8
Sot. Sci. Med. Vol. 30. No. IO, pp. 1041-1048. 1990 Printed m Great Britain. All rights reserved 0277-9536190 $3.00 + 0.00 CopyrIght [c 1990 Pergamon Press plc THE RELATIVE INFLUENCE OF THE COMMUNITY AND THE HEALTH SYSTEM ON WORK PERFORMANCE: A CASE STUDY OF COMMUNITY HEALTH WORKERS IN COLOMBIA SHEILA A. ROBINSON’.’ and DONALD E. LARSEN’ ‘Department of Community Health Sciences and ‘Division of International Development, The University of Calgary, 3330 Hospital Drive N.W., Calgary, Alberta. Canada T2N 4Nl Abstract-A central component of the primary health care approach in developing countries has been the development and utilization of community-based health workers (CHWs) within the national health system. While the use of these front line workers has the potential to positively influence health behavior and health status in rural communities, there continues to be challenges to efTecti\;e implementation of CHW programs. Reports of high turnover rates, absenteeism, poor quality of work, and low morale among CHWs have often been associated with weak organizational and managerial capacity of government health systems. However, no systematic research has examined the contribution of work-re- lated factors to CHW job performance. The research reported in this paper examines the relative influence of reward and feedback factors associated with the community compared to those associated with the health system on the performance of CHWs. The data are drawn from a broader study of health promoters (CHWs) conducted in two departments (provinces) in Colombia in 1986. The research was based on a theoretical model of worker performance that focuses on job related sources of rewards and feedback. A survey research design was employed to obtain information from a random sample of rural health promoters (N = 179) and their auxiliary nurse supervisors about CHW performance and contributing factors. The findings indicate that feedback and rewards from the community have a greater influence on work performance (defined as degree of perceived goal attainment on job tasks) than do those stemming from the health system. Work performance was shown to be more strongly associated with feedback factors such as the perceived value community members place on HP activities and direct observations of health improvement, than with the supervisory feedback. Work performance was also more strongly associated with the perceived reward of having influence in the community than with rewards associated with the health system. working with other HPs, written commendation and salary. These results suggest that the CHW may have stronger links to, and dependency on, the community for rewards, feedback and motivation to perform than has generally been acknowledged. The authors suggest a health system participation model that would focus management support on the worker+ommunity interface rather than the worker-health service interface. It is argued that if the national health system were to consciously promote and strengthen the relationship between the CHW and her community. this would positively affect performance of CHWs. Kq,, ~~ords--community health worker, work performance, management, primary health care INTRODUCTION Community health workers (CHWs) are a central component of the primary health care (PHC) ap- proach to improving health service utilization and health status in under-serviced rural areas of develop- ing countries [l]. Within a typical PHC framework, CHWs form the front line, or the base of a human resource pyramid that consists of a multi-tiered refer- ral network for rural health services. These indige- nous auxiliary health workers are selected from their villages. They typically receive a short training lasting from a few weeks to a few months, and subsequently provide basic preventive. promotive, and curative health services as volunteers or as personnel paid by the government health system or the community. The use of community-based workers as part of the government health system represents a major innova- tion for man) developing countries. Experience with these workers so far has shown that CHW schemes have functioned with varying degrees of success. Evaluations have indicated that this type of worker can have a positive effect on health service coverage and utilization, health behavior and, by inference, on the health status of the population [2-6]. However, skepticism has been expressed about whether these workers can have any significant impact on a com- munity’s health status, given their short training and l&k of regular supervision [7]. In addition, there are many reports in the literature describing high turnover rates among workers, frequent absenteeism, poor quality of work, and health worker dissatisfac- tion [8-l 11.In sum, as a recent comprehensive review of large scale CHW programs concluded, the community-based worker’s potential has not yet been realized [3]. Countries that are attempting to develop CHW schemes within primary health care are becoming increasingly aware of both the potential benefits and problems associated with these schemes. They are placing priority on solving problems related to the CHW’s role in accordance with their own needs, resources and constraints. As part of this effort there is growing interest in identifying personal and social 1041

The relative influence of the community and the health system on work performance: A case study of community health workers in Colombia

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Sot. Sci. Med. Vol. 30. No. IO, pp. 1041-1048. 1990 Printed m Great Britain. All rights reserved

0277-9536190 $3.00 + 0.00 CopyrIght [c 1990 Pergamon Press plc

THE RELATIVE INFLUENCE OF THE COMMUNITY AND THE HEALTH SYSTEM ON WORK PERFORMANCE:

A CASE STUDY OF COMMUNITY HEALTH WORKERS IN COLOMBIA

SHEILA A. ROBINSON’.’ and DONALD E. LARSEN’

‘Department of Community Health Sciences and ‘Division of International Development, The University of Calgary, 3330 Hospital Drive N.W., Calgary, Alberta. Canada T2N 4Nl

Abstract-A central component of the primary health care approach in developing countries has been the development and utilization of community-based health workers (CHWs) within the national health system. While the use of these front line workers has the potential to positively influence health behavior and health status in rural communities, there continues to be challenges to efTecti\;e implementation of CHW programs. Reports of high turnover rates, absenteeism, poor quality of work, and low morale among CHWs have often been associated with weak organizational and managerial capacity of government health systems. However, no systematic research has examined the contribution of work-re- lated factors to CHW job performance. The research reported in this paper examines the relative influence of reward and feedback factors associated with the community compared to those associated with the health system on the performance of CHWs.

The data are drawn from a broader study of health promoters (CHWs) conducted in two departments (provinces) in Colombia in 1986. The research was based on a theoretical model of worker performance that focuses on job related sources of rewards and feedback. A survey research design was employed to obtain information from a random sample of rural health promoters (N = 179) and their auxiliary nurse supervisors about CHW performance and contributing factors.

The findings indicate that feedback and rewards from the community have a greater influence on work performance (defined as degree of perceived goal attainment on job tasks) than do those stemming from the health system. Work performance was shown to be more strongly associated with feedback factors such as the perceived value community members place on HP activities and direct observations of health improvement, than with the supervisory feedback. Work performance was also more strongly associated with the perceived reward of having influence in the community than with rewards associated with the health system. working with other HPs, written commendation and salary.

These results suggest that the CHW may have stronger links to, and dependency on, the community for rewards, feedback and motivation to perform than has generally been acknowledged. The authors suggest a health system participation model that would focus management support on the worker+ommunity interface rather than the worker-health service interface. It is argued that if the national health system were to consciously promote and strengthen the relationship between the CHW and her community. this would positively affect performance of CHWs.

Kq,, ~~ords--community health worker, work performance, management, primary health care

INTRODUCTION

Community health workers (CHWs) are a central component of the primary health care (PHC) ap- proach to improving health service utilization and health status in under-serviced rural areas of develop- ing countries [l]. Within a typical PHC framework, CHWs form the front line, or the base of a human resource pyramid that consists of a multi-tiered refer- ral network for rural health services. These indige- nous auxiliary health workers are selected from their villages. They typically receive a short training lasting from a few weeks to a few months, and subsequently provide basic preventive. promotive, and curative health services as volunteers or as personnel paid by the government health system or the community.

The use of community-based workers as part of the government health system represents a major innova- tion for man) developing countries. Experience with these workers so far has shown that CHW schemes have functioned with varying degrees of success. Evaluations have indicated that this type of worker

can have a positive effect on health service coverage and utilization, health behavior and, by inference, on the health status of the population [2-6]. However, skepticism has been expressed about whether these workers can have any significant impact on a com- munity’s health status, given their short training and l&k of regular supervision [7]. In addition, there are many reports in the literature describing high turnover rates among workers, frequent absenteeism, poor quality of work, and health worker dissatisfac- tion [8-l 11. In sum, as a recent comprehensive review of large scale CHW programs concluded, the community-based worker’s potential has not yet been realized [3].

Countries that are attempting to develop CHW schemes within primary health care are becoming increasingly aware of both the potential benefits and problems associated with these schemes. They are placing priority on solving problems related to the CHW’s role in accordance with their own needs, resources and constraints. As part of this effort there is growing interest in identifying personal and social

1041

1042 SHEILA A. ROBINSON and DONALD E. LARSEN

factors that influence the motivation and perfor- mance of CHWs.

Primary health care literature emphasizes that a high level of job performance among CHW can best be achieved by having a management system which includes regular contact between the CHW and a local supervisor, a method of evaluating CHW per- formance, and a program of continuing education. These recommendations are based in part on field reports which cite poor communication and weak supervision, as well as a lack of supplies, as factors which adversely affect CHW job performance [12-1.51. In general, the literature suggests that the major cause of sub-standard performance and low morale among community-based workers is inade- quate logistic and management support provided to the worker by the health system. This conclusion focuses attention entirely on the health system as the primary source of influence on CHWs’ motivation and performance and thereby ignores other poten- tially important factors. According to theory and research on organizational behavior [ 161, motivation and work performance are affected by a complex set of factors, including individual capabilities and skills, the need for growth, rewards and feedback associated with the work, and the work environment. In the case of the CHW the primary work environment is the community and not a facility where the worker is in daily contact with the health system. Indeed, CHWs spend almost all their time in the community relating to clients in their own homes. It is reasonable to propose that the community, that is, the people to whom CHWs provide services, may have a significant impact on CHWs’ job performance.

To date, there has been no research which has systematically attempted to assess the impact of either the health system or the community on CHW performance. The purpose of this paper is to present data drawn from a survey which, among other goals, addressed the question of the relative influence of the community and the health system on CHW work performance.

Answers to this and related questions about CHW motivation and performance are of considerable

practical importance in the current climate of limited financial resources for health services in developing countries. In the 1980s. internal health budgets have generally not increased and often have been reduced. At the same time external aid to the health sector of developing countries has also declined. Data about CHW motivation and performance could be used by health planners to make more informed decisions about the most effective allocation of scarce manage- ment resources in order to maximize CHW effective- ness within primary health care. More broadly, these data can also stimulate thought about new or alterna- tive approaches to management of CHWs. as illus- trated by the proposals discussed at the conclusion of this paper.

CONCEPTUAL FRAMEWORK

The data reported in this paper are drawn from a broader study of rural CHWs conducted in Colombia in 1986 [17]. The broader study had two goals relative to work performance of CHWs: to identify the contributions of perceived reward and feedback to CHW job performance, and to compare the work performance of two groups of CHWs who had been trained under different systems.

The conceptual framework used for this study was adapted from the ‘General Model of Work Behavior’ [ 181, and is based on the expectancy-valence theory of work performance [ 19,201. According to expectancy- valence theory, workers are motivated to perform their duties if they perceive that their performance will lead to valued rewards [19]. Performance is also affected by feedback from relevant sources. Behavior that is followed by positive reinforcement (i.e. feed- back) is more likely to recur than behavior that is followed by negative reinforcement or by no rein- forcement at all. Thus, the theory proposes that workers allocate their effort toward performance according to the mix of consequences they derive from the various sources of reward and feedback.

The study’s conceptual framework (Fig. 1) focuses on the influence of perceived rewards (as antecedents of behavior) and feedback factors (as consequences of

(Antecedents) ’ (-) f Motivation

Perceived (Consequences)

Rewards: Feedback: Intrinsic Human - Worthwhile

work - Supervisor

-Achievement - Community

of goals - Peers

+ Instrumental

-Commendations -salary -Collegiality I

Fig. I. Conceptual framework.

Performance of health workers in Colombia 1043

those eligible) participated in the study, but complete information was available for 176.

Based on demographic information obtained in this study, the largest proportion (35.1%) of the HPs in the sample were between 26 and 30 years of age, with an age range from 20 to 50 years. The HPs had completed between 3 and 11 years of formal educa- tion with a mean of 5.9 years. This is slightly more than the basic 5 years of school that most Colom- bians receive. All but 3 of the 186 persons in the sample were women, which reflects the fact that the role has been female in Colombia, as in much of Latin America. The majority (85%) of the women were married, and all had lived in their communities for their entire lifetime. They had been working in the role of HP for an average of 6.6 years (range = I-17 years). The HPs provide services for between 50 and 330 families each (mean = 150.3, SD 79.5) or roughly 900 persons in the average community. Fifty percent of the population they serve is under the age of 15. The annual census that the HPs complete in their rural community provides them with comprehensive information on the population for which they are responsible.

The HPs major contact with the community consists of visiting homes on a rotational basis within her geographical area. She also has contact with groups in the community on a planned basis for the purpose of providing health education sessions. In addition, in Bolivar, HPs convene formal biannual meetings with the community to report on the health status of the community and to discuss pertinent health concerns.

The HP has formal contact with the health system in two ways: direct supervision in the community by her auxiliary nurse supervisor, and group meetings at the health center of all area HPs with their supervisor for the purpose of in-service education. Direct super- vision in the community and group meetings are expected to take place on a monthly basis. In general, HPs receive substantially less supervision and some- what less in-service education than what was intended by the government health system as part of its management role. Group meetings were held monthly in 83.3% of the total sample. Less than 40% (38.7%) of the sample reported monthly supervision, while 22.6% reported bi-monthly supervision, and another 38.7% reported supervision every 3 months or less frequently. This infrequent supervision pattern is consistent with both an earlier Colombia-wide assess- ment of primary health care [22] and with patterns reported in other countries [23,24].

behavior) on job performance. Only variables related to the work environment are considered in this performance model.

Work performance is defined as the degree to which duties associated with the job are carried out. Rewards are benefits that the worker expects to receive as a result of expending effort to perform adequately on the job. Rewards can be either intrin- sic, emanating from the work itself, or extrinsic, derived from sources external to the work. Intrinsic rewards include a feeling that the work is worthwhile and satisfaction gained from achievement of goals. Extrinsic rewards include influence and status in the community, commendations, salary and opportunity to interact with fellow workers (‘collegiahty’).

Feedback is defined as information provided to the worker about the quality of his or her job perfor- mance. There are two general sources of feedback, human and instrumental. In this study human sources included the supervisor, the community and peers. Instrumental sources of feedback included work activities and the worker-maintained record system that is used to monitor the community’s health status. Motivation, defined as an employee’s desire to perform effectively on the job, is also subject to the influence of rewards and feedback. The re- search question addressed in this paper is approached from the perspective of selected segments of the foregoing model, namely, human and instrumental feedback and extrinsic rewards.

RESEARCH SITE AND SAMPLE

Colombia’s national primary health care program, formally established in 1975, since 1970 has trained a type of CHW, called health promoters (HPs), to provide basic health services to rural communities. They have been paid members of the government health system since 1976. Training is of 3 months duration, and includes classroom, demonstration, and practical application of skills in their own com- munity. Colombia’s relatively long standing experi- ence with HPs provides an appropriate context in which to investigate factors associated with their work performance. As in other countries, Colombian HPs provide health, nutrition and sanitation education, maternal and child health and family planning services, immunization, endemic disease control services. some minor treatment of common illness. and essential drugs [21]. They also make referrals of high risk or complicated cases to the nearest health facility.

The study was conducted in Cordoba and Bolivar, two Atlantic coastal Departments (provinces), each of which is divided into five administrative regions. The number of HPs selected from each region was proportional to the total number in the province. Based on sample size calculations, the goal was to obtain 53% of the eligible HPs in each province for the sample. Excluded from the sample were those HPs employed for less than one year and those who work in communities of more than 2500 people (the designated cut-off in Colombia for an urban center). A random sample of health centers, which have from 2 to 9 HPs. was selected from each region to obtain the required sample size. A total of 186 HPs (59% of

MEASUREMENT OF PERFORMANCE, REWARDS AND FEEDBACK

Questionnaires were orally administered to small groups of HPs by trained Colombian field researchers; HPs recorded their responses on individ- ual answer sheets. Questionnaires and data collection procedures had been pretested in a pilot study. Community visits by the researchers yielded contex- tual information (e.g. common health problems, liv- ing conditions) and supplementary performance data (e.g. HP rapport with community members), as well as verification of some survey information.

1044 SHEILA A. ROBINSON and DONALD E. LARSEN

There were two sources of data about rewards and feedback. The first source was two ranking exercises developed for the study, one for rewards, the other for feedback. Four rewards and five feedback items were each typed on a separate card. A respondent was asked to rank the cards in order of how important she felt each item was in influencing her work perfor- mance (e.g. the most important reward was placed in first position, the least important in fourth position). In analyzing these data, a mean rank was calculated for each reward and feedback item. Mean ranks were compared by all possible t-tests (two tailed) to deter- mine whether the ranks were significantly different from one another. A P-value of P < 0.01 was used for the l-tests to account for multiple comparisons.

The second source of reward and feedback data was the Job Diagnostic Survey (JDS) [25]. This widely used instrument is designed to collect information on various dimensions of the relationship between the individual and his or her work, such as levels of motivation and satisfaction and the individual’s need for growth. The instrument was translated into Spanish specifically for this project; special proce- dures were undertaken to ensure its cross-cultural applicability [ 171. The instrument provided reliable and valid measures of ‘feedback from supervisor’ and ‘feedback from the job itself’. For example, in one of the three-item ‘feedback from the supervisor’ mea- sures, HPs were asked to indicate whether they were satisfied or not (on a five point Likert scale) with this statement: ‘the amount of support and guidance I receive from my supervisor’. Similarly, for the ‘feed- back from the job itself’ measure, respondents were asked to agree or disagree with the statement, ‘just monitoring my records provides a chance for me to know how well I am doing on the job’. In addition to the JDS measures, a similar three item measure of ‘feedback from the community’ was developed and tested for this study. Respondents were asked, for instance, to agree or disagree on a five-point scale with the statement, ‘community members let me know that they appreciate my visits to their home for health promotion activities’.

A IO-item work performance scale was developed for this study to assess the degree of goal attainment on a variety of job tasks [17]. Each HP and her supervisor was asked to rate the HP’s actual perfor- mance over the last month relative to regional health service goals. Each item was rated from 1 (poor) to 5 (excellent), in keeping with a familiar performance scoring in the Colombian public school system. The scale provides a composite job performance score, and sub-scale scores for performance in the areas of health promotion, health monitoring, home visiting and communications. The work performance data

reported in this paper are restricted to the composite job performance scores derived from the HPs’ self- assessment. These scores can range from a low of 10 to a high of 50.

Data from the work performance scale and the JDS were analyzed by linear regression to determine if the specific measures of feedback were significant predictors of job performance. This regression analy- sis focused on the relative importance of three factors (feedback from the supervisor, the job and the com- munity) in terms of the amount of variance in job performance which was explained by each factor. In linear stepwise regression analysis, the factor which explains the most variance of job performance is also the most strongly associated with level of job perfor- mance.

The specific feedback and reward indicators in the JDS and ranking exercises were classified for the purposes of this paper as stemming from either the health system or the community. They included three types of feedback from the community: (1) how much value the community members place on the CHW’s activities (as perceived by the HP); (2) changes in the community’s health status or health behavior (as observed directly by the HP); and (3) changes in the community’s health status (observed indirectly by HPs through monitoring the record system which provides ongoing information about health status of individuals and families). While the latter type of feedback might be seen as stemming from the health system, the content of the feedback comes from the community. Therefore, for the purpose of this paper the third measure of feedback can be seen as having a dual source. There were also three types of feedback from the health system: (1) the frequency of verbal input about performance received by the HP from the supervisor; (2) the perceived quality of that feedback; and (3) discussion with other HPs about work prob- lems. The rewards considered in this paper are those extrinsic to the CHW work activities. The rewards that derive from the health system were salary, pay, written commendations (a valued reward in the Colombian context), and the opportunity to interact with other HPs, or collegiahty. The reward that derives from the community was an HP’s perception that she has influence in the community.

RESULTS

The data presented here address the question of the relative influence of two major sources of feedback and rewards, the health system and the community, on work performance of HPs in Colombia. Table 1 displays the HPs’ rankings of the perceived relative importance of various sources of feedback to their

Table I. HPs DerceDtion of the relattve imtmrtance of sources of feedback m mfluenciw work performance

Importance

High Low I 2 3 4 5 Meall

Sources of feedback No. (%) No. (%) No. (%) No. (96) No. (%) ranks

I. Changes in health observed in community 104 (58.1) 35 (19.6) 27Cl5.l) 4 (2.2) 9 (5.0) (I .76) 2. Interaction with community 23 (12.8) 41 (22.9) 51 (28.5) 38 (21.2) 25C14.0) (2.99) 3. Changes in health observed in records 21 (11.7) 48 (26.8) 32tl7.9) 29 ( 16.2) 48 (26.8) (3.18) 4. Discussion with HPs 19clO.6) 34 (19.0) 32 (17.9) 42 (23.5) 52c29.1) (3.41) 5. Interaction with supervisor II i6.I)’ 21 (11.7) 37 (20.7) 66 (36.9) 44 (24.6) (3.62)

Performance, of health workers in Colombia 1045

Table 2. Source of feedback as a predictor of work performance: results of linear stepwise regression analysis

step Source of feedback Cumulative R* l&ease in R?

Beta coefficient

I Community 0.08 0.08 0.24 2 Record svstem 0.12 0.04 0.19 3 Super& l

Total variance explained = 12%. F = 7.47, df 174, P c 0.10. l F to enter not significant at P < 0.10.

job performance. The sources of feedback are listed in order of importance based on their respective mean ranking. The mean for feedback source No. 1 is significantly different from all other items. Items No. 2 and No. 3 are significantly different from No. 4 and No. 5, but not from one another. Similarly, items No. 4 and No. 5 did not rank significantly different from one another.

The data in Table 1 show that direct observation of changes in the community’s health was the factor which most influenced the HPs’ job performance. Personal contact with community members (in the form of verbal feedback) and observation of change in the community’s health based on information provided in the record system were the second most important factors perceived to influence work perfor- mance. Discussion with other HPs and feedback from the supervisor were viewed as the least important determinants of work performance. Those sources of feedback ranked in the top three positions are associ- ated with the community, whereas the last two are associated with the health system.

Table 2 shows the results of the linear stepwise regression describing the relationship between work performance scale and three sources of feedback: the record system, the community and the supervisor. Feedback from the community and feedback from the records contribute in a statistically significant way to the explained variance. Feedback from the super- visor, which is more weakly associated with perfor- mance, does not contribute significantly to the variance on performance. In other words, there is a stronger positive association between feedback from the community and from the records and perfor- mance than there is between feedback from the supervisor and job performance. These findings lend support to those in Table 1.

Data presented in Table 3 indicate how HPs ranked four extrinsic rewards, that is, rewards exter- nal to the work itself. in relation to one another in terms of how important each was in influencing their performance. The mean ranks for each of these extrinsic rewards are significantly different from one another. The rewards are listed in the table in order of their overall importance to the HPs. The most highly ranked external reward is having ‘influence in

the community’. The other three rewards are all related to the HP’s association with the health sys- tem. The ‘opportunity to work with other HPs’ was ranked second, ‘written commendations’ third, and ‘salary’ the least important reward.

DISCUSSION

Overall, the findings indicate that feedback and rewards which derive from the community have greater influence on the HPs’ job performance than do feedback and rewards which stem from the health system. For example, level of work performance was shown to be more strongly associated with feedback factors such as the high value community members place on HP activities, and the HP’s observations of improvements in the community’s health. Work per- formance was also strongly associated with the per- ceived reward of having influence in the community. In contrast, work performance was weakly associated with feedback from the health system (e.g. discussion with other HPs, and supervisory contacts), and with perceived rewards from the health system (e.g. oppor- tunity to interact with other HPs, receiving written commendations and salary).

Further research in Colombia and other develop- ing countries is required to determine if generaliza- tions are warranted in respect to the major findings of this study. These Colombia data, however, suggest that the CHW has much stronger links to, and dependency on, the community for rewards, feed- back, and therefore motivation to perform than has generally been acknowledged. That is, she receives her primary rewards through her work in the commu- nity, and the feedback about her performance that has the most impact comes from the community. It would appear that the crux of the CHW’s assessment of her performance in the role of HP is largely determined in the context of her relationship with the community.

It has generally been acknowledged that the CHW has some influence and status in the community, as illustrated by the fact that a CHW candidate is recommended or endorsed in some way by the com- munity in order to be selected for the position. What is significant about these Colombian findings is that

Table 3. HPs perception of the relative importance of extrinsic rewards in influencing work performance

Perceived rewards

Importance

High Low I 2 3 4 Total Mean

No. (%) No. (%) No. (%) No. (%) number rank

I. Influence in community 126 (70.4) 41 (22.0) 10 (5.6) 2(1.1) 179 (1.43) 2. Interaction with other HPs 27 (15.2) 93 (52.2) 47 (26.4) I I (6.2) 178 (2.28) 3. Written commendation 19 (10.3) 32(17.8) 80 (44.9) 48 (27.0) 179 (2.79) 4. Salary 7 (4.7) 12(8.1) 41 (27.7) 88 (59.5) 158 (3.32)

IO46 SHEILA A. ROBINSON and DONALD E. LARSEN

the CHWs ranked ‘having influence in the commu- nity’ (among four possibilities) as the most important extrinsic reward affecting their performance. Infor- mal observations by the investigators indicated that this influence takes the form of being opinion leaders on a variety of issues of concern to the community. The fact that having influence in the community is highly valued by community-based workers adds a dimension to their role which may not be shared with most other health workers, particularly those based in institutions.

There are several possible explanations for the paramount importance of the community to the performance of CHWs. CHWs receive a short train- ing program, and therefore their socialization into the culture of the health system is minimal. Furthermore, the CHW operates in relative isolation from the health system in a rural community which has its own culture, of which the CHW is a part. If the commu- nity, not the health system, is her primary reference group, it is not surprising that the feedback a CHW receives from her daily job activities and from the community has a significant bearing on her perfor- mance.

The findings do not support what appears to be a widely held assumption that the health system plays the primary role in influencing motivation and per- formance of CHWs. Within primary.health care the concept of health system support has traditionally meant the provision of logistic and management mechanisms to enable the CHW to carry out her job activities. Operationally this means the provision of supplies and drugs, along with regular supervision and continuing education to maintain CHW skills, to provide some problem solving assistance, to monitor record keeping, and to maintain accountability. The emphasis in this support has been on health system goals and on health system inputs to achieve these goals.

This interpretation of management support is mod- eled on institutional-based health services in devel- oped countries. In hospital and ciinic situations patients come to the providers for care. Health worker activities are well contained within the health service infrastructure: supplies, supervision, record keeping, and evaluation are provided on site. Operat- ing within that tradition, it is understandable that the clinic-based auxiliary nurse who supervises the CHW tends to limit the focus of her supervision to health center goals and activities, such as record keeping, during brief supervision visits, and on CHW partici- pation during monthly meetings at the health center. Given the unique community work context of the CHWs, as described above, and the reality of current supervision patterns, the health service needs to reframe its thinking about how it supports CHWs and in what context it assesses their performance.

IMPLICATIONS FOR MANAGEMENT OF HEALTH SERVICES

The major implication of the findings of this study is that the health system needs to change its manage- ment orientation so that it emphasises the CHW-community relationship and places less em- phasis on the CHW-health system interface. The

findings suggest that a management orientation that consciously promotes, fosters and strengthens the relationship between the CHW and her community would improve her work performance. morale and commitment to the role. How can this shift in management orientation be brought about?

The Alma-Ata declaration on primary health care [l] indicated that the full participation of the commu- nity must be a central component of PHC. This has generally been interpreted to mean that the commu- nity participates in selecting, supporting and perhaps financing the health worker as she provides services for the community. In other words, ‘community participation’ has in practice been a mechanism by which the community supports the delivery of health services. We suggest the implementation of a mirror image concept, namely, health sysrem participation, which refers to mechanisms by which the health service supports the interface between the CHW and her community. The underlying rationale of this concept is that whatever contributes to strengthening that relationship and the CHW’s status in the com- munity, may, in turn, contribute to CHW perfor- mance, and ultimately to promoting the goals of the health system.

In operational terms the concept of henlth system participation translates into a need for a partial reorientation in the selection and training of CHWs. and in the management techniques currently employed by the health system. In regard to selection of CHWs, it suggests a reaffirmation of the importance of selecting candidates on the basis of their demonstrated involvement in and commitment to the community.

In terms of training CHWs, the concept of henlth system participation suggests that the blueprint for the content of their curriculum should be based on the results of a community survey of health needs that can be completed by the CHW candidate at the beginning of her training. In other words, the content and skills that are taught should relate directly to interventions or health education that are appropri- ate for the health problems of the community. This training strategy has been used successfully in a number of national CHW programs, e.g. Tanzania and Colombia. This training orientation serves the function of solidifying the CHW’s connection with the community. This in turn may enhance her status as she attempts to address those needs with subse- quent services. Another aspect of the training which follows from this orientation is that the largest per- centage of the training time should be spent in the community. The time a CHW spends in the commu- nity engaged in ‘hands-on’ endeavors heightens her visibility and emphasizes her relationship with the community.

Within the management domain, the concept of health svstem participation leads to three practical suggestions. First, the information system used by CHWs should be designed in such a way that its primary function is to support CHWs and only secondarily be used for purposes of supervision and monthly reporting of statistics to the health system. The worker should see the information system as a tool for her own activities and for identifying health needs and changes in health status of the community.

Performance of health workers in Colombia 1047

Designed in this way, the information system can become a useful tool which enables the CHW to share health information with the community and to iden- tify current problems that need to be addresed by the community. In addition to regular informal sharing of information, a more formal mechanism could be employed. This is illustrated by the Colombian CIMDER methodology which employs a semi- annual meeting with the community to share infor- mation about health progress [26]. Information sharing mechanisms could be developed and fostered by the health system, and included in the training program with very little cost. This not only raises consciousness in the community about health issues in order to promote joint collaboration for particular health promotion activities, but it can have an addi- tional motivational effect on the worker. A meeting with the community provides the health worker with a forum at which her accountability to the commu- nity can be strengthened and at which she can receive feedback from the community.

The second suggestion in the management domain is that mechanisms could be developed to establish work goals for community-based workers and to ensure that they receive regular feedback about their performance related to those goals. Job activity goals (e.g. number of home visits, immunization targets, family planning acceptors) should be clear to the worker and oriented as much as possible to commu- nity concerns’and priorities. The worker, in collabo- ration with her supervisor, should be encouraged to set goals that are in keeping with the needs of her particular community. Regular feedback about per- formance on community-focused work goals could come either from the supervisor, or from a worker- controlled record system similar to that discussed above. Such community-focused goal setting and feedback could lead to enhanced CHW motivation and performance and possibly greater achievement of health system goals.

The third suggestion in the management domain relates to the supervisor’s role vis-a-vis the CHW. First, it needs to be understood and acknowledged that supervision, as currently practiced, may have relatively little impact on CHW performance and motivation. To have more impact, supervisors must focus more attention on the process rather than the content of the CHW’s role and activities within the community. For example, emphasis could be placed on promoting positive interactions with community members and dialogue within the community on relevant issues. While others have called for support- ive. educational supervision [ 14,211, what is proposed here goes one step further by suggesting an additional objective for the supervisor which addresses this question: ‘How can my contact with the CHW con- tribute to the further development of her relationship with the community? This objective presumes that the supervisor recognizes that the CHW is a self- directed worker who is aware of community needs, and is likelv to have defined her role in the commu- nity vis-a-& these needs. With such an orientation the supervisor would assume a role that facilitates a strong CHWxommunity relationship rather than one. more commonly adopted, that involves policing or monitoring the CHW.

Recognizing that supervisors will continue to visit the CHW in her community infrequently, due to financial and transport constraints, how can the concept of health system participation be incorporated into alternative forms of supervision? One alternative method currently being employed in some settings [23,26] is group supervision, in which the supervisor works with CHWs during regular group meetings to solve problems they have encountered in the field. Although group supervision does not substitute for the supervisory support of the CHW in the commu- nity setting, it too can promote the relationship of the CHW with the community if the focus of discussion is on solving community-based problems by means of sharing and role playing. This alternative mode of supervision can also affect motivation by fostering peer support among CHWs, which, as our findings indicate, is perceived to be as important a factor as supervisory feedback to the CHWs’ performance.

In conclusion, the findings of this study underscore the importance of adopting a community orientation in the management of CHWs. Historically, the signifi- cance of the CHW’s links with the community has been acknowledged and operationalized in the CHW selection process, and more recently in the training process. However, when it comes to subsequent man- agement of CHWs, it has been implied in the litera- ture and reflected in practice that the CHWs’ primary accountability and loyalty is to the health system. This attitude seems to be the case regardless of whether the CHW is a volunteer, remunerated through the community, or is a paid employee of the government health system. Given the findings of this study about the relative importance of the commu- nity to the CHW’s performance, it is necessary to re-examine and re-affirm the importance of a commu- nity orientation throughout all aspects of CHW programs within primary health care.

We have suggested a strategy that could be em- ployed by the health system which may enhance the performance of community-based workers. This management strategy would not focus on health system targets directly, but indirectly through the health system participation approach discussed above. The strategy does not in any way diminish the importance and necessity of the health system provid- ing adequate supplies and supervision for CHWs in the field. While the viability and effectiveness of this strategy needs to be tested in different practice set- tings, the concept of health system participation adds a new perspective on the management of this very unique and pivotal worker within the framework of primary health care.

Acknowledgements-The authors acknowledge the advice and support of Dr Jorge Saravia, Director of CIMDER, Centro de Invetigacio Multidisciplinarias en Desarrollo. of the Univsidad de Valle in Cali, Colombia in the design and implementation of this research; the advice of Professor Emeritus N. R. E. Fendall, School of Tropical Medicine, University of Liverpool, U.K.; and the Health Services of the Departments of Cordoba and Bolivar for their cooper- ation in the completion of the study. The research was sup- ported in part by the National Health Research and Devel- opment Program through a National Health Ph.D. Fellow- ship to S. A. Robinson and a grant from the International Development Research Centre (IDRC), Ottawa, Canada.

1048 SHEILA A. ROBINSON and DONALD E. LARSEN

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REFERENCES 13.

World Health Organization and United Nations Chil- 14. dren’s Fund. Primary Health Care (Reoort of the Inter- national Conference on Primary tieaith Care, Alma- 15. Ata, U.S.S.R., September 1978). WHO, Geneva, 1978. Bender D. E. and Pitkin K. Bridging the gap: the village health worker as the cornerstone of the primary health care model. Sot. Sci. Med. 25, 515-528, 1987. 16. Berman P. A., Davidson R. G. and Burger S. E. Community-based health workers: head start or false 17. start toward health for all? Sot. Sci. Med. 25, 443-459, 1987. Mangelsdorf K. R. The selection and training of pri- mary health care workers in Ecuador: issues and alter- natives for public policy. Int. J. Hlth Serv. 18, 471-493, 18. 1988. Pan American Health Organization (PAHO). Evalua- tion of the strategy for “Health for All bv the Year 2000”. In 7th Rep% on World Health Situaiion, Vol. 3. 19. PAHO, Washington, D.C., 1986. Saravia J.. de Salazar L.. Villafane P.. Valencia L. G. ef 20. al. Primera evaluation de1 sistema de servicios de aiencion primaria integral en areas que utilizan metodologia. 21. CIMDER. CIMDER. Cali. Colombia, 1981. Skeet M. Community health workers: promoters or 22. inhibitors of primary health care. Wld Hlth Forum 5, 291-295, 1984. Gonzalez C. Simplified medicine in the Venezuela health services. In Healih by the People (Edited by Newell K.), 23. DD. 169-189. WHO. Geneva. 1975. ‘tiewell K. (Ed.) Health by the People. WHO, Geneva, 1975. 24. Storms D. Training and working with auxiliary health workers: lessons from developing countries. (Mono- graph series No. 3). American Public Health Associa- tion (International Health Programs), Washington. 25. D.C., 1979. PRICOR. Brief summaries of PRICOR-supported srudies. Center for Human Services, Chevy Chase, MD, 26. 1987. Favin M., Parlato P. and Kessler S. Primary health care progress and problems: experiences from 52 countries. 27. Paper No. I1 of selected papers from the WFPHA IV International Conference, February, 1984, Tel Aviv, Israel, 1984.

Joseph S. and Russell S. Is primary care the wabe of the future? Sot. Sci. Med. 14C, 137-144. 1980. Kleczkowski B. M. Health system support for prlmay health care. Publ. Hlth Rep. 80, 1984. Simmons R., Phillips J. F. and Rahman M. Strengthen- ing government health and family planning programs: findings from an action research projection rural Bangladesh. Stud. Family Plann. 15, 212-221. 1984. Steers R. M. and Porter L. W. Motiration and @hrk Behavior. McGraw-Hill, Toronto, 1983. Robinson S. A. Job performance of community health workers in Colombia. Unpublished Ph.D. thesis. Uni- versity of Calgary, Calgary. Canada. 1987 (Ottawa: National Library of Canada. microfiche No. 0315424281). Strasser S. and Bateman T. Perception and motivation. In Health Care Management: A ?e.yt tn 0rgani:ational Theory and Behacior (Edited by Shortell S. M. and Kaluzny A. D.), pp. 77--127. Wiley. Toronto. 1983. Porter i. W. and Bawler E. E. Managerial Attitudes and Performance. Irwin-Dorsey, Homewood, IL. 1968. Vroom V. H. Work and Motivation. Wiley. New York. 1964. Fendall N. R. E. Primary health care: issues and constraints. Third Wld Plann. Rec. 3, 387401, 1981. de Zubiria R., de La Vega B.. Galan R. and Valero L. A. Atencio Primaria: Evaluation de Extension de Cobertura en Servicio de Salud. Ministry of Health. Bogata, 1986. Jacobson M. L. Individual and group supervision of community health workers in Kenya: a comparison. J. Hlth Admin. Educ. 5, 83-94, 1987. Robinson S. A. Community health workers in less developed countries: the Jamaican community health aide program. Unpublished Master’s thesis. University of Calgary, Calgary, Canada, 1979. Hackman J. R. and Oldham G. R. Development of the job diagnostic survey. J. appl. Ps.vchol. 60, 159-170. 1975. Echeverri O., Villafane P. and de Gonzalez V. Elsisrema de information “La Caja Maestra” y el Plan de Trabajo. CIMDER, Cali, Colombia. 1982. Foreit J. R. and Foreit K. G. Quarterly versus monthly supervision of CBD family planning programs: an experimental study in Northeast Brazil. Stud. Fam. Plann. 15, 112-120, 1984.