Designing Incentive Structures for Frontline Health Workers

One of the core initiatives of India’s National Health Mission (NRHM) is to provide improved access and responsiveness to healthcare at the community level through female village level frontline health workers known as Accredited Social Health Activists (ASHAs). The “ASHAs”, in addition to being a liaison between the community and the public health system, are also cultural mediators and agents of social change.

Although ASHAs are considered volunteers, the government has introduced a performance-based payment (PBP) incentive structure to DSC_0250motivate and support them in fulfilling their responsibilities around routine immunization and facilitating institutional deliveries. At present the performance of ASHAs is tracked quantitatively, a practice that makes it easy to calculate financial incentives to be given but conversely makes it difficult to identify what interventions are needed in order to massively improve quality of service at the front line level.

A key challenge identified  by the Bihar Innovation lab is that certain aspects of the work done by ASHAs are financially compensated for, as opposed to others. As a result functions which are financially rewarded are often prioritized over other functions (for example the nutrition of the mother) which are more holistically aligned with the needs of the mother and the child.

The Bihar Innovation Lab therefore believes that the public health system needs to relook at the role that financial incentives need to play as a facilitator of idealized behavior at the front line level. This needs to be complemented by supporting structures in the public health system that look at reinforcing  a sense of social responsibility and self efficacy on the part of the ASHAs.

The fieldwork in Bihar shows that a substantial portion of ASHAs’ time is spent only on accompanying pregnant women to institutions for delivery and immunization. ASHAs are less active in promoting services such as postnatal and newborn care and other responsibilities like promotion of awareness on hygiene, sanitation and counsel on family planning (because these are not directly tied to incentive payments). While incentives for FLWs and beneficiaries have worked in increasing mobilization over the last couple of years, the existing incentive structures are based only on quantitative parameters and not qualitative parameters that can help facilitate behavioral change. For example, the ASHAs performance is evaluated based upon the number of institutionalized deliveries, and routine immunizations done for children, rather than on developing a more nuanced understanding of the condition of the woman when she comes in for delivery at a public facility. There is a strong need to graduate onto a mother centric health system, and the role of the ASHA therefore, needs to be rethought of in that context.

It is important to understand that ASHAs are limited by different institutional factors that need to be understood and tackled systematically. These include number-based remuneration structures, poor institutional support, and the rigid hierarchical structure of the health system as well as a dearth of participation at the community level. Each of these problems require diverse solutions that are collaborative and participatory in nature.

These and more, have been worked upon by the Bihar Innovation Lab, and will be showcased and discussed upon, at the Health Public conclave that will be held at the Vihara Innovation campus in New Delhi, on the 22nd of August 2014.

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