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BACKGROUND: Globally, and in low and middle income countries (LMIC) specifically, there is a critical shortage of workers. The use of volunteers to support such care delivery systems has been examined, there is scant literature on the impact of volunteers on child outcome in high human immunodeficiency virus (HIV)-affected communities. OBJECTIVES: To examine the differential impact of paid versus volunteer workforce in Community Based Organisations (CBOs) providing care to children and families affected by the HIV epidemic in South Africa and Malawi on child outcomes over time. METHODS: This study compared child outcomes for 989 consecutive children attending CBOs (0.7% refusal) at baseline and 854 at follow-up (86.3% response rate). RESULTS: Children attending CBOs with paid staff had higher self-esteem, fewer emotional/behavioural problems and less perceived stigma. Likewise, children attending CBOs with paid staff had fewer educational risks, and 20 heightened cognitive performance, and the digit-span memory test. After controlling for outcome at baseline, gender, age, HIV status, and disability, attending a CBO with paid staff remained a significant independent predictor of higher self-esteem scores, less perceived stigma, as well as fewer educational risks and better performance on the drawing test. We found no associations between CBO attendance - paid or volunteer - and children's depressive and trauma symptoms. CONCLUSIONS: Our findings show that in order to most optimally impact on child outcome 30 community-based workers (CBWs) should ideally be paid with trained staff. Specialised input for more severe child difficulties is needed.
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