Key message box 1. Summary
Key findings
We reviewed the literature to identify what kinds of incentives and remuneration have been offered to community health workers (CHWs), how these incentives have influenced CHW motivation, and how programmatic and contextual factors have shaped the relationships between incentives and CHW motivation • There is an extremely wide variety of incentives offered in CHW programmes around the world, and these function at individual as well as health system and community levels • CHW motivations can be affected by tensions between altruistic and material imperatives, by the social dimensions of their relationships to members of the health system and community, and by cultural, economic, and political contexts • CHW motivations are likely to change over time, which means that CHW programmes must be able to assess and respond to changes in the effectiveness of various incentives • WHO guidelines on CHWs have recently emphasized the importance of decent working conditions and fair labour practices in CHW programmes
Key implications
Our review concludes that: • Sustaining CHW motivation requires focused and consistent investment in locally meaningful and sustainable forms of incentives, typically with some clear support from or involvement from the state. CHW motivation cannot be sustained if CHWs are seen as a temporary or a civil society solution to health system failures • Sustaining CHW motivation requires thinking about incentives as multidimensional and about CHW motivation as something that changes over time • All of this in turn requires a health system that is functional and effective enough to provide a clear role and proper support for CHWs