Health Systems for Outcomes Publication 53123 Economic Valuations of Community Health Workers' Recompense in Zambia Drafted by Hong Wang and Nora Groce July 2008 Economic Valuations Of Community Health Workers' Recompense in Zambia Drafted by Hong Wang, MD, PhD Nora Groce, PhD July 21, 2008 Executive summary In African countries, Community Health Workers (CHWs) are mostly volunteers who are selected by the communities after receiving short-term training on health care to enable them to implement basic health interventions in their villages. Where access to health facilities is generally poor, CHWs are sometimes the only source of health care available to the needy. Although many countries recognize CHWs as an integral part of service delivery systems and human resources for health, CHWs are almost always unpaid or receive only nominal reimbursement. As a result, the CHW workforce is very unstable, suffering a high dropout rate. Realizing the problem, several countries in Africa are exploring monetary incentives together with contracting arrangement in an effort to revitalize the CHW system. The objectives of this study are two-fold: (1) to estimate the economic value of CHW. In addition, current CHW's workload and responsibilities and (2) to obtain a preliminary understand of both CHWs' opinions of the role they serve in their communities (job satisfaction) and how these services are viewed by members of their communities For the quantitative portion of this study, two contingency valuations (CV) have been used, one for willingness to pay (WTP) by local community members for CHWs, and another for willingness to accept (WTA) by the community health workers (CHW) to work in their local community. Cluster sampling methods are used for the selection of CHWs. Cluster plus systematic sampling methods will be applied to select local community members. The descriptive statistic methods are used for the data 1 analysis and the Tobit model has been used to identify the factors that affect WTP and WTA of the CHW. An additional qualitative component of this study collected information through in- depth interviews and focus groups with CHWs and a series of in-depth interviews with community members who are recipients of CHW care, as well as with selected clinicians and members of staff at the Ministry of Health. This data was analyzed using theme content analysis. This study was conducted in two rural districts of Zambia, Chibombo and Chongwe. In each district, three communities served by CHWs were selected to represent varied community socio-economic strata (i) above average income earning community (ii) average income earning community and (iii) below average income earning. A total of 43 CHWs and 186 community members participated in this study. The results find that the mean age of surveyed community members is 41 years old. About 63% of them are female. The year of formal education is 7 years. The average household size is 7 household members. The average income per capita is about K620,000 per year. The health status as measured by having the problem in any of the five dimensions in EQ-5D instrument is 34%. The average travel time (by conventional measure) from home to the nearest first aid facility is about 77 minutes. Cost of CHW's service per household is about K4,119 per year. The total medical expense, including medical service and drugs expenditure, per household is about K87,454 per year, which is abut 2% of their total annual household income. About 91% of surveyed community members reported that CHW played very important role in maintaining/improving the health of the local residents. Over 84% community members believed that CHW should receive cash income in exchange for their service delivery. The WTP from one household for the CHW's service is about K2,000 per month. The total WTP for a CHW in a 250 household community would be about K6,000,000. This WTP is significantly associated with household income, family size, and health care expenditure on CHW's services. 2 The results also indicate that the mean age of surveyed CHW is 44 years old. About 80% of them are male. About 56% of them were born locally and the average length of living in this community is about 36 years. About 84% of them are married with family size of 9 household members. The average income per capita is about K850,000 per year. The average CHW has about 8 years work experience as a CHW after their pre-service training. The average length of training to become a CHW is about 5 weeks. About 30% of them never obtained additional training after the pre- service training. In average, they spent about 5.5 hours per day seeing patients, and the average number of patients is about 10 per day. They report spending about 23 days per month working as a CHW. In addition, they spent about 7.6 hours per month on providing public health service to the community. The WTA as a CHW working in local community is about K6,800,000. This WTA is significantly associated with their working experience. Following tentative conclusion can be draw from the results of this study. 1. There is general consensus among community members that CHW's services are very important in maintaining/improving the health status of local residents 2. Although the CHW is considered to be a volunteer, their service is not free. Each household spends about K4,119 on CHW service, which is about K1,029,750 per year in a community with 250 households. 3. The total WTP from community members for a CHW in a 250 household community is about K6,000,000; and the WTA as a CHW working in local community is about K6,800,000. Therefore, there is potential for raising the funds from the community to cover CHW services. 4. CHW spend about 5.5 hours per day working on health related work. There is potential to strengthening their functions to make them full time CHW if their salary is covered by the community. 5. The average pre-service training for CHW is only 5 weeks and at least 30% of them did not have any in-service training in the past three years. More training is needed in order to ensure the quality of their services. 6. While 70% of CHWs report having some training following their initial training period, in fact, most receive only a small amount of training following the initial 3 training. Moreover, there is no single set of subjects or training manuals that ensure that this subsequent training is systematic or coordinated. 7. While each household spends about K4,119 on CHW service, CHWs themselves do perceive themselves as benefiting economically significantly from this outlay of cash. While some receive payment for medications (when their drug kits have been refilled), they do not receive direct payment for care rendered. Indeed, serving as a CHW seems to be a net drain on the household budget of CHWs themselves - they devote a significant among of time and energy to providing care, time and energy that is taken away from their abilities to provide for their own families through other means. Moreover, all CHWs interviewed noted that they routinely paid for transportation for themselves (and sometimes for their poorer) patients, to and from the clinics when more advanced care was needed, and a number noted that they sometimes pay for drugs when patients are in dire need and unable to pay. 8. CHWs see their role more as a `professional calling' than as one of several ways to earn a living. They take pride in what they do, but feel that their efforts are often not fully appreciated. Additionally, they serve as `front line' responders to the health needs of their communities and as a bridge into the formal health care system. They care for populations that range from 2500 to 6000 individuals. They not only that they spend 5.5 hours per day (on average) working on health related work, but that these 5.5 hours can come at any point during the day or night, and that with no backup, all those who were interviewed have effectively `on call' 24 hours a day/ 7 days a week for years. All reported however to be keen to expand their role to more full time care providers should they be able to be reimbursed to offset the time devoted to this. 4 I. Background It is well recognized that community-based health interventions are essential for achieving better health outcomes. The Declaration of Alma Alta in 1978 and the subsequent Ottawa Charter formally acknowledged community-based health interventions as an integral part of primary health care. Since then, there has been rich evidence pointing to the importance and effectiveness of health services delivered at the community level and healthy behavior in household settings. For example, a number of studies have indicated that the health services that can be delivered outside of health facilities and at community settings, such as immunization, vitamin A, family planning, Oral Rehydration Therapy (ORT), are both more accessible (particularly to the poor) and highly cost-effective. Health literature also revealed that domestic hygiene practice and healthy behavior, such as condom use, bednet use, breastfeeding, hand-washing, and clean drinking water can reduce child mortality significantly and control communicable diseases effectively. It is estimated that, for developing countries to reach the health-related. Millennium Development Goals (MDGs), scaling up the coverage of community-based health interventions is simply a must. In African countries, community-based health interventions are normally delivered by a combination of health professionals and community Health Workers (CHWs). CHWs are mostly volunteers who are selected by the communities and received short-term training on health care to enable them to implement basic health interventions in their villages. CHWs play an important role in implementing community-based health interventions, either serving as direct providers of basic health services or assisting health professionals by organizing health campaigns and referring patients to health facilities. They are also responsible for disseminating health knowledge and materials for behavior changes. In Africa where the access to health facilities is generally poor, CHWs are sometimes the only source of health care available to the needy. Although many countries recognize CHWs as an integral part of service delivery systems and human resources for health, there are usually no formal policies and systematic arrangements on the recruitment, incentives, performance evaluation, accountability, and sustainability of CHWs. In particular, CHWs are almost always 5 unpaid or receive only nominal reimbursement. The common incentives given to them are mostly non-monetary, in the forms of training, drug kits, bicycles, a possibility of being recruited as a formal health professional with a stable salary, free or discounted health care, and/or materials for recognition (e.g. T-shirts). As a result, the CHW workforce is very unstable, suffering a high dropout rate. At worst, the number of active CHW is unknown in some countries. This situation has adversely affected the delivery of community-based interventions. Realizing the problem, several countries in Africa, such as Lesotho, Mozambique, Rwanda, are exploring monetary incentives together with contracting arrangement in an effort of revitalizing the CHW system. Yet, there has been strikingly little research on comprehensive assessments of the CHW system. While some early studies looked at what types of individuals would be best to choose for such positions and how to most successfully train such individuals in the initial phase of their careers, evidence on the incentives and sustainability of the CHW system are almost non-existent. Among the things that are urgently needed for policy-making and that the health community knows little about are: What is the appropriate price or value (in monetary terms) to motivate a potential CHW to deliver a package of health interventions; what is the willingness for a community to pay for CHWs' health services; how effective village health workers are over time in providing care and disseminating health information; how effective village health workers are in keeping their skills and knowledge base current and accurate; how many village health workers remain active as full time health workers once they return to their communities after their training, and if they remain active, what prompts them to do so; how they are viewed and how their services are assessed by fellow villagers and village leaders; what relationships they establish and maintain over time with formally trained heath care workers at local clinics and hospitals. Answering those questions is of great importance for developing policies and strategies to strengthen and sustain service delivery at the community level. The objective of this report primarily focuses on the issue of the economic valuation of CHW recompense, which is directly related to the sustainability of CHW in the remote areas. In addition, current CHW's workload and responsibility and the attitude they and members of their communities have to their roles, have been also investigated in this study. 6 II. Methods Two contingency valuations (CV) have been used in the quantitative study, one for willingness to pay (WTP) by local community members for CHWs, and another for willingness to accept (WTA) by the community health workers (CHW) to work in their local community. In addition to the CV questions, the background and validity- checking questions will be also included in the questionnaires. Cluster sampling method has been used for the selection of CHWs. Cluster plus systematic sampling methods have been applied to select local community members. The descriptive statistic methods are used of the data analysis. In addition Tobit model has been used to identify the factors that affect WTP and WTA of CHWs. In Zambia, this study was conducted in two rural districts of Zambia, Chibombo and Chongwe. In each district, three communities served by CHWs were also purposefully selected to represent varied community socio-economic strata (i) above average income earning community (ii) average income earning community and (iii) below average income earning. A total of 43 CHWs and 186 Community Members participated in this study. The qualitative results provide additional insight into the motivation that brought CHWs into the field and kept them at their posts. Afocus groups of 5 CHWs was held in Chongwe and 6 CHWs were brought together in a focus group in Chibombo. These focus groups were supplemented by 3 in-depth interviews with CHWs in each location and 24 in-depth interviews held among community members in Chongwe. While additional interviews would have added to the depth of the findings, theme content analysis at this stage shows clear consistent agreement in the data on the finding reported below. These qualitative findings were supplemented by interviews at the ministerial level, as well as a series of field interviews at the District hospital and clinic level by one of the authors of this study (Dr. Groce) during a field visit in May, 2008. 7 III. Results 1. Socio-economic status (SES) of surveyed community members Table 1 displayed that among 186 surveyed community members, the mean age of surveyed community members was 41 years old. Approximately 63% of the respondents were female. The years of formal education were about 7 years. The average household size was about 7 household members. The average income per capita was about K620,000 per year. Most of surveyed community members considered their economic and social statuses at the average or above average levels. The health status as measured by having the problem in any of the five dimensions in EQ-5D instrument was 34%. The average travel time (by conventional measure) from home to the nearest first aid facility was about 77 minutes. Cost of CHW's service per household was about K4,119 per year. In addition to the payment in cash, 45.4% of the residents thought that the CHW was currently receiving non- monetary benefits, which included bicycler or bus fare, better/free health care for himself/herself and family members, goodwill from the community, gifts from patients, and so forth. The total medical expense, including medical service and medication expenditure, per household is about K87,454 per year , which is abut 2% of their total annual household income. 2. Community members' assessment to CHW The results in Table 2 displayed that the most majority of surveyed community members (91%) considered that CHW played very important role in maintain/improve the health of the local residents. In terms of working load of the VHW, only about 34% of the respondents stated that the CHW was performing a full- time job, based on their current activities. Regarding the satisfaction in terms of transportation time, waiting time, costs, service quality, and service attitude, the community members were more satisfied with the CHW than other healthcare providers. 8 The top five responsibilities that the community members considered the CHWs were taking now were providing medical care for minor illness and emergency care, identification of high risk cases and referrals to health center or hospital, giving out basic medicines, promoting preventive measures at individual level, and coordination with govt/health institutes/village leaders for health service delivery. In the meanwhile, top five responsibilities that the community members considered the CHWs were not taking now, but should be, were overseeing complex treatment in patients' house, providing immunization to children, identifying disease outbreaks and providing assistance to the patients, providing social and emotional support for the sick patients in the community, and giving out birth control pills and condoms (Table 3). 3. Willingness to Pay to CHW The results in Table 4 displayed that the Willingness-to-pay (WTP) from one household for the CHW's service in their community is about K2,000 per month. The total WTP for a CHW in a 250 households community per year would be about K6,000,000. The results also showed that that over 91% of the respondents are willing to pay for keeping the CHW working at the village. Approximately 32% of the respondents are willing to pay K1­1,000 per month, with about 26% and 21% of the respondents being willing to pay K1,001-2,000 per month and K2,001-5,000 per month, respectively. In the meanwhile, about 12% of the respondents are willing to pay more than K5,000 per month for the services provided by the VHWs. In terms of the question of whose income that CHW's income should be equivalent to, most of community members' responses refer to "local government employee", "local school teacher", or "domestic worker". The analysis of the community members' WTP indicates that household income, family size, and health expenditure on CHW services significantly influence their willingness to pay for the CHW's service. Households with high income are willing to pay more contribution to keep the VHW working in the village. Household with high health expenditure on the CHW services are willing to pay more for services provided by the CHW. We expect other factors, such as health status and workload indicators, are also significantly related to WTP. However, none of them significantly 9 influence the WTP (Table 5). The results suggest that WTP for the CHW service is highly correlated with community members' ability to pay and their possibilities to use more services provided by the CHWs. 4. SES of Community Health Workers Table 6 displayed the SES of surveyed CHW. The results displayed that the mean age of surveyed CHW is 44 years old. About 79% of them are Male. About 56% of them were born locally and the average years of living in this community is about 36 years. About 84% of they married with family size of 9 household members. The average year of general education is about 9 years. The average income per capita is about K850,000 per year, which is higher than the average income per capita among surveyed community members. Most of them, however, also considered their economic status, as well as social status, is at the average level in their community (Table 6). 5. Community Health Workers' working status The mean year of receiving pre-service training is at the Year 2000. CHW has about 8 years working experiences as CHW after their pre-service training. The average training length is about 5 weeks. About 30% of them never obtained additional training after the pre-service training in the past three years. In average, they spent about 5.5 hours per day engaged in seeing patients; and the average number of patients they have encountered is about 10 per day. They spend about 23 days per month working as a CHW. In addition, they spent about 7.6 hours per month on providing public health service to the community. Nearly a half of surveyed CHWs do not satisfied their current role in term of CHW and their current living conditions (Table 7). The results in Table 8 displayed that CHW currently provides both preventive and curative services to local residents. The results of this study displayed that their top five responsibilities mainly focus on preventive services and patients care services. 10 Among those that CHW did not responsible for currently but should be responsible for, medical service delivery, and patient care service ranked the highest. 6. Willingness to accept as a CHW The results in Table 9 displayed that CHW are expected to get K570,000 payment per month, which is about K6,800,000 per year, which is slightly higher than the WTP from community members. This WTA is significantly associated with their working experience. We expected that WTA should be associated with other factors such as their current income level and pre-service and in-service training. However, these results are not statistically significant probably mainly due the small sample size.. In terms of the question of whose income that CHW's income should equivalent to, about 60% CHWs considered that CHWs' income level should be similar to "local government employee" or "local school teacher", which is also very similar to the response from community members. 7. Qualitative Data ­ In-depth Interviews and Focus Group Responses from CHWs and Community Members The qualitative data collected in both the in-depth interviews and the focus group sessions were intended to correspond to and supplement the qualitative survey instruments used here. The results show a more nuanced and complex system, one that warrants care consideration should changes be instituted. Among the key findings were the following: · CHWs are currently selected by the Neighborhood Health Committees and community leaders based on their perceived intelligence, sense of responsibility and commitment to the community. They are selected as adults (most are between the ages of 25 and 35 when chosen), and undertake this invitation to serve as a serious commitment. Most reported that they were willing to undertake the role because of the need for someone with health skills at the community level and they have continued in the role because of they feel they are continuously of service to their communities. The knowledge of health care also is seen as often 11 being of direct benefit to members of their immediate families as well. Thus CHWs see themselves, and are seen by members of their communities as a respected professional group and not simply as `volunteers'. · The average length of training for CHWs is 5 weeks, although several CHWs reported receiving a training that lasted for as little as 2 weeks. o CHWs have been trained over the years as a distinct group, separate from TBA and also separate from a growing number of ancillary `health resource distributors'. These other health care providers receive a much shorter term and narrower training to provide HIV/AIDS care in the home, distribute TB medications through DOTS programs, promote the use of bed nets or other very directed functions. While these individuals are often also referred to as `CHWs' by some NGOs, in fact the CHWs are a distinct group who function as `generalists' to the communities they serve, have far more extensive training. o A fairly standard set of training materials have been developed by the MOH for CHWs, but due to funding limitations in recent years, the MOH has not consistently trained CHWs for some years past. Thus there is not a new stream of CHWs joining those who have already received training. CHWs who now serve communities have been in place for 5 to 15 years or more. They are thus an older and aging group. Plans are underway through the MOH to revitalize the CHW workers, and a new training manual is currently under development, but the exact time frame to revise and recruit new CHWs is still being worked out o Supplementary training for CHWs is undertake from time to time at the District level, but a significant number of CHWs (30%) report having received no retraining in the past 3 years and at least one CHW interviewed reported not having received any retraining in the past 15 years. All expressed strong interest in receiving supplementary training in order to better serve their communities. There seems to be no consistent set of training manuals, subjects or ability to evaluate such additional trainings. o While additional training is scarce, CHWs report continually trying to learn new things that can be of help to their patients. For some 12 who have practiced for many years, their overall level of knowledge may exceed what is shown by their formal training, and this level of experience should be evaluated and built upon. · The role of the CHW at the community level extends beyond the direct provision of health care, and this should be acknowledged in any planning activities: o Under the current Zambian system, the planning of health care at the community level in rural areas is overseen by the Neighborhood Health Committees. While Neighborhood Health Committees in some areas are more active than in others, and while this system may be in currently in flux, the local CHW is a member of and reports to this Committee. (Although it is also the case, that many CHWs report they cannot spare the time or transportation expenses to regularly attend Committee meetings). Nonetheless, part of the role of the CHW is in helping to set the health agenda of the community in which he/she works; o CHWs are charged with informing the community about public health issues, in addition to delivering health care at the individual level. Many do this by using public events, community gatherings or other venues where small or large crowds gather to make announcements or give short trainings. As one CHW reported "I show up anytime we have a public gathering and I beg the chief to give me 10 minutes to talk. I do it all the time." · CHWs ­ Working Conditions o CHW serve as `front line' responders to the health needs of their communities and as a bridge into the formal health care system. It is hard to overstate the important role and the level of stress of the role that they have been asked undertake: Among those interviewed, most report they care for populations that range from 2500 to 6000 individuals. On average, the CHWs surveyed report that they spend 5.5 hours per day (on average) working on health related work and seeing on average 10 patients. But that these 5.5 13 hours can come at any point during the day or night: a CHW may spend 2 hours in the middle of the night walking several miles to the bedside of one patient, see someone else who comes to their home mid-morning, be called away to accompany another sick person to the hospital in the late afternoon; and then see 4 patients who drop by their homestead in the evening for care. Each patient who calls on them takes the CHW away from their farmstead or shop, where they are working to support or care for their own households. CHW work from home, which means that they are not only available at all times, but that when called to provide health care, they must drop what they are doing in their household or come in from their fields, to attend to the sick person. They do all of this with no backup. All those who were interviewed have effectively `on call' 24 hours a day/ 7 days a week for years. · Professional interactions o Fellow CHW - CHWs serve a village or group of villages and the surrounding countryside. While they at times see fellow CHWs at the clinic or hospital when they both are bringing patients in, or see other CHWs at the occasional training, most are professionally isolated. Because of the large catchment area that each is responsible for, it is extremely rare for one CHW to be able to help another with coverage should there be an emergency or should one CHW himself/herself become ill. All expressed strong interests in building networks with fellow CHWs as part of professional enhancement o Staff at clinics and hospitals ­ CHWs interviewed stated that they were treated with respect by staff and the local clinics and hospitals. Interviews among staff at the local clinics and hospital also showed that there was an appreciation for the hard work that the CHWs do. However, in a system with little resources and a clinical staff already stretched thin, there was no attempt to provide follow up on patients to CHWs ­ something that CHWs 14 themselves reported would improve their ability to serve the patients they send to the hospitals and then attend when they come back to the community. o MOH ­ At the MOH level, several individuals are taking the lead in revitalizing CHWs. Specifically, Dr. Miriam Lebetwa is currently drafting a National Training Plan for Pre and In-Service CHWs. Overall however, CHWs have received little attention in the current discussions of the pressing need for health professionals. Strikingly, the entire system is founded on the assumption that CHWs will continue to provide services at the local level, but few plans or diagrams extend out into the local communities. Rather, discussion is centered on links between health posts ­ (which are now being expanded into health clinics in most areas), health clinics themselves and then health care at the hospital level. CHWs are strikingly absent from all these discussions. This is not unique to Zambia, but a more widespread problem throughout Africa and globally. Even the recent WHO study of health care manpower barely mentions CHWs. · Reimbursement/ Lack of Reimbursement o Monetary ­ Currently, CHWs are considered to be volunteers and are not paid for their efforts. Additionally: Some reimbursement is provided through the sale of drugs from the drug kits distributed at the clinic level to CHWs. But many CHWs report that their drug kits are not regularly replenished ­ (some have had been replenished since at least 2006 and possibly earlier) ­ and when they are unable to obtain drugs through the clinics, some CHW report buying drugs or other essential health care items such as bandages, out of their own household budgets. Clinics report that they try to share what drugs and health care items they have with CHWs, but when there is not enough to go around, priority is given to the needs of patients within the hospital; Many CHWs report that not only are they NOT paid, but that they often have to expend money from their own household budgets for travel to and from the clinic or local 15 hospital. When a patient is very ill, many report either going with the patient to the clinic or hospital or traveling to the hospital themselves to get help for the patient. Currently, bus and taxi fare is not reimbursed; When trainings are held, funds for transportation and lunch is generally promised, although at times, CHWs report not being reimbursed as promised. Trainings are not held regularly in many places, but CHWs noted that the funds provided for travel and food are much appreciated when they are. No compensation is given for the time such trainings take away from the CHWs home or fields; In discussion of how CHWs work at the national and international levels and in the CHW literature, there is often some assumption that grateful patients and communities would help CHWs by donating food, time to help in the fields or other non-monetary forms of compensation that would offset the time and energy donated by the CHWs. In Zambia this does not seem to be the case. CHWs reported that they `rarely' or `never' received non-monetary payment for their services. And of those who did report such non-monetary reimbursement, the sums involved ­ (a bag of cornmeal here, a chicken there) ­ do not being to cover the amount of the time and energy these CHWs have donated to their communities. CHWs interviewed also mentioned non-monetary incentives and specifically noted the following: o There is pressing need of some non- monetary items that would greatly enhance their abilities to serve their communities. Among the items that consistently came up were: Bicycles ­ CHWs cover significant areas on foot. Most have never received bicycles, but all mentioned how much a bicycle would improve their ability to serve their 16 communities. (One person mentioned that he had received a bicycle in 1985, but it is now been `reduced to a frame.') Bicycle parts that would allow them to maintain their bicycles in good working order were also noted to be essential; Gumboots and raincoats were also requested ­ both for the rainy season and because poisonous snakes are a real risk for CHWs as they cross the fields, especially at night. In the case of these items the issues were two- fold: the actual need for the items in order to do the `volunteer' work that is expected of them and the fact that distribution of such items would also reflect a recognition by the MOH, clinic and their communities, of the value of the services they are providing. * Members of the communities interviewed reported appreciated the services they received from CHWs, but many also noted that the CHWs had volunteered for the positions, and so knew what they were getting into. A significant number also thought that the CHWs were making a good living by selling drugs and/or were being paid a salary by the MOH. A number also saw the CHWs as representatives of the government and held them accountable for government policies including in such non-medical as reporting poachers and others who evaded the law. Such incorrect assumptions places additional stress on an already stressed group of volunteers. · Non-Monetary stresses o In any discussion of monetary re-imbursement, it is important to underscore that the data suggests that the people who serve as CHWs are taking a significant amount of time and energy away 17 from their abilities to provide for their own families. While most report that their incomes are at least `average' for the communities in which they live, it is important to keep in mind that: CHWs are selected because they are considered to be unusually competent young adults with considerable potential. Thus, with the Zambian shift to an increasingly cash-based economy, the CHWs are also people who would be more likely to do well. If they begin to lag behind their neighbors ­ distributing `free' health care as a volunteer while many others are beginning to be paid for activities that were previously obtained through exchange - Zambia stands to loose many of its best and brightest CHWs; Little information was available about how many people trained as CHWs may already be dropping out of the system. No records are kept on this group, and this study concentrated on those who were still working at CHWs. Nonetheless, all CHWs were able to cite examples of people, trained as CHWS who no longer worked as CHWs or who worked now only part-time. o Some dropped out early in their careers, but a number seem to have stepped down after years of service because of the unrelenting demands of the job. o Of even more concern, MOH people, clinicians and CHWs all cite increasing attention given to `health workers'; `community outreach workers' and other types of health care deliverers who are being hired by vertical programs run by international NGOs. These vertical programs are now also beginning to draw CHWs away from their practices. The new non-CHW outreach workers have much less training and much less experience that 18 CHWs, but they are being paid for their time. In communities where there are few paying jobs and even people with `average' income struggle to meet the basics, CHWs ­ many with decades of experience ­ are beginning to watch as young people with little or no experience are being hired as part or full time health `experts' and given additional incentives such as on-going training, bicycles and gum boots. Growing numbers of CHWs are beginning to pay attention and think that their skills and abilities might be worth at least as much as these young, inexperienced community outreach workers. And a growing number of international NGOs coming into the area, are beginning to realize that their ability to effectively reach and serve communities with targeted vertical programs, such as AIDS and TB medication programs, would be done far more easily if jobs were offered to established, respected CHWs, who already have all the connections and experience needed to quickly get new programs up and running. The `poaching' of experienced CHWs by INGOs appears to be a growing threat, as the best of the CHWs are beginning to be sought out, either to take on part-time work for the INGOs in addition to their own CHW work or are being hired full-time to run programs. While the CHWs interviewed for this study were adamant in their wanting to stay to serve the community full time, this may prove increasingly problematic for many who must weight their dedication against the needs of their families in an increasingly cash-based 19 economy. Other CHWs have already left for these `greener fields'. · Finally, CHWs consider themselves a professional ­ albeit voluntary - group. Those interviewed were keenly aware not only of their own contributions to their communities, but also to the fact that they are rarely or never consulted by fellow clinicians and have little or no contact with the MOH outside of sitting as one member of the Neighborhood Health Committees. As one CHW who participated in the focus groups stated, "since I volunteered in 1985, today has been the first time to have a discussion of our plight." Any efforts to strengthen the CHW system must acknowledge and built on this sense of professional dedication. While monetary incentives are an important component of stabilizing and building this community health base, incentives such as additional training and skill development, professional certification and other marks of accomplishment and appreciation will be important to keep and expand this vital group of health care workers. IV. Conclusion and policy implications 1. There is general consensus among community members that CHW's services are very important in maintaining/improving their health status. Although CHW only received 5 week pre-service training, they are playing very important roles in providing both preventive and curative services to the individual residents as well as to the community. Most of the community members very satisfy with the CHW's works and they would like CHW to play more important roles on the aspects of patient cares and patient supports, in addition to their current roles on the prevention and treatment functions. These results implied that although CHWs works are very basic and routine, all of their works are highly related to the achievement of Millennium Development Goals (MDGs). CHW should be strengthened as the health system improvement strategies, especially in the resource scarce areas. 20 2. Although CHW is considered as a volunteer, their service is not free. Each household spend about K4,119 on CHW service, which is about K1,029,750 per year in a community with 250 households. On the one hand, this result displayed the need of CHW service from community; on the other hand, this result displayed the need for the regulation in terms of payment of CHW services. CHW health service is associated with the cost. Without cost recovery mechanism, CHW health service would not be sustainable in long-run. Better regulation would made the payment from patient to CHW more transparent and make CHW more accountable. 3. The amount of WTP from community members is significantly higher than what they are currently paid. The results of study displayed that the total WTP from community members for a CHW in a 250 households community is about K6,000,000. This figure is about 6 times as much as household currently paid. In addition, the amount of WTP is significantly related to the ability to pay and the need for CHW services. These results imply that there are potential funding resources for CHW services within the community. WTP does not equal to the actual payment. Appropriate financing policy and mechanism should be developed in order to make sure that this resource can be mobilized and used in more effective, efficient, and equitable ways. 4. CHW need to be paid for their efforts of delivering health services. The results displayed that WTA as a CHW working in local community is about K6,800,000. Their income should be similar to the income levels of "local government employee" or "local school teacher". Although this figure is higher than WTP from community members, the gap between WTA and WTP is not as big as we expected. Certainly, WTP and WTA here is only the partial cost of CHW health services. It only reflects the labor cost. Other costs of services still need to be financed through other financing mechanism. 5. CHW is still part-time job position. CHW spend about 5.5 hours per day working on health related work. If CHW get paid, their workload has to be in the consideration. In addition, the results also displayed that there is potential to increase the CHW responsibility to meet the increase need for CHW health services at community level. 21 6. The quality of CHW needs to be improved. On average, the pre-service training for CHW is only about 5 weeks. About 30% of them did not get any in-service training in the past three years. Since CHW is taking so much responsibility at the community level, the quality of their services is very critical. CHW training curriculum need to be reviewed and modified, if needed, in order to meet the increasing need to CHW and their current and newly developed responsibilities. Policies related continuous education also needs to be developed in order to update CHWs knowledge and skill to provide quality of health care services to the community. 7. CHWs consider themselves and are considered by members of their communities and local health professionals, to be professional ­ albeit voluntary ­ health care workers. Reimbursement in greatly needed, in addition to additional training and support. But this group must also be approached as an established and respected part of the health care system, and not simply as employees showing up for pay. From the MOH down, plans and programmes must include feedback from CHWs themselves. Otherwise, there is a looming crisis at hand at the community level. Lack of on-going training to bring new members into the pool of current CHW, the stress of the positions and the aging workforce of CHWs now in place, in addition to the encroaching competition of vertical programs, like AIDS and TB outreach projects, means that unless energy and attention is given to this work force soon, Zambia may loose a vital link in its health care system. 22 Table 1. Community member's Socio-Economic Status in Zambia N=186 Variables Mean S.D. Age 40.91 55.84 Gender Male 0.37 0.48 Female 0.63 0.48 Married status Unmarried 0.06 0.25 Married 0.83 0.38 Legally separated/Divorced/Widowed 0.11 0.31 Position Household head 0.45 0.50 Family size 7.01 3.36 Year of general education 7.08 2.68 Religious Catholic 0.24 0.43 Protestant 0.70 0.46 Others 0.06 0.25 Expenditure per capita per year (K) 414,927 1,151,538 Income per capita per year (K) 620,104 1,329,593 Perceived economic status Above average 0.45 0.50 Average 0.47 0.50 Below 0.08 0.27 Perceived Social status Above average 0.30 0.46 Average 0.55 0.50 Below 0.15 0.35 Distance to village health post(Mins) 77.08 68.11 23 Health Status EQ-5D 0.34 0.47 Health expenditure on CHW service per year 4,119 6,681 Overall health expenditure per year 87,454 262,215 24 Table 2. The community members' assessment to CHW in Zambia Assessment to CHW Mean S.D. Considering CHW as a full-time job 0.34 0.47 Importance to improve health 0.91 0.28 Satisfaction to CHW Transportation time 0.69 0.47 Waiting time 0.74 0.44 Costs 0.83 0.38 Service quality 0.85 0.36 Service attitude 0.85 0.36 Satisfaction to other health care provider Transportation time 0.27 0.44 Waiting time 0.39 0.49 Costs 0.82 0.39 Service quality 0.72 0.45 Service attitude 0.68 0.47 25 Table 3. Community members' assessment to the current functions of Community Health Workers in Zambia Responsible Should Service categories Total for now responsible Providing medical care for minor illness & emergency care 87.4% 6.0% 93.4% Identification of high risk cases and referrals to health center or hospital 73.5% 20.4% 93.9% Giving out basic medicines 72.2% 20.3% 92.5% Promoting preventive measures at individual level 71.1% 14.5% 85.6% Coordination with govt/health institutes/village leaders for health service delivery 68.7% 23.8% 92.5% Gathering health information (births, deaths, health surveys or disease surveillance etc.) 66.2% 26.4% 92.6% Providing social and emotional support for the sick patients in the community 57.5% 34.9% 92.4% Identifying disease outbreaks and providing assistance to the patients 43.2% 37.7% 80.9% Giving out birth control pills, condoms, etc. 39.6% 32.6% 72.2% Providing immunization to children 33.6% 38.5% 72.1% Overseeing complex treatment in patients' home (like aids medications, TB treatments) 20.4% 50.7% 71.1% 26 Table 4. Willingness-to-pay for VHW's services in Zambia Willingness-to-pay Mean S.D WTP WTP by one households per month (K) 2,000 WTP by 250 households per month (K) 500,000 WTP by 250 households per year (K) 6,000,000 Distribution of WTP per month (K) 0 0.09 0.28 1-1000 0.32 0.47 1001-2000 0.11 0.32 2001-5000 0.26 0.44 >5000 0.22 0.42 Equivalent payment groups Domestic worker 0.28 0.45 Trader in the marketplace 0.11 0.32 Local school teacher 0.26 0.44 Local government employee 0.28 0.45 NGO staff at local level 0.07 0.26 27 Table 5: Factors affect willingness-to-pay in Zambia Variables Coef. S. E. P Age 36-55 -200.63 2757.03 >55 2517.39 3841.84 Gender Female -697.92 2744.62 Education Year of general education -335.56 483.18 Household size Household size 623.08 371.71 * Household income Ln(income) 1040.81 586.23 * Distance from village health post Travel time -10.24 17.35 EQ5D EQ-5D -3147.96 2602.98 Healthcare expenditure Ln(hlthexp) 811.26 378.44 ** VHW's Working load Full-time job 29.21 2531.11 Dependent variable: WTP * significant at 10%; ** significant at 5%; *** significant at 1% 28 Table 6. Community Health Worker's Socio-Economic Status in Zambia Variables Mean S.D. Age 43.81 7.96 Gender Male 0.79 0.41 Female 0.21 0.41 Birth place In this community 0.56 0.50 Outside 0.44 0.50 Length of living in this community 35.60 12.80 Married status Married 0.84 0.37 Others 0.16 0.37 Family size 8.90 2.30 Year of general education 8.90 2.30 Religious Catholic 0.28 0.45 Protestant 0.58 0.50 Others 0.14 0.35 Expenditure per capita per year (K) 607,795 825,513 Income per capita per year (K) 847,180 1,332,239 Perceived economic status Above average 0.07 0.26 Average 0.49 0.51 Below 0.42 0.50 Perceived Social status Above average 0.26 0.44 Average 0.49 0.51 Below 0.21 0.41 29 Table 7. The training, workload, and satisfaction of the community health workers Variables Mean S.D. Year of receiving pre-service training 2000 6.00 Years of working as CHW 7.95 6.17 Length of pre-service training (weeks) 5.50 2.60 In-service training in past three years No 0.30 0.46 1-2 times 0.44 0.50 3- times 0.23 0.43 Hours per day seeing patients 4.80 3.60 Number of patients per day 9.74 7.31 Working day per month 23.48 10.36 Hours per month on public health service delivery 7.62 19.25 Receiving non-monetary incentive Yes 0.33 0.47 No 0.65 0.48 Satisfaction about their current roles Satisfied 0.28 0.45 Neutral 0.23 0.43 dissatisfied 0.47 0.50 Satisfaction about current living condition Satisfied 0.14 0.35 Neutral 0.35 0.48 dissatisfied 0.5 0.5 30 Table 8. CHWs' assessment to their current functions in Zambia Responsible for Should Service categories Total now responsible Promoting preventive measures at community level 97.6 0.0 97.6 Coordination with govt/health institutes/village leaders for health service delivery 95.1 0.0 95.1 Promoting preventive measures at individual level 90.0 5.0 95.0 Identification of high risk cases and referrals to health center or hospital 87.5 5.0 92.5 Providing social and emotional support for the sick patients in the community 82.5 5.0 87.5 Accompanying patients to hospital or health centers 80.0 10.0 90.0 Gathering health information (births, deaths, health surveys or disease surveillance etc.) 78.1 9.8 87.8 Identifying disease outbreaks and providing assistance to the patients 78.1 7.3 85.4 Giving out birth control pills, condoms, etc. 71.4 7.1 78.6 Providing medical care for minor illness & emergency care 62.5 12.5 75.0 Providing immunization to children 56.4 7.7 64.1 Giving out basic medicines 51.2 19.5 70.7 Overseeing complex treatment in patients' home (like aids medications, TB treatments) 45.0 17.5 62.5 31 Table 9. Willingness To Accept(WTA) of CHW Groups Mean S.D. WTA How much should WHW be paid per month (K) 569,756 589,811 How much should WHW be paid per year (K) 6,837,073 7,077,737 Equivalent payment groups Local government employee 0.37 0.49 Local school teacher 0.21 0.41 Domestic worker 0.16 0.37 NGO staff at local level 0.16 0.37 Others 0.09 0.29 32 Although many countries recognize CHWs as an integral part of service delivery systems and human resources for health, CHWs are almost always unpaid or receive only nominal reimbursement. The objectives of this study, conducted in in two rural districts of Zambia, are two-fold: (1) to estimate the economic value of Community Health Workers (CHW's) and (2) to obtain a preliminary understand of both CHWs' opinions of the role they serve in their communities (job satisfaction) and how these services are viewed by members of their communities. 2009 © All Rights Reserved. Health Systems for Outcomes Publication THE WORLD BANK