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Understanding factors that help retain and sustain CHW in health systems

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Rohina Joshi, Senior Research Fellow, The George Institute for Global Health explicates on the role of Community Health Workers (CHWs) and how a sustainable model is required to retain them in the Indian healthcare domain

CHW forms the essential link between communities and health systems in low-and-middle income countries. Often working as volunteers on performance-based incentives, CHWs deliver several interventions aimed at attaining the Sustainable Development Goals for health. CHWs have been credited with improvements in health and social outcomes, particularly in relation to reproductive and child health. Yet, many CHWs work without adequate training, remuneration, supportive supervision or basic entitlements under domestic labour laws which results in low motivation levels and high attrition rates.

India has one of the world’s largest CHW initiatives. The George Institute for Global Health, conducted a discrete choice experiment to identify the key motivational factors that may help retain Accredited Social Health Activists (ASHAs) in service in Andhra Pradesh, India. A discrete choice experiment is a survey which elicits preferences of individuals from a range of choices. It helps researchers and policy makers understand how individuals select attributes of a programme. We developed an android-tablet based DCE for ASHAs (https://link.springer.com/content /pdf/10.1186%2Fs13690-019-0346-0.pdf). Our study which included 299 ASHAs, found that more than 85 per cent of the participating ASHAs wanted opportunities to progress their career and were willing to sacrifice Rs 2530 ($35.45) out of their monthly salary for a job that offers promotion. Other factors that they chose included having a fixed salary (as opposed to performance based incentives) and free family health care.

Our results are also broadly consistent with DCEs done among nurses in Malawi, and Laos, and community health officers in Ghana which showed career development and continuing education are the two influencers in shaping the preference profile. These findings are similar to a mixed-methods study done in Haryana which identified the passion for work, financial incentives, community recognition, and training as the key motivators. While training with an opportunity for promotion is not a direct financial incentive, it offers job security, higher salary, more authority and recognition.

Priority free family health-check and low workload were other driving factors that affected the ASHAs’ choices. These findings support the growing evidence of the importance of the non-financial interventions in motivating community health workers in developing countries. Financial incentives should ideally be accompanied by a non-financial package that could be tailored to the local context. Both options are indispensable, where monetary incentives provide security and allows for personal development of the workers; non-monetary incentives provide satisfaction and can optimize the CHW’s performance.

The recent World Health Organization guidelines for optimising CHW programs recommends training, supportive supervision, appropriate remuneration, written contracts with detailed job description, health worker rights and opportunities for career development to motivate and retain CHWs in the health system (https:// apps.who.int/iris/bitstream/handle/10665/275474/9789241550369-eng.pdf?ua=1&ua=1).

Government of India recently announced a revised pay scale for the ASHAs with social security cover. Given that different states in India have the authority to implement the new recommendations, the following years will see how this policy is rolled out in the different regions of India.

This study has relevance for both India and other countries with CHW programmes. CHW programmes across the globe face similar issues of low motivation, and poor morale which leads to poor health outcomes of the community. Understanding health worker choices and addressing them could resolve some of these issues. Policy decisions should take health worker preferences into account to motivate, retain and sustain CHWs and their efforts in achieving SDGs.

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