Fair pay, performance optimizer, or status marker? The social meaning of remuneration for India's women community health workers

What kind of remuneration is appropriate for a Community Health Worker? The literature on CHW incentives largely emphasizes their impact on worker motivations and on health outcomes, including on non-incentivized outcomes. While these are relevant, they miss what Viviana Zelizer calls the social meaning of money, that is, how social relations and cultural values shape and constrain the qualitative life of different monies. I draw on 12 months of ethnographic fieldwork, including 80 interviews, conducted in 2018-19 in north India on Accredited Social Health Activists or ASHAs, the world's largest CHW program. ASHAs are appointed as volunteers and paid through performance-based incentives. I find that respondents' comments reveal three social meanings of remuneration for CHWs: 1) the “fair pay” view in which pay ought to be commensurate with work; 2) “performance optimizer” which regards that remuneration as best which motivates the best performance from the worker; and 3) the “status marker” view in which pay signifies socially ascribed value on a hierarchy of work. While the first two views follow a market logic of money—money is an instrument that measures or stimulates behavior—and proponents could be pro-incentives or pro-salaries, the third view, “status marker”, sees money relationally. Given that all other health department personnel are paid salaries, “status marker” proponents argue that incentives create stigma, erode legitimacy, and sanction mistreatment for ASHAs. Notably, while experts took a mix of views, ASHAs overwhelmingly took the status marker view. My findings reveal how gender-caste-class power infuses one's view of CHW remuneration.