Tag Archives: CHWs

To what degree should we rely on volunteers to get the work done in ending maternal and child deaths?

I think the evidence we are seeing on Care Groups is proof that there’s a large role for community-level volunteers in bringing about the sort of changes that we want to see and that are necessary for ending child deaths. But it goes beyond that. It’s not just that volunteers are the best way to stretch a rupee or dollar. Not paying people can lead to better performance on some tasks than paying them. There’s recent evidence that for simple, straightforward tasks that only require mechanical skills, monetary rewards work great: Higher pay = better performance. But when a task gets more complicated, when it requires even rudimentary cognitive skills, larger monetary rewards lead to poorer performance. This is not a hunch. This is based on research by economists at MIT, Univ of Chicago, and Carnegie Mellon (funded by the Federal Reserve), and has been replicated in developing country settings. And in my opinion, the persuasive, thinking on your feet, working-around-barriers work that we need people to do to promote behavior change is far from a mechanical skill. This health promotion work – when it’s kept light and not burdensome – also has a high non-monetary pay-off for the volunteer in terms of some of the things which do motivate people: achieving mastery, having autonomy, and gaining purpose through what they do.

Another lesson that I take away from this work is that paying “a little something” can often hurt productivity and results.  Imagine if you had a neighbor who asks you for a ride to the store, but then insists that they pay you $1 for it.  Are you more likely to take them?  Many times, these small offers of monetary incentives actually turn us off, and they can make us process the request differently, looking at cost-benefit rather than drawing on our other (higher?) motivations.  With Care Groups, no monetary incentives are given to the Care Group volunteers (who do 80% or more of the actual work) and we have seen that even the non-monetary (but tangible) incentive of a $5 wrap-around skirt each year (with health messages on them) often cause more problems than they resolve, and programs can be entirely successful without them.  (Now we should be thinking creatively about how we can help volunteers to offset the time they spend on this work, like giving them time-saving things [e.g., pressure cookers?] that decrease their time burdens at home.)  In short, we were never just Homo Economicus, completely rational and narrowly self-interested, economically-driven actors.  We are so much better than that, and I have always found that those old models that look at people that way are dehumanizing, quite incomplete, and need to be jettisoned.

But don’t take my word for it: Watch this entertaining video presentation by Daniel Pink (author of Drive) on this new line of research. Think about what this means for you, your organization and how you do your projects, and add a comment below.  Warning:  If you are 50 or older (like me), you might want to move your screen away from you about two feet.  It move very quickly, and otherwise you might get nauseas. : )  Click the arrows in the bottom-right corner to see if full-screen.


And by the way, if you are asking yourself where I get the motivation to maintain this site and write these blogs, I’ll give you a hint — no one’s paying me. : )  Something deeper is going on.

— Tom Davis

Senior Specialist for Social & Behavioral Change, TOPS Project
Senior Program Director, Program Quality Improvement, Food for the Hungry

Care Groups: Using the Power of Social Networks

I’ve been reading a host of exciting books on social networks and social network theory lately:  Linked, Connected, etc.   We are not talking about Facebook here, but the networks that we find in all communities and countries, regardless of their internet connectivity.  Findings presented in Connected show that we have a measurable influence out to three degrees — our friends’ friends’ friends — in our social network.  There are more and more studies showing how behaviors and outcomes spread through networks including cigarette smoking/cessation, obesity, and even happiness.   New findings in social network theory are driving changes in many domains including genetics, behaviorism, health promotion.

As I’ve read these books, I’ve become increasingly convinced that one reason we are seeing such amazing results in behavior change using Care Groups is that we are utilizing the power of scale-free social networks.  By having beneficiary mothers choose “their” Leader Mother (who does health promotion with them), they are more likely to be choosing one of the “hubs” in their social network — someone who is in a much better position to convince them to make healthy changes.  Also, with the structure put in place by Care Groups, there are fewer links to traverse between any two given mothers, so communication and persuasion is enhanced.   The mothers who serve as connectors between mothers are also more likely to be practicing healthy behaviors, and so healthy behaviors are more likely to be spread.  If  a Leader Mother — who is more often than not a hub — hears about a positive story of a mother using ORS, for example, she is more likely to transmit that information to other mothers with which she is connected (since it is in tune with her beliefs and experience) than she is to transmit a story about ORS “not working.”  Certain types of information (e.g., pro-exclusive breastfeeeding info) is preferentially transmitted through the social network, and that’s important when you are going against the prevailing cultural practice.

I am convinced, however, that we could be doing a lot more to harness the power of social networks for child survival and community health if more of us understood the latest findings and developed the tools needed to better understand the networks that we are dealing with and our effect on those networks.  Findings from modeling on immunization strategies, for example, show that we could dramatically decrease the number of people who we need to immunize to stop an epidemic if we focused on people’s acquaintances (who are more likely to be hubs) in a given community.  Given that behaviors also flow through these social networks, it would make sense that focusing more on those hubs (and using them to influence others) should make behavior change happen more quickly and at lower cost.  Doing some social network analysis can also help us to know who in the broader community to target and who has the most influence on mothers and their child survival behaviors.  (See this article on breastfeeding and social networks in Bolivia, for example.)

If you are new to social networks, I recommend these videos on social network theory and acquaintance immunization.


Efficient Immunization Approaches to Avoid Epidemic Spreading

Tom Davis, MPH

Chairman, CORE Group Board of Directors

Director of Health Programs, Food for the Hungry

The Care Group Buzz

Care Groups:  Pulling Mothers Together

Welcome to Care Group Info! I’m Tom Davis, Chairman of the Board, CORE Group, and Director of Health Programs for Food for the Hungry.  The CORE Group is THE network for people who work in community health, and the CORE Group has been instrumental in documenting this approach and getting the word out to others.  If you are looking to learn more about methods to reach the poor with lifesaving information at low cost, you’re in the right place.  Care Groups have been around now for 12 years, but recently they have been gaining a lot more attention by international NGOs and multilateral organizations.  If you are new to Care Groups, I recommend you watch the narrated presentation we have posted.  If you are more of a reader, download the manual.

I learned about Care Groups 12 years ago from one of the original developers of the approach, Dr. Pieter Ernst in Mozambique.  (The other main collaborator on the methodology is Dr. Muriel Elmer, formerly with World Relief.)  In Food for the Hungry, we began using them at that point and have used them in many settings in the world (most in Africa) since then.  When — with World Relief — we started to gather information on the results of Care Groups and compared them to other child survival projects, we realized that this was a very special approach that deserved a lot more attention — hence the website.

For example, in our Care Group project using Care Groups in Mozambique (sponsored by USAID), we have seen a 42% drop in malnutrition (underweight) in only 2.5 years.  The cost per beneficiary there is a mere $3.60 per beneficiary per year.  By doing Lives Saved Analysis (using the Bellagio Lives Saved Calculator — the same one used in the Lancet Child Survival Series), we found that for only $305, we could save the life of one child.  This is about 1/4 of the cost to save life for a typical (and very cost-effective) USAID funded child survival program.

As I have read more of the literature on networks, persuasion, community-based social marketing and other disciplines, I have more and more hypotheses about the power of Care Groups and why they are successful.  But these are mostly hunches at this point.  What we do know is that they work.  What we need to do now is to better explore why they work, under what conditions they work, and how to convince policy makers to scale up the approach where it has been effective..

In future posts, we can discuss some of the possible reasons for Care Groups’ success.

Tom Davis

Chairman of the Board, CORE Group

Dir. of Health Programs, Food for the Hungry