This post is a collaboration between members of the Community Health Impact Coalition, Women in Global Health, and UN Women. A full list of contributors can be read at the end of the post.

  • The problem: Dual-cadre community health worker (CHW) programmes, that combine salaried and volunteer CHWs, have been growing, but the status of volunteers in these programmes remains potentially precarious and prone to exploitation.
  • Why it matters: Without adequate safeguards, dual-cadre programmes risk entrenching gender and other inequalities.
  • The solution: Policymakers, funders and programme implementers should strive to better understand the difference between arrangements that are exploitative and ones that are not.

Community health workers (CHWs) are critical to the COVID-19 response, going house to house tracing contacts, making referrals for testing, promoting public health measures, providing maternal, child and chronic disease care, and delivering vaccines. Health care delivered by CHWs reduces morbidity and mortality while providing a return on investment of up to 10:1 in many countries across the globe.

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There is an emerging consensus that CHWs should be paid, but progress has been slow. Estimates suggest that across the African continent, more than four in five CHWs go unpaid, often as part of so-called “two-tiered” or “dual cadre systems” in which a salaried CHW works alongside a group of volunteer CHWs. We fear that these systems, while being heralded as innovations, are replicating potentially exploitative dynamics under a new name.

Dual cade systems emerge for several reasons: as response to health worker shortages (e.g. Ghana); to provide additional coverage and density of promotive health services without increasing the professionalised cadre (e.g. Ethiopia); or to continue to engage previous volunteers who may not meet new qualifications (e.g. illiterate women) when a more professionalised cadre is established (e.g. Zambia).

Unpaid work has hidden costs

In dual cadre systems, volunteer CHWs are typically responsible for delivering promotive services with supervision from a separate cadre of better supported, salaried CHWs. It is not atypical for these ‘hidden’ volunteers — typically women — to work long hours with no or minimal pay. Even in systems where CHWs do receive incentives, the work expected frequent exceeds the time workers have available, and this is can be exacerbated when a system relies on volunteers: an analysis in Rwanda found that carrying out the assigned health promotion services would require CHWs to spend more than twice as much time per year than the programme had budgeted.

The risk of harm is reason enough to oppose dual cadre programs until decision-makers better understand the difference between arrangements that are exploitative and ones that are not.

While many volunteers obtain meaning and pleasure from serving their community, the risk of exploitation is high. Unpaid volunteer work cannot be considered a free choice in contexts where health systems are poorly resourced, poverty is rampant and access to decent work opportunities is limited, particularly for women. For women, long hours spent on unpaid volunteer labour come on top of heavy unpaid domestic work responsibilities which together are likely to exacerbate women's time and income poverty. In dual cadre systems, where volunteers work alongside better-compensated peers, they often experience particular frustration and disillusionment with their work. In Ethiopia, where a dual cadre system has existed for more than 15 years, volunteers report high levels of psychosocial distress.

The time to think about safeguards is now

The reliance on volunteer CHWs is inconsistent with international commitments, including those on universal health coverage (UHC), decent work and gender equality in the Sustainable Development Goals. Robust primary health care systems are essential for achieving UHC; but they cannot be built on the back of women’s unpaid volunteer labour. Yet, when asked about features that would safeguard against this type of abuse in dual cadre programmes, most researchers, funders, and policymakers we informally surveyed had no answer.

Drawing on the available evidence as well as consultations with CHWs and the organisations that support them, we outline three initial steps for improving the quality of CHW programmes and safeguard against exploitation in dual cadre programmes:

Plan coverage. To avoid “empty scale up” or overburdening of CHWs, it is critical to systematically model realistic options for CHW allocation and time use. The Community Health Worker Coverage and Capacity Tool (C3 Tool), for example, can be used to analyse the amount of time CHWs would need to fulfill all of their responsibilities and achieve predetermined coverage targets, and compare that against expected hours worked. Volunteer cadres should not be used to fill gaps in otherwise inadequate coverage ratios of CHW to population.

Measure time. Another important step would be to measure actual time use. This is still rarely done across CHW programmes and can be particularly dangerous in set-ups where volunteers are relied upon to deliver care.

Support CHWs. Whether CHWs are full-time workers or simply volunteering a couple of hours a week, they should be treated like professionals and supported in line with the 2018 WHO Guideline for CHWs. This includes demonstrating they have key competencies prior to serving and providing them with essential supplies, such as personal protective equipment; consistent coaching and feedback, opportunities for career advancement; and financial compensation commensurate with their tasks and responsibilities. The CHW AIM tool is a useful framework for establishing a baseline of the current level of systems support to specific CHW cadres and tracking progress over time.

Beyond these critical first steps, more work is needed on how to safely and respectfully run dual cadre programs. In the meantime, the risk of harm is reason enough to oppose dual cadre programs until decision-makers better understand the difference between arrangements that are exploitative and ones that are not.

Authors

Community Health Impact Coalition: Madeleine Ballard, Carey Westgate, Jennifer Foth, Stephanie Rapp, Hope Ngwira, Kyle Muther, Jennifer Schechter, Daniel Palazuelos, Matthew French, Helen Olsen, Rebecca Alban, Meg McLaughlin, Ash Rogers

Women in Global Health: Ann Keeling, Roopa Dhatt

UN Women: Silke Staab

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