In May 2022, at the 75th World Health Assembly, the WHO Director-General gave one of his Global Health Leaders awards to India’s roughly one million Accredited Social Health Activists, the women known as ASHAs who link villages to the public health system. They had carried an enormous share of the pandemic response: tracking households, supporting vaccination, checking on the sick.
The honour was deserved. It also sat awkwardly next to a basic fact about the job. ASHAs were designed as “activists,” not employees. Their pay is built largely from task-based incentives, with a fixed component that varies by state. Commentators in The Lancet Regional Health – Southeast Asia greeted the award by asking whether it was time to move beyond rhetoric to action.
That tension runs through community health worker programmes everywhere. Governments praise community health workers as the backbone of primary care, and then design their jobs as if they were a volunteer effort that happens to be essential. The standard diagnosis for what follows is burnout. My argument is that burnout is the wrong word. It describes an individual’s exhaustion. What is really happening is a design choice: programmes that scale by adding tasks without adding pay, supervision or career, and that rely on the goodwill of women in poor communities to absorb the difference.
The scaling trap
Community health worker programmes usually start small and focused. A pilot trains local women to promote safe delivery, or to treat childhood pneumonia and diarrhoea, or to distribute bed nets. The tasks are clear. The workload is manageable. The results are often impressive, and they get published.
Then the programme scales, and something predictable happens. Every other health programme notices that there is now a trusted person in every village. The tuberculosis programme wants her to trace contacts. The nutrition programme wants her to measure children’s arms. The immunisation programme wants her to find defaulters. The data system wants her to fill in registers. Each request is reasonable in isolation. Each comes with its own training, its own form and, sometimes, its own small incentive.
Nobody owns her total workload. The community health worker becomes a shared resource that no single programme is responsible for, and like most shared resources, she gets overused.
This is the heart of the problem. Scaling a community health worker programme is not mainly a question of training more people. It is a question of who controls the job description once many programmes depend on it.
Why incentive pay makes it worse
Many programmes pay community health workers through a patchwork of per-task incentives rather than a salary. There are reasons for this. Incentives look cheaper, because you only pay for work done. They seem to align pay with results. And they fit the fiction that community health workers are volunteers receiving a token of appreciation rather than workers receiving wages.
The WHO’s 2018 guideline on community health worker programmes, the first evidence-based global guidance on the subject, came down against that model. It recommends paying community health workers a financial package commensurate with the demands and complexity of their job, and advises against paying them exclusively or predominantly through performance-based incentives.
The reasoning is worth spelling out, because it is not obvious to finance ministries. Per-task incentives push workers toward the tasks that pay, and away from those that do not. Counselling a family about a child’s feeding may matter more than registering a pregnancy, but if only the registration earns money, the incentive tells the worker which one her time is worth. Incentive pay also makes income unpredictable, which matters a great deal to women supporting households. And it quietly shifts the risk of every system failure onto the worker: if the vaccine is out of stock, she cannot earn the immunisation incentive, however hard she worked to bring the child in.
A scenario: one worker, one month
Consider a hypothetical community health worker in a rural district, responsible for a few hundred households.
At the start of the month she has a list: new pregnancies to register, newborns to visit within days of birth, children to bring for immunisation, TB contacts to trace, households to survey for a nutrition campaign, and a monthly report to submit in three formats for three programmes. She has a phone that the digital health programme wants her to use for real-time reporting, but no data allowance to use it.
Halfway through the month, a measles case is reported in a neighbouring village. The district asks her to join a door-to-door campaign for a week, unpaid beyond a small daily allowance. Her regular visits slip. At the end of the month, her incentive payment is lower than usual, because she registered fewer pregnancies and her immunisation numbers dropped while she was on the campaign. The payment arrives two months late.
She is not burnt out because she lacks resilience. She is doing more work for less predictable money, with nobody accountable for the overall load. Any rational person in her position would reduce effort, or leave, or both.
The strongest counterargument
The case for volunteer or incentive-based models is not foolish, and it deserves a fair statement.
First, cost. Paying hundreds of thousands of community health workers a regular salary is a large, permanent commitment to the public wage bill. In countries with tight fiscal limits, salaried community health workers may compete with nurses and doctors for the same money. Incentive models let governments reach more villages for the same budget.
Second, community embeddedness. Part of the value of a community health worker is that she is of the community, not an agent of the state. Some argue that turning her into a civil servant, with the bureaucracy and transfers that go with it, weakens that bond.
Third, flexibility. Many community health workers do this work part-time alongside farming, trading and caring for families. A rigid salaried post might not suit them.
These arguments partly hold. Fiscal limits are real, and a programme that pays a smaller number of workers properly may reach fewer villages than one that pays many badly. Community embeddedness matters and is worth protecting. But the evidence behind the WHO guidance, and the experience of programmes that have relied on incentives at scale, suggests that the hidden costs are large: high turnover, uneven quality, neglect of unpaid tasks, and repeated retraining as workers leave. A programme that constantly replaces its workforce is not cheap. It is just paying in a currency that does not appear in the budget.
There is also a middle path. Ethiopia’s Health Extension Program, launched in the early 2000s, took a different approach by employing salaried health extension workers as part of the formal health system. It is not the only model, and it has faced its own challenges, but it shows that treating community health workers as part of the workforce is a viable choice rather than a utopian one.
The supervision gap
If pay is the most discussed weakness of community health worker programmes, supervision is the most neglected.
A community health worker is often the least trained person in the health system and the most isolated. She makes judgement calls alone: whether a child’s breathing is fast enough to need referral, whether a pregnant woman’s headache is a warning sign. Good supervision gives her someone to call, a chance to review difficult cases, refresher training and the sense that the system has noticed her work.
In many programmes, supervision exists mainly on paper. The supervisor is a nurse at the health centre with a full clinical workload, no transport budget and dozens of community health workers to oversee. Supervision visits, when they happen, turn into checks on registers rather than support for practice. The result is that workers feel monitored but not supported, which is close to the worst combination for morale.
Supervision is also where scaling costs hide. A programme can train a thousand new workers quickly. It cannot so quickly find the supervisors, vehicles and fuel to support them. Programmes that scale the workforce faster than supervision are building in the conditions for decline.
Second-order effects
The way community health workers are employed shapes the whole health system.
It shapes gender equity. Most community health workers are women. Programmes that rely on their unpaid or underpaid labour are, in practice, subsidising the health system with women’s time. That has consequences for household incomes and for women’s economic independence.
It shapes data quality. Workers paid per recorded task have a reason to record tasks, whether or not they were done well. Workers overloaded with reporting spend time filling forms rather than visiting households. Health information systems that rely on community reporting inherit both problems.
It shapes political stability. In India, ASHAs have protested repeatedly for fixed pay and recognition as workers. When community health workers organise, governments face a choice between negotiating, which raises costs, and resisting, which risks the service. Neither is a crisis if pay is designed properly from the start.
It shapes the rest of the workforce. When community health workers take on tasks that nurses once did, the nursing workforce can focus on more complex care. But if community health workers are unsupported, the tasks bounce back up to overstretched clinics.
What sustainable scaling looks like
- Give someone ownership of the whole job. A single unit should approve every new task assigned to community health workers, with the authority to say no or to require extra resources.
- Pay a predictable base. A fixed component that covers the core role, with incentives as a smaller top-up, is closer to what the WHO guidance recommends than pure task-based pay.
- Budget supervision as seriously as salaries. Supportive supervision, not inspection, is what keeps quality up and turnover down.
- Build a career. Pathways into nursing, midwifery or supervisory roles give community health workers a reason to stay and grow.
- Pay on time. Late payment is one of the most corrosive and most fixable failures.
- Cut reporting burden. Consolidate forms and make digital tools work offline, with data costs covered.
What this means for each actor
For health ministries, the key decision is whether community health workers are part of the workforce plan or outside it. If they are essential, they should be planned, budgeted and paid as workers.
For finance ministries, the relevant comparison is not the cost of salaries against the cost of incentives. It is the cost of a stable workforce against the cost of turnover, retraining and lost effectiveness.
For funders, many community health worker programmes began with donor money, often with incentive structures designed for short projects. Funders should help governments move to sustainable domestic pay rather than designing new parallel incentive schemes for each programme.
For clinicians and facility managers, community health workers are colleagues. Treating them as data collectors or messengers wastes what they know about their communities.
What to watch next
Watch whether governments that praised community health workers during the pandemic have since moved toward fixed pay and formal recognition. Watch whether health ministries create a single point of control over community health worker tasks. And watch turnover rates, which are the most honest indicator of whether a programme is scaling sustainably or simply burning through goodwill.
Community health workers are often described as the backbone of primary health care. Backbones need to be looked after. A programme that keeps adding weight without adding support should not be surprised when something breaks.
If you run or fund a community health worker programme, who decides what gets added to their workload, and who has the power to say no?
