Major issues of CHWs
CHWs have been working within public health care systems in several countries across the globe for decades but they are the only cadre of health workers that do not have a standard payment pattern. CHWs in some countries like Brazil do receive salaries like their colleagues, however largely CHWs receive honorariums/incentives.
We have several international testimonials that 'performance based finance' or 'performance based incentives' are successful in motivating health workers. This is encouraging. However, we need to understand the universal understanding of the term 'performance based finance' or 'performance based incentives'. Incentives by their very definition, are additional sums to a basic payment, granted as a recognition of better performance by a worker. The idea is to encourage motivation in the recipient worker.
But what if the entire payment of a worker consists only of incentives without a basic payment? Would this system of payment really be considered as an incentive by the recipient worker? This discussion is about CHWs in India but applies to all CHW programs within government health care systems regardless of the country where they function.
In India, there are two separate patterns of payment for two separate CHW programs. The Anganwadi workers receive a fixed amount every month, but there are no social security or pension benefits. The basis for setting the fixed amount is not in accordance to any national/international norm. The ASHA workers receive what is called as ‘task-based incentives’ every month from the government for their work.
Every month, ASHAs do a number of tasks. Each task has a fixed incentive associated with it. The total tasks done by each ASHA are recorded by their supervisors and the commensurate incentives are then allocated every month under each respective health program. These health programs can be from the State or from the Central government. The incentive too comes from both these sources, directly into the bank account of the ASHAs.
There is no other payment like a salary for the ASHAs. There are no social security or pension benefits either. The basis for setting the amount for the incentive for each task is not known. A few State governments do give the ASHAs a set monthly amount in addition to incentives. In most of the States however, the incentive system is followed.
The word ‘incentive’ is a misnomer because this is the sole payment, without a basic salary. Rather their payment is actually task-based compensation. The term incentive is used because ASHAs are designated as volunteers, they are not employees, hence cannot be termed to be receiving compensation in any form from the government.
An argument is often raised that incentives will keep the motivation of the CHWs higher and prevent complacency from setting in. In actuality, the uncertainty of income due to the incentives system, demotivates these workers. A combination of a fixed amount and performance-based incentives, as demonstrated in some States is a viable alternative.