TY - JOUR T1 - Improving Community Health Worker Compensation: A Case Study From India Using Quantitative Projection Modeling and Incentive Design Principles JF - Global Health: Science and Practice JO - GLOB HEALTH SCI PRACT DO - 10.9745/GHSP-D-21-00413 VL - 10 IS - 3 SP - e2100413 AU - Mokshada Jain AU - Yael Caplan AU - Banadakoppa Manjappa Ramesh AU - Hannah Kemp AU - Bettina Hammer AU - Shajy Isac AU - James Blanchard AU - Vasanthakumar Namasivayam AU - Sema K. Sgaier Y1 - 2022/06/29 UR - http://www.ghspjournal.org/content/10/3/e2100413.abstract N2 - Key FindingsUsing earnings projection models, we identified gaps and implementation challenges in the accredited social health activist (ASHA) incentive structure that may affect ASHAs' motivation and desired health outcomes.ASHAs could more than double earnings by achieving full coverage and completing activities fully within their control.Government payments are higher than the modeled actual earnings, hinting at overpayment due to receipt of full payment despite only partial completion of antenatal care, postnatal care, and immunization incentives and suggesting that the current design does not motivate ASHAs to complete a series of outcomes.Key ImplicationsChallenges such as issues in the disbursement of payments, payment on partial completion of tasks, incentive dependence on household actions, ASHAs not performing at their full potential, and lacking awareness of the quantum of incentive present several opportunities for policy makers to improve CHW compensation structures. Possible courses of action include improving the incentives model design to help community health workers achieve outcomes and the incentive tracking and payments machinery.Updating incentive structures for community health workers using lessons on incentive design from the field can improve CHW effectiveness in India and globally.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. ER -