Tanzanian CHWs with various years and types of experience were interviewed to understand their motivation to continue their CHW work despite not being paid a salary. The data presented here suggest that, to better maintain or increase motivation among CHWs, it may be useful for program managers to examine the four sources of CHW motivation identified in this study: individual, family, community, and organizational (Table
3). By examining these sources of motivation in Tanzania, we came to two major conclusions that can inform CHW program incentive structures and address gaps in the literature.
First, familial support, including monetary and non-monetary forms of support, emerged as an important motivator for CHWs like Salum and Rehema. Other studies have shown that CHWs often do not feel sufficiently supported by the health system
[3, 31] and cannot always rely on their communities for long-term support
[3, 18, 39]. In this study, the family was found to provide support when other sources are insufficient. Family members provide CHWs with moral support, money for transportation and work supplies, lodging, help with farm and domestic work, and help with CHW tasks. Similarly, five of the studies summarized in Table
1 found that CHWs receive support from their families, including encouragement
[16, 36–38], financial support
, and help with household chores and CHW tasks
[15, 16, 36, 37].
Our finding that the family is overall a source of positive support for CHWs represents a departure from the literature. In the seven studies summarized in Table
1 that found the family to influence motivation, the family is less frequently described as a primarily positive influence on CHWs
 and is more often described as concurrently a motivator and a deterrent or as primarily a demotivator. Four of the five studies that found that families support CHWs also found that families are a source of discouragement
[15, 16, 37, 38]. Two studies found that families primarily disapprove of CHW work and show a lack of support
[14, 28]. Familial disapproval was found to be a barrier particularly for female CHWs who could not continue CHW tasks after marriage or whose husbands saw the long hours and work-associated travel as inappropriate for women or a waste of time
[14–16, 38]. Interestingly, none of the female CHWs interviewed in this study reported being discouraged by their husbands and both male and female CHWs felt encouraged by their families.
Despite the important role, both positive and negative, that the family appears to play in CHW motivation, conceptual models often do not highlight the family as an existing or potential source of motivation or reason for retention
[17, 19, 38]. The framework presented by Alam et al., however, includes the family as a factor affecting the retention of female volunteer health workers in Bangladesh and therefore aligns well with our findings. Together, the four levels of motivation in the framework paint a more complete picture of how CHWs are logistically able to maintain their commitment to volunteer work despite not being paid a salary (Table
The conclusion that CHWs depend on their families for motivation has implications for program implementers because CHW performance has been shown to improve when they feel sufficiently supported
. Rates of attrition may be higher for volunteer CHWs who are unable to mobilize moral, material, or financial support from members of their household compared to those who have access to this source of support
. Alam et al. found that in Bangladesh, CHWs with no or few household responsibilities were more than twice as likely to continue their CHW work, suggesting that retention may be higher for CHWs whose families help with domestic work and child rearing. In two other studies in Bangladesh and one in Kenya, former female CHWs cited familial disapproval as a reason for resigning
[14–16]. Therefore, program implementers should consider working with family members of CHWs to help garner moral and perhaps other types of support and should evaluate possible barriers to mobilizing this support
The dependence on family for material and financial support, however, brings into question the extent of the burden placed on CHW households as a result of not paying CHWs, a consequence of volunteer work that has not been adequately explored in the literature. Because of already-existing hardships, it may be difficult for families to devote significant time to helping with CHW and household tasks and to sustain certain levels of material or financial support to facilitate a CHW’s volunteerism. Policy-makers and program implementers should therefore not consider the family to be a substitute for financial or material forms of motivation. Instead, they should define a package of incentives with components that alleviate the burden that volunteer work places on families, such as providing monetary earnings, income generating opportunities, paths for career advancement, work supplies, housing, and transportation
. The organizational level can thereby help ensure that the family remains a sustainable source of support for CHWs.
Our second conclusion is that the strong volunteer spirit expressed by many of the interviewed CHWs, such as Salum, does not preclude a desire for financial rewards. Monetary compensation or in-kind alternatives provided by the health system that accurately reflect the value given to CHW work could in fact reinforce existing motivation at the individual level by making CHWs feel supported and able to devote more time to health-related activities without feeling they are neglecting other responsibilities
[18, 24, 28].
The CHWs interviewed seemed to be motivated by a genuine concern for their neighbors, as expressed by the desire to provide education where it is lacking and to prevent common tragedies, like the loss of a child. In addition, the CHWs interviewed who describe their work as a 'calling’ are attracted to public service and find personal satisfaction and pride in helping their communities. Similarly, a quantitative study on volunteer CHWs in northwestern Tanzania found that 85% of CHWs continue to volunteer because they enjoy the job
. This drive to serve others may be influenced by political, religious, or historical patterns or events
. As Ramirez-Valles explains, motives are 'socially constructed guides for action. They are rooted in the local context and individuals’ life stories’
. The Tanzania context has been influenced by the socialist leanings of Julius Nyerere, in power for over two decades, as voiced in the Arusha Declaration of 1967
[49, 50]. Nyerere called for the formation of a socialist state, including the promotion of self-reliance, an emphasis on hard work, and cooperation among citizens
. To put these values into practice, the government prescribed the formation of ujamaa villages to facilitate cooperative production and self-sufficiency
. Thus, a willingness to contribute to a collective good must be considered within the resulting post-colonial Tanzanian context.
This strong exhibition of altruism and empathy for community members does not, however, contradict a desire to be financially rewarded for one’s efforts. Of the 16 studies listed in Table
1 that found altruism or helping one’s community to be a motivator, 13 also found financial motivators, or the lack thereof, to be an incentive, or deterrent, for CHWs
[4, 12, 14, 16, 27, 29, 31–34, 37–39]. Although interviewed CHWs appreciated the stipends they earned for fulfilling certain obligations, such as attending trainings, CHWs interviewed in this study and in the summarized studies cited the challenges of not being paid a regular salary and not having enough time for income-generating activities
[4, 16, 28, 32, 37]. The need for a regular income can be a deterrent to becoming a CHW and can cause CHWs to drop out or devote less time to their CHW work
[12, 14–16, 29, 32, 38]. Salum, for example, decided to volunteer only a few times a month to make time for his farm work.
Despite the challenges, the CHWs interviewed continued their volunteer work, often for over a decade, with neither an abundance of financial resources of their own nor substantial financial or material remuneration. Thus, rather than incentives decreasing or 'crowding out’ intrinsic motivation by being seen as controlling and thereby decreasing worker confidence
, which has been named a negative consequence of paying CHWs
, the evidence presented here suggests that monetary or in-kind external rewards would 'crowd in’ intrinsic motivation by making CHWs feel more supported, confident, and less restricted in their work
. Researchers in Iran came to a similar conclusion that for CHWs who already enjoy their work, but who are dissatisfied with payment, improving payment and professional opportunities would increase job satisfaction
. Countries such as Tanzania that are deterred from paying salaries by fiscal and administrative constraints can nonetheless address the financial needs of CHWs through alternative income-generating activities such as loans and the selling of health-related products, opportunities for career advancement and professional development such as training and supportive supervision, and non-monetary substitutes for remuneration such as transportation and supplies
. The resulting package of incentives delivered at the organizational level that is adequate for allowing CHWs to feasibly devote time to health-related activities could reinforce existing altruism and amplify CHWs’ existing commitment to their work.
This study is limited by several factors. In any research, one must contend with social desirability bias, or respondents sharing information that they believe a research team is expecting to hear. We sought to mitigate this through prolonged engagement in the field and in-depth probing as well as rapport building. In terms of external validity, Morogoro Region is slightly less poor than other regions of Tanzania, with a slightly lower TFR
. It is also geographically closer to the major metropolises of Dar-es-Salaam and Dodoma. These factors must be considered when gauging generalizability. In terms of study design, we are limited by having data from only two CHWs with <5 years of experience and by the absence of interviews with ex-CHWs who could have provided insights into why CHWs discontinue their work. Our research also did not examine CHW motivation by demographic characteristic, so we recommend further research that analyzes differences in motivation by factors such as length of service, gender, age, and marital status. Data analysis may have been limited by a possible loss of nuance during translation from Swahili to English. However, whenever possible, transcript translations were cross-checked by colleagues fluent in Swahili and English.