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Used and abused - community volunteers need a policy

28 April 2008, 13:00

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Multiple health programmes – as many as 68 in Nigeria alone – are using unpaid or low-paid community volunteers, and other sectors such as environment, water and agriculture are doing the same. A new study of reimbursement of health volunteers is revealing the need for an internationally agreed strategy

Community volunteers – unpaid or very poorly paid local workers from the villages and slums of developing countries – are proving increasingly valuable to many health, water and agricultural programmes. They know their own people, and they know how to help them.

But as this gets more widely known, programmes using them are beginning to overlap, some in the same villages and some even with the same volunteers – while there is no coherent policy for how “use” or to reward them.

In any industry, this would be called exploitation – but because it is aid, the issue is being conveniently ignored. It’s not only unfair, it’s a waste of a resource, and a recipe for disaster as demands and expectations of these people increase.

But community volunteers can do great things. In a recent issue, we reported on a study supported by the Programme for Research and Training on Tropical Diseases (TDR) and the African Programme for Onchocerciasis Control (APOC).

READ ON: African Programme for Onchocerciasis Control – community-directed treatment with ivermectin

This indicated that allowing communities to make their own choice of unpaid volunteers for the distribution of ivermectin tablets for onchocerciasis could also double provision of malaria treatments, bed nets and vitamin A, and improve TB diagnosis.

Now another APOC report on payment of volunteers (APOC relies on community choice of volunteers, and their goodwill) is showing that the use of community volunteers is rife among health programmes, and in programmes dealing with water, agriculture and the environment, and that some pay and some don’t, and in a wide variety of ways and levels.

As a result, there is emerging across the whole world of development a great potential resource for evidence of what makes for success among community volunteers – if only it were scientifically studied and compared. But also looming is the potential for the deep confusion, disillusionment and even abuse of volunteers.

SEE ARTICLE: Drug distribution – trust the people

RealHealthNews says it’s time for cross-programme, multi-agency, coherent research on what works best – both for programmes and for the volunteers themselves – and the creation of an evidence-based, joint policy on how these volunteers should be selected, employed – and, if they wish – rewarded for their work.

In this way a tremendous potential resource for development, one that could even define development itself – the capacity and energy of the very people in need – could be created across the whole field of development.

In detail, in a multi-country study for APOC, Michelle Remme, Elizabeth Elhassan, Uwem Ekpo, Zakariaou Njoumemi, Nwaorgu Obioma, Asa Turinde Kabali, Kora Tushune and others report that the use of community volunteers for service delivery is common in the health, water, agricultural and environmental sectors.

“It’s time for cross-programme, multi-agency, coherent research on what works best – both for programmes and for community volunteers themselves”


“All but one of the sixteen ministries visited at the national level engage community volunteers in their activities, with as many as 68 health programmes using volunteers at the federal level in Nigeria” they say. “Cameroon reports 12 health programmes using community volunteers, Uganda 49 and Ethiopia 58.”

“The study focused on the issue of “external monetary incentives” [EMI] provided to community volunteers. The main objective of the study was to document policies on these incentives by different health programmes, the determinants of these policies and to what extent they overlap at the implementation level. Four countries and ten sites were included in the study: Nigeria (six sites), Cameroon (two sites), Uganda (one site) and Ethiopia (one site). A qualitative approach was adopted, as data was collected with checklists and document reviews” report the authors.

“There is limited guidance from government regarding EMI, with a few notable exceptions. Six out of fifteen ministries studied reported having a general policy on EMI. The ministries of Agriculture and Water seem to have the most grip on matters, whereas only one Ministry of Health (Cameroon) in the study and one Ministry of Environment (Nigeria) has a general policy on EMI.

“Where such a policy exists, it tends to prescribe the provision of EMI” (ie to demand it), the authors say. “The Ethiopian Ministry of Water is the only ministry in the study to have a general policy to not give EMI. This lack of guidance goes a long way in explaining the lack of harmonisation on the issue. Moreover, where a general policy exists it tends to be rather generic, without specific parameters for standardisation.”

“Most health programmes have a policy/practice of giving external monetary incentives,” the report says. “Only the national data of Nigeria and Uganda contradict this, with less than half of programmes that use community volunteers, having a policy/practice to give EMI. At sub-national level, the reality is that programmes with a policy/practice to give EMI are by far the majority (approximately four out of five).

“The two major reasons reported for giving EMI are to motivate volunteers and to facilitate service delivery. The main reason not to give EMI is to ensure sustainability.

“Cash incentives are the most common types of external monetary incentives (excluding low cost in-kind incentives like T-shirts, caps, refreshments, etc). Transport allowances, stipends and per diems are typical forms of EMI and they often represent a sizeable income, especially when compared to GDP per capita.

“The average monetary value of EMI varies per site (from US$ 20 to US$ 310 per volunteer per year) and per health issue (from US$ 10 to US$ 290 per volunteer per year). TB/Leprosy, Reproductive health, STI/HIV/AIDS, Malaria, Nutrition and Immunisation are the health issues providing the highest EMI. These also happen to be the issues receiving the largest donor funds.

“Donors play a significant role in setting these EMI. Their role is mostly indirect, through the provision of funds. Yet some donors appear to be influencing policies more directly by actually convincing programme managers to have a certain policy or by making it a funding condition.

“Current geographical overlap is high, with an average of 10 programmes overlapping per district. And this number is only likely to increase. The financial cost of these EMI to the health systems is considerable” the authors find.

“The occurrence of using the same community volunteers between programmes is highly variable. Where it is done, it could have the positive effect of alleviating some issues, especially if programmes that share volunteers also have a concomitant joint policy on EMI. However, this is not yet the case and where sharing is common, providing programme-specific EMI remains equally common.

“All in all, coordination and mostly harmonisation are very limited. Where reported, harmonisation remains incomplete, as is the case in Cameroon, where programmes continue to provide their own incentives funded out of their own baskets.

“The study suggests that there is a need to formulate a general policy at the national level to guide the implementation of the widespread practice of giving EMI to community volunteers” the authors conclude.

SEE LIST: Community of authors

“The current fragmentation of incentive packages is neither cost-effective nor a fine example of coordination in the health sector” they say.

This research needs to be carried through into a second phase, the authors say, “to determine whether the policies identified here are reflected in practice, among the communities and community health workers themselves.”

This second phase is currently part of TDR’s business plan for 2008-2013. Concrete activities will be decided during the first meeting of the TDR Scientific Advisory Committee in May 2008, Michelle Remme told RealHealthNews.

>by Robert Walgate

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