Lay workers in directly observed treatment (DOT) programmes for tuberculosis in high burden settings: Should they be paid? A review of behavioural perspectives

The current global tuberculosis (TB) epidemic has pressured health care managers, particularly in developing countries, to seek for alternative, innovative ways of delivering effective treatment to the large number of TB patients diagnosed annually. One strategy employed is direct observation of treatment (DOT) for all patients. In high-burden settings innovation with this strategy has resulted into the use of lay community members to supervise TB patients during the duration of anti-TB treatment. However, community involvement in health programmes is not a simple matter. There is often a need for continued motivation of community members in order to ensure sustainability of such projects. Lay workers may demand payment for work done particularly if this takes up a reasonable proportion of their time. TB treatment, by its very nature, lasts for a considerable period and this paper seeks to examine behavioural perspectives that attempt to address the issue of whether lay workers in such programmes should be paid for their services. The theories explored suggest intrinsic and extrinsic motivation as factors that lead people to volunteer for health programmes. Intrinsic motivation encompasses such feelings as empathy and altruism as well as other factors such as religious and cultural conviction. The authors argue however that in high-burden TB settings, these factors alone may be inadequate to provide continued motivation for lay worker involvement in health programmes. Extrinsic motivators, of which money is the strongest example, then also serve to keep sustained interest particularly in resource-limited settings where people expect payment for work done. The debate on whether lay workers in health programmes should be paid is thus compounded by issues such as what factors one believes are responsible for motivation in particular contextual settings; how long lay persons are expected to perform tasks at hand; the capacity that exists to pay them and the sustainability of the motivating option chosen. We recommend more qualitative research to be done on this issue in high TB burden settings.