Community health worker payment processes: a qualitative assessment of experiences in two Indian states

Community health worker (CHWs) remuneration has received some attention in terms of the design of incentives, however, there is a lack of systematic data on the processes by which CHWs are paid. We aimed to study existing payment processes including the role of digitization and its effects on CHW experiences with receiving full and timely compensation, and identify barriers and facilitators to the payment process. We studied payment processes for the Accredited Social Health Activist (ASHA) in India in two states with varying levels of performance and payment systems and conducted 53 in-depth interviews and eight focus group discussions across three categories of respondents (37 ASHA workers, 46 supervisors, and 34 managers/health system leaders). The data was coded thematically using inductive and deductive coding methods organized around five steps of the payment process: (i) recording of work, (ii) claim submission, (iii) claim verification, (iv) claim processing, and (v) payment disbursement. We observed complex sub-processes within each stage of the payment process that adversely impacted payment timelines, CHW workload, and motivation, even where digital tools provide support. Local administrative initiative and positive organizational culture overcame these challenges to standardize and simplify processes for recording work, submitting claims, and maintaining adequate funds, facilitating timely payments. Complete digitization of disbursement through the public financial management system improved timeliness, transparency, and satisfaction among CHWs compared to earlier cash and cheque-based payments. The potential digitization of service delivery records for claim submission was met with mixed perceptions among CHWs and their supervisors. Our study contributes to the body of knowledge on CHW compensation by delineating the processes by which financial incentives are paid and offering insights for low and middle-income countries to improve the efficiency of payment systems.