Performance-based incentives on community health worker outcomes, a systematic review

Thomas Gadsden, Sikhumbuzo Mabunda, Anna Palagyi, Asri Maharani, Sujarwoto Sujarwoto, Michelle Baddeley, Stephen Jan

Research output: Contribution to journalArticlepeer-review


Objective To review the evidence on the impact on measurable outcomes of performance-based incentives for community health workers (CHWs) in low- and
middle-income countries.
Methods We conducted a systematic review of intervention studies published before November 2020 that evaluated the impact of financial and non-financial performance-based incentives for CHWs. Outcomes included patient health indicators; quality, utilization or delivery of health-care services; and CHW motivation or satisfaction. We assessed risk of bias for all included studies using the Cochrane tool. We based our narrative synthesis on a framework for measuring the performance of CHW programmes, comprising inputs, processes, performance outputs and health outcomes.
Results Two reviewers screened 2811 records; we included 12 studies, 11 of
which were randomized controlled trials and one a non-randomized trial. We found that non-financial, publicly displayed recognition of CHWs’ efforts was effective in improved service delivery outcomes. While large financial incentives were more effective than small ones in bringing about improved performance, they often resulted in the reallocation of effort away from other, non-incentivized tasks. We found no studies that tested a combined package of financial and non-financial incentives. The rationale for the design of performance-based incentives or explanation of how incentives interacted with contextual factors were rarely reported.
Conclusion Financial performance-based incentives alone can improve CHW
service delivery outcomes, but at the risk of unincentivized tasks being neglected. As calls to professionalize CHW programmes gain momentum, research that explores the interactions among different forms of incentives, context and sustainability is needed.
Original languageEnglish
Pages (from-to)1-25
Number of pages25
JournalWorld Health Organization. Bulletin
Publication statusPublished - 20 Aug 2021


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