Recruiting and Motivating Community Health Workers in ZambiaPDF version

Nava Ashraf
Oriana Bandiera
Scott Lee
Lusaka, Zambia
Research Initiative: 
Policy Issue: 

Community health workers (CHWs) are commonly regarded as a potential solution to the shortage of formal health workers throughout sub-Saharan Africa. Recruited from their communities, trained, and then deployed back to their communities, it is thought that CHWs are more likely to have the necessary relationships, local knowledge, and sense of community responsibility to deliver health services to underserved populations in rural areas, where retention of formal health workers is a perennial challenge.

While small-scale, informal CHW programs have existed for many years, recently many countries in sub-Saharan Africa have sought to formalize the CHW cadre and implement national CHW programs at scale. Little is known, however, about how to carry out this process effectively. In particular, there is a dearth of evidence on two fundamental questions: Who are the ‘right’ people within communities to become CHWs, and how can incentives be used to motivate CHWs to the highest performance levels? Recruiting the best workers and motivating them effectively are critical for ensuring low turnover and high performance of a national CHW workforce.

Context of the Evaluation: 

In 2010, the Government of Zambia announced a new national Community Health Worker Strategy that will aim to train 5,000 new CHWs by 2015—a massive investment in a country with only 6,000 nurses. These community health workers will undergo a year of formal training, and will then be posted back to their rural communities, where it is envisioned that they will do most of their work directly within the community (rather than operate from a health facility). The national strategy intends that CHWs will be the first line of health care for Zambians living in the most remote regions of the country.

Before launching the full strategy, the Government of Zambia is implementing a pilot study involving the recruitment, training, and deployment of 315 community health workers across 48 rural districts to examine the most successful methods of recruiting and compensating CHWs.

Details of the Intervention: 

To examine the selection of community health workers, two recruitment treatments will be used in the pilot study, which will vary in the way in which the job opportunity is framed. In a randomly selected half of the 48 participating districts, recruitment messages will emphasize the “community” benefits of becoming a CHW, such as serving and being a leader in one’s community. In the other half, recruitment efforts will emphasize the “career” benefits of becoming a CHW, such as opportunities for promotion or further professional development. The hypothesis of this experiment is that the recruitment treatments will select for CHWs who possess different characteristics and motivations, and those differences may predict long-term retention and performance.  

Furthermore, in collaboration with the Government of Zambia, researchers are refining a set of incentive schemes that will be tested in order to understand how they affect CHW motivation and performance. It is expected that the final schemes will focus on non-monetary incentives, such as providing CHWs with professional feedback, social recognition, and career advancement opportunities. By randomly allocating the same 48 districts to receive different incentives, the project will be able to test both the overall effects of different reward schemes as well as how the schemes interact with the manner in which CHWs were recruited.

The immediate goal of this study is to provide practical guidance to the Government of Zambia as it prepares to implement the full national CHW strategy. More broadly, this study will give insight to governments and policy makers on how various sources of social recognition (e.g., from government, peers, or the community) and methods of performance feedback (e.g., absolute or relative) can affect the recruitment and motivations of health workers, in ways that potentially predict job performance.

Results and Policy Lessons: 

Results forthcoming.

Related Papers Citations: 

Ashraf, Nava, Oriana Bandiera, and Scott Lee. "Do-Gooders and Go-Getters: Career Incentives, Selection, and Performance in Public Service Delivery." Working Paper, July 2014.