Compensation Strategies

Note many of these are not mutually exclusive

Flat, regionally competitive salary

Pros/Benefits

Simple accounting

Most familiar and comparable to other jobs

Cons/Dangers

Little financial incentive for good performance

Community Prestige

Pros/Benefits

Should be less economically costly. 

Community-driven, in line with broader community development/mobilization goals.

Cons/Dangers

Difficult to measure effectiveness.

Assistance to Family

These might include healthcare, childcare, and education benefits. 

Pros/Benefits

Community-driven, in line with broader community development/mobilization goals.

Could be helpful with retention, particularly as the CHWs gain skills that might be applicable to urban areas.

Cons/Dangers

Could be costly and difficult to draw boundaries

Atomized, performance-based incentives

Some areas that we are considering incentivizing include:

• attendance of training sessions and weekly follow-up meetings at the clinic
• encouraging women in their wards to attend antenatal care visits, both initial referral and follow-up
• bringing women in for deliveries at our clinic
• encouraging follow-up of treated patients at our clinic of conditions such as abscess, malnutrition, or tuberculosis.
• encouraging families to bring in children for vaccination and routine pediatric follow-up to the clinic

Some of these have been incorporated into India's National ASHA program

Pros/Benefits

Probably the most direct, financial strategy for performance-based accountability

Cons/Dangers

"Gaming the system" to provide the quotas that people expect, whether or not they are made explicit.  In a survey of our previous CHW programs at the MV sites, we found that people literally reported doing the impossible to stay in line with perceived (completely unstated!) expectations.  I have been particularly concerned about the underreporting of mortality, for instance.   The creation of an open information sharing environment really requires that the community members, CHWs and supervisors -- along with other people in the community who respect the importance of these functions -- are involved.  This takes the weight off the CHWs in terms of outcomes, but fosters gains in quality of performance.  We are in the process of "re-opening" our CHW program, and I will send you all the tools we are creating if you are interested, along with our strategy documents.

Mobile Phones

Major issue here is getting that CDMA tower built in Bayalpata-- lobbying process ongoing.

Career Mobility

Provide CHWs with possibility to become "senior CHW" or even receive an educational scholarship for ANM, HA, lab tech, MBBS, etc. training

Example Programs

Millenium Villages (as per jot)

- rapid feedback via mobile phones / reporting about the health status of all the people in the CHW catchment zones

- tri-directional feedback from the community, CHW and CHW supervisor

- a base salary, priority for free health care (including their family)

- and non-monetary incentives like the ability to keep the mobile after 2-3 years of good performance (also maintains the care of the phone) / iconic backpacks for supplies

- elevation to "senior CHW" (who is responsible for other CHWs) via extra training

The factor that ups the ante for us is that once CHWs are trained, there is a large incentive to leave the rural area and go to secondary cities.  This creates an inherent asymmetry such that simply salary support does not maintain retention and certainly doesn't have an appreciable impact upon motivation.  Keeping this in mind, the underlying principles for the approaches above are to

1) create an environment where the CHWs family is supported, which also enhances their respect in the community

2) provide opportunities for advancement without losing health care capacity

3) increase feedback on quality of care and interactions and transparency so everyone involved knows the dimensions of the issues and the direction of their movement.

Point #3 is important because I don't want to begin incentivizing atomized issues in clinical care.  This creates an environment where those skills that are not incentivized become lower priority, and you "train" the system to only work for direct incentives.  Nevertheless, the problem remains, and if you have a finite list that you don't see expanding, then I wouldn't say no out of principle.  But point #3 coupled with #1 and 2 place the emphasis on the process of providing care in the context of community and career.  One of the major reasons that motivation is low is that people generally perform what feel like automated tasks without any feedback.  This requires that there are effective and simple tools to aid supervisors (or senior CHWs).  We can send you what we are using.

Furthermore, we are developing tools/impact assessments to gauge the program in terms of cost and quality of care (a very, very rough draft is attached, confidential and still needs a lot of work on quality of care but we will have this soon and I will make sure to include your program in the distribution if you are interested).

ASHA Program (as per Nirupam Bajpai, via jot)

URL of the Ministry of Health website that will give you detailed info on the ASHA program:

http://mohfw.nic.in/NRHM/asha.htm

They have not released much data to date.  In our evaluation of the NRHM, much of the focus will be on the ASHA workers.  We plan on addressing the following issues among others:

●          Are there clearly identifiable norms and processes that guide the recruitment of ASHA workers (e.g., an ASHA worker should be from the same village where she will serve?) Are these norms being followed?

●          whether proper recruitment, comprehensive training, effective control and oversight and timely and adequate payments of the ASHAs is in place?

●          Are the roles and responsibilities of the ASHA worker vis-à-vis other government functionaries defined, articulated, and communicated (e.g., with ANMs, anganwadi workers, PHC officials, panchayati raj officials, etc.) in such a way as to reduce conflict between the different agencies, but also allow her to still be effective? Is her role/job definition simple enough that it is likely to be followed in practice?

●          Are there simple tools, processes, and management information systems (MIS) that an ASHA worker has to help her in her day-to-day job and monitor the effectiveness of her performance?

●          Are the incentive systems of the ASHA worker aligned with doing the few simple things that will have the most health impact among women and children?

●          Does the ASHA worker receive adequate support and coaching from supervisors, and support from PHCs, Panchayati Raj, and the ICDS system to be able to deliver effectively on her job?  Are the ASHA workers paid on time and adequately?  Are they adequately supplied with medical kits?

I hope this is useful. Thanks - Nirupam"