CHWs (69) What do community health workers want?

16 June, 2019

Below are the citation and abstract of a new paper in BMJ GlobalHealth,and a comment from me.

CITATION: Abdel-All M, Angell B, Jan S, et al What do community health workers want? Findings of a discrete choice experiment among Accredited Social Health Activists (ASHAs) in India BMJ Global Health 2019;4:e001509.


Introduction: A number of factors contribute to the performance and motivation of India’s Accredited Social Health Activists (ASHAs). This study aims to identify the key motivational factors (and their relative importance) that may help retain ASHAs in service.

Methods: A discrete choice experiment (DCE) survey presented ASHAs with eight unlabelled choice sets, each describing two hypothetical jobs that varied based on five attributes, specifically salary, workload, travel allowance, supervision and other job benefits. Multinomial logit and latent class (LC) models were used to estimate stated preferences for the attributes.

Result: We invited 318 ASHAs from 53 primary health centres of Guntur, a district in south India. The DCE was completed by 299 ASHAs using Android tablets. ASHAs were found to exhibit a strong preference for jobs that incorporated training leading to promotion, a fixed salary and free family healthcare. ASHAs were willing to sacrifice 2530 Indian rupee (INR) from their monthly salary, for a job offering training leading to promotion opportunity and 879 INR for a free family health-check. However, there was significant heterogeneity in preferences across the respondents. The LC model identified three distinct groups (comprising 51%, 35% and 13% of our cohort, respectively). Group 1 and 2 preferences were dominated by the training and salary attributes with group 2 having higher preference for free family health-check while group 3 preferences were dominated by workload. Relative to group 3, ASHAs in groups 1 and 2 were more likely to have a higher level of education and less likely to be the main income earners for their families.

Conclusion: ASHAs are motivated by both non-financial and financial factors and there is significant heterogeneity between workers. Policy decisions aimed at overcoming workforce attrition should target those areas that are most valued by ASHAs to maximise the value of investments into these workers.

COMMENT (NPW): ASHAs (community health workers in India) 'are motivated by both non-financial and financial factors'. Interestingly, they were found 'to exhibit a strong preference for jobs that incorporated training leading to promotion, a fixed salary and free family healthcare'.

Currently the career progression opportunities for CHWs worldwide are limited. Just as with other health workers, it make sense to have a career ladder with the possibility of further training for 'higher cadres'. Personally, I find the systematic promotion of career pathways quite exciting - this has the potential not only to be a motivating factor for selection, certification, and service, but also to strengthen links between CHWs and other members of the primary healthcare team. Indeed, a health professional who originally trained as a CHW and who has then goneon to further training will have exceptional skills and qualities that are less likely to be seen in colleagues who have not had that experience.

All this is reflected in Recommendation 9 of the CHW Guideline: 'a career ladder should be offered to practising CHWs'.

Best wishes, Neil

Coordinator, HIFA Project on Community Health Workers

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: