Altruism or Exploitation? Rethinking the Ethics of Unpaid Lay Community Health Workers in Sub- Saharan Africa. The Case of Zambia.

Introduction While there is a global consensus that Lay Community Health Workers (CHWs) should be formally remunerated for their time and effort, they remain unsalaried in most Sub-Saharan African countries, including Zambia. Does this constitute exploitation? To answer this question, we conducted a qualitative study in Lusaka province of Zambia where we interviewed Lay CHWs attached to government healthcare facilities. We juxtaposed the Sub-Saharan African Communitarian (Ubuntu) ethical system and Western ethics to discuss the findings. Study Methods We conducted qualitative interviews with thirty-five Lay Community Health Workers in three districts of Lusaka province in Zambia. We adapted the Braun and Clarke (2006) six-step framework of thematic analysis and NVivo computer software to analyse data. Study Findings Lay CHWs were motivated by both the intrinsic Ubuntu altruism and economic benefits as they provided community health services in their respective localities. Although they complained about low and inconsistent stipends, as well as a lack of equipment, that did not stop them from serving their communities because of their intrinsic Ubuntu motivation to care for others. Conclusion Our study found no evidence that paying Lay CHWs undermined their intrinsic Ubuntu motivation to aid other people, as they continued to serve their communities whether they received stipends or not. It is also our considered view that Lay CHWs are exploited due to their vulnerable positionality, and to avoid that, they should be formally remunerated in line  with the WHO recommendation.