Improving Community Health Worker Compensation: A Case Study From India Using Quantitative Projection Modeling and Incentive Design Principles

Abstract

Introduction: Although community health workers (CHWs) are effective at mobilizing important health behaviors, there is limited evidence on how financial incentive systems can best be designed to drive their effectiveness. This study intends to bridge this evidence gap by analyzing the compensation model of India's accredited social health activist (ASHA) program and identifying areas of improvement in the system's design and implementation.

Methods: We analyze the ASHA program in Uttar Pradesh, India. ASHAs receive compensation through a mix of program-linked, performance-based, and routine activity-based incentive structures. Using multiple data sources, including a novel linked household and ASHA survey, we estimate ASHA performance-linked incentive earnings under different scenarios of ASHA actions and household behaviors. Juxtaposing statistical projection models and actual government payments, we identified which incentives promised the highest payments, which were claimed or not, which could be claimed more by increasing ASHA actions, and which were paid despite not meeting payment criteria. We also report findings on ASHA awareness of and experiences with claiming incentives.

Results: We find crucial gaps and implementation challenges in the ASHA incentive structure. ASHAs could double their earnings by completing certain tasks within their control. ASHAs may also be paid for partial completion of activities, as incentives are paid in lump sums for a series of activities rather than for each activity. Family planning incentives have the largest gap between potential and actual earnings. Incentivizing ASHAs for achieving certain health outcomes is inefficient, as no clear linkage was found between the achievability of such health outcomes and the claim amounts.

Conclusion: There are several opportunities for improving CHW compensation, from improving the incentive claims process to shifting focus to achievable outcomes. Optimizing incentive system designs can further enhance CHW effectiveness globally to affect key health behaviors.

FIGURE 1

ASHA Earnings Fall Short of Earning Potential^a Abbreviations: ASHA, accredited social health activist; FP, family planning; GoUP, Government of Uttar Pradesh. ^a There is a large gap between ASHA earning potential, demonstrated by the perfect ASHA-actual household model, and actual earnings, demonstrated by the actual ASHA-actual household model. This is coupled by overpayment, evidenced by the Indian rupee 1,255 difference between the actual ASHA-actual household model and the actual payments reported by the government. State-wide fiscal year 2017–2018 payments data were used except for FP (excluding postpartum intrauterine device) and full immunization, for which fiscal year 2015–2016 data are used given estimates are from 2015–2016 surveys for these indicators.

FIGURE 2

ASHAs Are Overpaid for Many Incentives^a Abbreviations: AA, actual ASHA-actual household model; ANC + ID, antenatal care and institutional delivery; ASHA, accredited social health activist; FP, family planning; JSY, Janani Suraksha Yojana safe motherhood intervention; PA, perfect ASHA-actual household model; PNC, postnatal care; PP, perfect ASHA-perfect household model. ^a PPIUCD incentive used statewide 2017–2018 FP payment data. For other FP incentives, 2015–2016 HPD data is used to match the 2015–2016 estimates. Payment data for sterilization is not available. So, the average earnings on sterilization as reported by ASHAs have been added. VHND mobilization payment updated with statewide fiscal year 2017–2018 but given immunization data uses National Family Health Survey 2015–2016 data, statewide fiscal year 2015–2016 data is used.

FIGURE 3

ASHA Incentive Amount Awareness Is Low^a Abbreviations: ANC, antenatal care; ASHA, accredited social health activist; FP, family planning; FS, female sterilization; ID, institutional delivery; MS, male sterilization; PNC, postnatal care; PPIUCD, postpartum intrauterine contraceptive device; VHIR, village health index register; VHND, village health nutrition day. ^a Most ASHAs are aware they get an incentive across items, but very few are aware of the exact amount; 68% ASHAs recognize the incentive amount for ID to be Indian rupee (INR) 600 and not the correct INR 300. Data from linked ASHA survey (N=1,502).

FIGURE 4

ASHA Incentive Claim Experiences (N=1,502)