Assessing the time use and payments of multipurpose community health workers for the various roles they play-a quantitative study of the Mitanin programme in India

Abstract

Background: Community health workers (CHWs) are crucial human resources for health. While specialist CHWs focus on a single disease vertically, the generalist or multipurpose CHWs perform wider functions. The current study was aimed at examining the time multipurpose CHWs spend on performing their different roles. This can help in understanding the importance they attach to each role. Since CHWs in many developing countries are classified as part-time volunteers, this study also aimed to assess the adequacy of CHW payments in relation to their time use.

Methods: The study covered a well-established CHW programme in India's Chhattisgarh state. It had 71,000 multipurpose part-time CHWs known as Mitanins. Data collection involved interviews with a representative sample of 660 rural and 406 urban Mitanins. A semi-structured tool was designed and field tested. It included 26 pre-coded activities of CHWs placed under their six purposes or roles. Prompting and triangulation were used during interviews to mitigate the possibility of over-reporting of work by CHWs. The recall period was of one week. Descriptive analysis included comparison of key indicators for rural and urban Mitanins. A multi-variate linear model was used to find the determinants of CHW time-use.

Results: The rural and urban Mitanins respectively spent 25.3 and 34.8 h per week on their CHW work. Apart from location (urban), the total time spent was associated with size of population covered. The time-use was well balanced between roles of service-linkage, providing health education and curative care directly, COVID-19 related work and action on social determinants of health. More than half of their time-use was for unpaid tasks. Most of the cash-incentives were concentrated on service linkage role. The average payment earned by Mitanins was less than 60% of legal minimum wage.

Conclusion: The time-use pattern of Mitanins was not dictated by cash-incentives and their solidarity with community seemed be a key motivator. To allow wide ranging CHW action like Mitanins, the population per CHW should be decided appropriately. The considerable time multipurpose CHWs spend on their work necessitates that developing countries develop policies to comply with World Health Organisation's recommendation to pay them fairly.

Keywords: CHW; Community health workers; Health volunteers; Incentives; India; Mitanin; Multipurpose workers; Payments; Time motion study; Time use.