Culture, status and context in community health worker pay: Pitfalls and opportunities for policy research. A commentary on Glenton et al. (2010)
Introduction
The sustainability and fairness of drawing on low-income women and to a lesser extent men for volunteer community health labor are hotly-contested and increasingly studied (Akintola, 2008, Maes, in press, Maes et al., 2010, Maes et al., 2010, Rödlach, 2009, Swidler and Watkins, 2009). In some nations, delivery of health care services, goods, and technologies relies heavily upon volunteer labor. At a societal level, large volunteer programs depend upon (i) expansive “pools” of people who are available (often because of underemployment) to serve as unpaid labor and (ii) the legal status of organizing and using unpaid labor. The promotion of volunteerism also depends on the perceived health needs of communities and the empowerment of communities to advocate for public and private (and mixed) services that might meet their needs. At an individual level, volunteering is tied to livelihood security, gender, social status, and shared understandings of service. Indeed high stakes and potential controversy are involved in questions of global health volunteerism in low-income settings. Research that examines volunteerism can thus have major impacts on the design of models for delivering health services and goods, and on the livelihoods of community health workers (CHW) and those they serve around the world.
In their Social Science & Medicine article “The female community health volunteer programme in Nepal: Decision makers’ perceptions of volunteerism, payment and other incentives” Glenton et al. (2010) make the apparently sound recommendation that, because volunteer CHW operate in various cultural and social contexts, a one-size-fits-all scheme for remunerating and sustaining “high-performance” CHW around the world is inappropriate. And yet the authors’ assertion that wages might be inappropriate in some contexts (particularly in the Nepal Female Community Health Volunteer [FCHV] Programme that they studied) is conceptually oversimplified and based on tenuous evidence. Glenton et al. make claims that have significant implications for development in a variety of contexts, and especially for women’s roles in healthcare in Nepal. We therefore aim in this commentary to (i) point out major shortcomings of the research reported by Glenton et al. and (ii) outline more rigorous research designs that are better positioned to make policy recommendations on the important issue of volunteer labor in global health.
Section snippets
Methodological pitfalls and opportunities
The Glenton et al. (2010) article reports on semi-structured interviews conducted with 19 purposively-selected government officials (“non-volunteer stakeholders”), 4 volunteers, and 2 activists affiliated with the FCHV program in Nepal. The article claims that, among officials and volunteers alike, regular wages are seen as financially unfeasible and also as a “potential threat to the Volunteers’ social respect, and thereby to their motivation” (Glenton et al., p.1920). The authors then suggest
The importance of context – gender, globalization, and health systems
Glenton et al. (2010) make the claim that cultural context justifies not paying women in Nepal for their healthcare labor. Thus the study falls into the trap of invoking “culture” to justify differential treatment of already disadvantaged groups (Hruschka & Hadley, 2008). Several studies have described how health professionals – some in positions similar to those of the stakeholders interviewed in the Glenton et al. study – inappropriately attribute high rates of disease in impoverished
Incentivization and innovation
Glenton et al. (2010) assert that the consequences of paying wages to the Nepali CHW in question would be predictable and negative. Based on the qualitative data they collected, the authors reason that receiving wages would cause the female workers to (i) lose respect in the eyes of their fellow community members, (ii) lose spiritual merit, and (iii) lose the intrinsic pro-social motivations that the authors theorize to exist among individual volunteers until wage-earning motivations move in to
Conclusion
Biased and decontextualized qualitative studies like that reported by Glenton et al. (2010) unfortunately miss the larger context and come up short on ethnographic insights. Thus they are not well positioned to speak in terms of an “overemphasis” on the payment of wages to CHWs.
In-depth ethnographic research coupled with well-designed surveys that include large samples of volunteers are necessary to clarify what is at stake for the multiple public, private, and state parties involved in
Acknowledgments
We would like to thank Jed Stevenson, James Broesch, Peter Brown, Christina Chan, Craig Hadley, Cari Maes, and Emily Mendenhall for their insights and comments.
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