Thanks for your question, Massimo. Remuneration for CHWs is an even more complicated issue than who will pay. There are multiple models for this.
On one side of the spectrum, CHWs can be paid employees in the government's health system, like in Iran. On the other hand, CHWs can be volunteers that receive minimal gifts or financial incentives, as in India. (For reference, I am using Singh et. al's 2015 paper "The effect of payment and incentives on motivation and focus of community health workers: five case studies from low-and middle-income countries" for these examples.) And there are a variety of remuneration models in between: full-time or ad-hoc "employment" by government or NGOs, performance-based incentives, entrepreneurship models with profit margins for selling merchandise, etc.
The new WHO guideline on CHWs assessed if practicing CHWs should be paid for their work or not. They determined that CHWs should be compensated in a manner appropriate for their skillset, hours worked, etc. There was not enough evidence to recommend a certain form of remuneration based on the systematic reviews available, other than to advise against performance-based incentives as the primary form of payment.
It seems that the "success" of these payment methods (measured by attrition rates, health outcomes) may also vary by context, but that more research is sorely needed. I look forward to hearing more about new research on CHW remuneration.
Amelia Plant, MPH
Maternal & Child Health, UC Berkeley
HIFA profile: Amelia Plant is a consultant in sexual & reproductive health research & practice. Projects have included: managing grants to African-based organizations that distribute contraceptives at the community level; surveying the data that links contraceptive use and fertility decline with economic development; co-authoring an online abortion course; and coding and analyzing qualitative data about LGBTQ experiences. Amelia is a member of both the HIFA project on community-health workers and the HIFA project on family planning.¦nbsp; She is originally from the USA and is currently based in Tunis, Tunisia. She is a member of the HIFA working group on Family Planning
asiplant AT gmail.com