Watching NoCounter interact with “Aunty” Martha (not their real names) in Mahwaqe, South Africa, and learning about NoCounter’s roles as Martha’s health advocate, personal trainer and medication manager was anything but dismal. So as a dismal scientist, I was fascinated by how Community Health Workers (CHWs) seem to contradict one of our most famous founders, Adam Smith. To help explain one of the concepts for which he would become famous, “the invisible hand”, Smith wrote: “I have never known much good done by those who affected to trade for the public good”.
To consider whether NoCounter and other CHWs are an exception to this statement, there are three questions that need to be considered:
Is the CHW doing good?
Almost all of the available research evidence suggests that CHWs are effective in enhancing the health of their communities, and since the World Health Organization also see CHWs as playing a pivotal role in helping countries achieve health-related Millennium Development Goals, it is most likely that CHWs are “doing good”. In Mahwaqe, we saw how NoCounter helped Martha do the chair yoga exercises that now mean she can walk and explained her medications, which helped Martha understand the importance of adherence.
Is the CHW trading?
NoCounter is giving up her time (working around 50% FTE) and in return, receives a stipend from an NGO of around R800 (~£36) per month and as such, is trading. However, as a maid in South Africa, she could earn around R1,200 (~£54) per month for the same hours, so NoCounter does not seem to be receiving the full monetary value of her time. If approximate role equivalence can be assumed, compared to a CHW in the US, NoCounter’s time is undervalued by a factor of around 8.5: a US CHW working for an hour could buy 3.3 McDonald’s Big Macs; NoCounter could buy 0.4.  NoCounter is also using her skills and experience to provide care, but economics would describe these as “non-rivalrous” and thus not directly tradable.
Is the CHW doing so for the public good or her own self-interest?
Adam Smith might be confused by NoCounter, because her aim doesn’t seem to be wealth maximisation. However, a “utility maximising” economist would argue that NoCounter is making up for not being paid the full monetary value of her time by obtaining utility either from substitutes for money or from directly helping her community. Even if NoCounter obtains utility from the latter, her motivation would still be to do public good. With regards to money substitutes, CHWs may also receive non-monetary incentives such as community respect, housing and access to health care and/or be motivated in their roles via the support of their families.  Furthermore, the CHW role is particularly desirable in areas where residents have a high marginal rate of substitution for leisure over consumption, since CHWs do not have to commute to their place of work. Finally, a by-product of NoCounter’s work as a CHW from which she benefits directly is that she lives in a healthier community: by encouraging vaccination of new-borns, for example, she is lowering her own risk of TB.
On this last question, the relative importance of the different reasons why CHWs undertake their role for a wage lower than they appear to be worth, we cannot be certain about the answer. Research in this area is critical given the push to eliminate the under-supply of CHWs. There are also additional pre-conditions – the organisational structure required to implement a successful CHW programme  – that also must be met before the demand for CHWs can be realised (made “effective”) in practice. Nevertheless, it is critical to determine whether all of the additional CHWs required to meet demand would also offer their labour at a low relative price. This was assumed in a costing exercise of a CHW roll-out programme, but which prima facie contradicts basic economic theory of demand and supply.
Fortunately for me, economics provides one approach to studying the interaction between monetary and non-monetary incentives with respect to the supply of labour, for example using discrete choice experiments, where CHWs would be asked to make a choice between a series of pairs of packages of stipend/salary, level of health produced, and non-monetary incentives (see  for an example). Such experiments would need to be repeated in (and possibly also within) different countries, since the relative value of “doing good” by volunteering may well differ according to a country’s stage in economic development. Such work would help to provide evidence regarding the sustainability of CHWs as a cadre of health care providers. Here, we hypothesise a U-shaped curve if propensity to volunteer is plotted against GDP per capita
— Celia Taylor, Senior Lecturer
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