Table 4.

Models not or partially meeting the WHO guideline

Remuneration model	Summary	Advantages	Disadvantages
Volunteer-based (Ghana)	CHVs are unpaid.	CHWs: Opportunity to gain experience.	CHWs: Few legal protections and/or benefits. Possibility of exploitation.
		Health system: No up-front expenditure.	Health system: Potential lack of accountability and control.
Cooperatives with performance based incentives (Rwanda)	CHWs are legally treated as volunteers and thus not entitled to salary.	CHW: Cooperative model provides opportunities to generate income from alternative sources.	CHWs: Few legal protections and/or employment benefits. Funds may be insufficient in comparison to CHW needs and efforts; one analysis found more than half reported that lack of financial support was a main obstacle for being effective in their jobs. Possible mismanagement of cooperative operations due to lack of support. Asks CHWs to split their attention between the cooperative enterprise and their job delivering health care.
	Compensation is via performance-based mechanisms plus income-generating cooperative model. Payment is dependent upon the CHWs meeting the targets set for each assignment. This payment is never made directly to individual CHWs but rather to their cooperatives.	Health system: No up-front expenditure, and allows for flexibility in terms of budgeting.	Health system: While Rwanda’s cooperative model is said to promote financial independence of CHWs and build entrepreneurial skills of CHWs, evidence of this is lacking. Only 1/3 of cooperatives are profitable.
Hybrid: Public sector & private sub-contracting (South Africa)	CHWs employed in the public sector or subcontracted through NGOs.		CHWs & health ystem: The absence of a single model leads to inequalities between CHWs and inconsistent integration of CHWs into the broader health system.
		CHWs: Public sector CHWs are more integrated in the provinces’ systematic responses and have greater work security.	CHWs: Existing protections apply only to government CHWs.
	CHWs in the public sector are more likely to be regulated under and benefit from minimum wage legislation and union-negotiated compensation agreements.	Health system: Flexibility for non-state actors and competitive landscape. The sub-contracting model relieves provincial health departments from having to manage an additional workforce.	Health system: Weak oversight and accountability mechanisms for gov’t sub-contractors managing CHWs: it is far more difficult to regulate work expectations, provision of essential equipment, compensation and remuneration where there is no cohesive structure of employment.

CHW – community health worker, CHV – community health volunteer