Fair Pay, Performance Optimizer, or Status Marker? The social meaning of remuneration for community health workers.

• In Event: 20481 - Section on Sociology of Development Roundtables
  In Refereed Roundtable (60 minute): Table 2. Health and Development

Abstract

What form of payment is appropriate for a community health worker? With staffing models ranging from highly trained, salaried CHWs to volunteers on limited training, the debate about how CHWs should be remunerated is an ongoing one. Here, I focus on the world’s largest community health worker program: India’s Accredited Social Health Activists or ASHAs, a nationwide cadre of one million women appointed as volunteers and paid through performance-based incentives. Performance-based incentive refers to the transfer of money conditional on the achievement of a predetermined target. The literature on incentives largely emphasizes its impact on worker motivations and on outcomes (including on non-incentivized outcomes). While these are relevant, they miss what Viviana Zelizer calls the social meaning of money. In 2018-19, I conducted 14 months of ethnographic fieldwork, including 60 interviews with ASHAs and 20 with ASHA program experts. I find that in discussions of whether ASHAs should be remunerated through incentives (as they currently are) or switched to salaries (as all other health department staff are) respondents reveal three social meanings of remuneration for community health workers, which I term “fair pay”, “performance optimizer” and “status marker”. I argue that the logic underlying both the “fair pay” and “performance optimizer” views is that money is an instrument with which to measure or stimulate behavior. The “status marker” view, however, offers a different logic: of money as embedded in social relations, that is, as both a product and signal of socially ascribed value. Ultimately, unless health policy accounts for what money signifies, and not only what it stimulates, states will benefit from and contribute to the marginalization of already marginalized workers.

Author

• Vrinda Marwah, University of South Florida