The Mixed Nature of Incentives for Community Health Workers: Lessons from a Qualitative Study in Two Districts in India

Abstract

Incentives play an important role in motivating community health workers (CHWs). In India, accredited social health activists (ASHAs) are female CHWs who provide a range of services, including those specific to reproductive, maternal, neonatal, child, and adolescent health. Qualitative interviews were conducted with 49 ASHAs and one of their family members (husband, mother-in-law, sister-in-law, or son) from Gurdaspur and Mewat districts to explore the role of family, community, and health system in supporting ASHAs in their work. Thematic analysis revealed that incentives were both empowering and a source of distress for ASHAs and their families. Earning income and contributing to the household’s financial wellbeing inspired a sense of financial independence and self-confidence for ASHAs, especially with respect to relations with their husbands and parents-in-law. In spite of the empowering effects of the incentives, they were a cause of distress. Low incentive rates relative to the level of effort required to complete ASHA responsibilities, compounded by irregular and incomplete payment, put pressure on families. ASHAs dedicated much of their time and own resources to perform their duties, drawing them away from their household responsibilities. Communication around incentives from supervisors may have led ASHAs to prioritize and promote those services that yielded higher incentives, as opposed to focusing on the most appropriate services for the client. ASHAs and their families maintained hope that their positions would eventually bring in a regular salary, which contributed to retention of ASHAs. Incentives, therefore, are both motivating and inspiring as well as a cause dissatisfaction among ASHAs and their families. Recommendations include revising the incentive scheme to be responsive to the time and effort required to complete tasks and the out-of-pocket costs incurred while working as an ASHA; improve communication to ASHAs on incentives and responsibilities; and ensure timely and complete payment of incentives to ASHAs. The findings from this study contribute to the existing literature on incentivized CHW programs and help throw added light on the role incentives play in family dynamics which affects performance of CHW.

Who is a community health worker? – a systematic review of definitions

“…In addition to these attributes, CHWs are expected to have other characteristics to better suit them for the role. In general, CHWs providing health services to women and children tend to be female [ 15 , 16 , 18 , 21 , 27 , 37 , 39 , 43 , 52 , 89 – 92 ] and those providing services in a health facility may be required to have some form of healthcare experience [ 23 , 24 ]. Previous primary or secondary education is sometimes considered in the selection of CHWs [ 24 , 28 , 29 , 46 ].…”

“…training provided in a health facility by NGOs) [ 4 , 19 , 21 , 43 , 50 , 53 , 91 , 99 , 123 , 124 ]. Individuals with some form of secondary education and subsequent job-related pre-service training outside a recognised training institution lasting any time from a few days to a few weeks [ 35 , 92 ]. Individuals with some form of secondary education and subsequent pre-service training in a recognised training institution lasting a few months to more than a year [ 18 , 26 , 27 , 32 , 39 , 46 , 52 , 68 , 125 – 127 ].…”

Remuneration systems of community health workers in India and promoted maternal health outcomes: a cross-sectional study

“…In 2010, Scott K. and Shanker S. also reported that ASHAs were limited by the performancebased payments and delayed incentives [16]. Some ASHAs have campaigned to change their payment method to a regular salary-based system rather than the unstable performance-based incentives, but this has not been approved by the NRHM [17]. Differences in the compensation system within states, variability in pregnancy cases within communities, and ability to rely on the incentives provided to ASHAs were not controlled for in this analysis but may all affect the results presented above.…”

What do community health workers want? Findings of a discrete choice experiment among Accredited Social Health Activists (ASHAs) in India

“…They are often confronted by challenges such as lack of support by supervisors, and insufficient and/or delayed remuneration which impacts their motivation12 and often leads to attrition. While some studies have explored factors which motivate ASHAs (eg, adequate compensation and community recognition),13 14 there is no empirical evidence about the relative importance of the different incentives that may help to retain ASHAs in service.…”