makers and programme managers should take into account the broader context and could adjust CHW programmes so that they trigger mechanisms that generate trusting relationships between CHWs, communities and other actors in the health system. This can contribute to enabling CHWs to perform well and responding to the opportunities offered by their unique intermediary position.
Introduction
Community health workers (CHWs) form an important point of interconnection between communities and the rest of the health system. CHWs are defined as health workers carrying out functions related to healthcare delivery; trained in some way in the context of the intervention, and having no formal professional or paraprofessional certificate or degree in tertiary education (Lewin et al., 2010). There are many different types of CHWs. They may address single or multiple health issues, and have differences in their levels of knowledge, training, remuneration and practice settings (Bloom & Standing, 2001). CHWs are often believed to increase equitable access to health care in low- and middle-income countries with constrained human resources for health (Bhutta, Lassi, Pariyo, & Huicho, 2010; Glenton et al., 2013). They act as intermediaries between communities and the health sector, and are sometimes referred to as cultural brokers, as they understand the socio-cultural norms of the communities they work in and are thus often well accepted by these communities (Maes & Kalofonos, 2013). The unique intermediary position of CHWs is therefore central to health system performance in these settings.
Many studies have demonstrated the effectiveness of CHWs in delivering key health interventions (Lewin et al., 2010) and the performance of CHWs remains an area of global focus. At the individual level, performance is influenced by factors like resource availability, competence and motivation. Contextual factors, such as socio-cultural and gender norms and health policies, combined with intervention-related factors, such as training and supervision, can have a direct influence on motivation and performance (Kok et al., 2014; Kok, Kane, et al., 2015; Naimoli, Frymus, Wuliji, Franco, & Newsome, 2014). Motivation and performance are complex social processes linked to feelings of self-fulfilment, achievement and recognition that are for a large part generated through interactions between health workers, communities served and the rest of the health system (Franco, Bennett, & Kanfer, 2002). Health workers’ capacity and motivation to deliver quality care depends on their knowledge, skills as well as their values and goals, which are continuously developed and adapted in relation to people in their environment (Mlotshwa, Harris, Schneider, & Moshabela, 2015; Rowe, de Savigny, Lanata, & Victora, 2005). The recognition that health workers are social actors points to the importance of intervention designs that stimulate and support trusting relationships, defined as respectful, fair and cooperative interactions between individuals (Gilson, 2003; Okello & Gilson, 2015).
There has been a growing interest in trusting relationships and their positive influence on health worker motivation and performance (Calnan & Rowe, 2007; Gidman, Ward, & McGregor, 2012; Gilson, Palmer, & Schneider, 2005; McCabe & Sambrook, 2014). Many studies focus on workplace trust: trust of the health worker in colleagues, supervisors, managers and the employing organisation as a whole (Albrecht & Travaglione, 2003; Gilson et al., 2005; McCabe & Sambrook, 2014; Topp & Chipukuma, 2016). Drawing on Hall, Dugan, Zheng, and Mishra (2001), we define trust as ‘the optimistic acceptance of a vulnerable situation in which the trustor believes the trustee will care for the trustor’s interest’. Trust can be built by personal behaviours and organisational practices that provide space for engagement and open dialogue (Gilson, 2006). Factors that have been found to influence workplace trust in public sector organisations are organisational support and decision-making practices, communication, feedback mechanisms, competence, performance appraisal and reward systems and job security (Albrecht & Travaglione, 2003; Nyhan, 2000). Hall et al. (2001) present fidelity, competence, honesty, confidentiality and ‘global trust’ (component of trust that is irreducible or not subject to dissection) as dimensions of trust. A recent literature review found four aspects that build and break trust in health sector encounters: sensitive use of discretionary power, perceived empathy, quality of medical care and workplace collegiality (Østergaard, 2015). Okello and Gilson (2015), in a recent systematic review that included studies with CHWs, concluded that workplace relationships and trust influence intrinsic motivation of health workers and thereby health worker performance.
