Role of community health workers monetary incentives on retention and health service delivery in Kibwezi district, Makueni county, Kenya

Abstract

The global policy of providing primary level care was initiated with the declaration of Alma-Ata in 1978.Kenya is a signatory to the AlmaAtta declaration. Implementation of the Community Health Services is a top priority for the Ministry of Public Health and Sanitation in Kenya. The second National Health Sector Strategic Plan (NHSSP II) defined a new approach to the delivery of Health Care Services to Kenyans, the Kenya Essential Package of Health (KEPH).CHWs are the key agents in the implementation of the community strategy. In Kibwezi District CHWs trained by MOPH&S do not receive monetary incentives while their counter parts trained by other partners (AMREF, USAID-APHIA II and USAID APHIA plus) receive monetary incentives. The study was done to find out the effect of monetary incentives on retention and performance of Community Health Workers in Kibwezi District in Kenya. A Cross-Sectional Comparative study design was used for the study. Qualitative data was collected through Key Informant Interviews and Focus Group Discussions were also conducted, one comprising of Community Health Committee members. Quantitative data was collected by the use of a structured questionnaire. Multi stage, purposive and simple random sampling were used to select 4 Community Units receiving incentives and 4 Community Units not receiving monetary incentives for comparison purposes. A total of 282 CHWs were interviewed 140 from Community Units receiving monetary incentives and 142 from CUs not receiving monetary incentives in Kibwezi District. Chi-square was used to establish the relationship between the research variables. Association between the variables was analyzed using chi-square tests and cross tabulations. Data was presented in form of figures, tables and narration. Age, [OR 3.6327 P= 0.022], marital status [OR 3.306 P= 0.018], education level.[OR 2.901786 P= 0.002], and occupation [OR 2.901786 P= 0.002]were significantly associated with performance of CHWs. Subsequent training[OR =2.7469, P value= 0.008], supervision [OR =5.95522, P= 0.0001], training partner [OR 3.97, P= 0.023]were significantly associated with performance. CHWS receiving monetary incentives were better performers. There was a significant difference in the number of women referred for antenatal care (P =0.022), number of women with newborns who had been counseled on exclusive breastfeeding (P =0.043) and the participation of CHWs in community dialogue days. (P=0.005) between the two groups. CUs receiving monetary incentives had better key health indicators in CUs receiving monetary incentives. There was a significant difference in the proportion of children below 5 years who were fully immunised (P= <0.0001), proportion of women who had attended 4 ANC visits (P=0.028) and the proportion of pregnant women delivering with a SBA. (P=0.003).CUs not receiving monetary incentives had higher attrition rates of CHWs (13%) than CUs receiving monetary incentives(4%).(P=0.013).There is a need for government and partners to explore sustainable perfomance based financial incentives which will ensure all the CHWs receive monetary incentives. Findings from this study will be used by the policy makers as a guide to decision making on improvement of performance and retention of CHWs and which will in turn improve health indicators of the communities at large.