To be capable of surveilling, preventing, and managing disease outbreaks, public health systems require trustworthy, community-embedded public health workers who are empowered to undertake their tasks as professionals. The world has not invested in this cadre of health workers, despite the lessons from Ebola. In a new paper, my co-authors and I discuss why, and how to fix this flaw in the specific context of India.

Before COVID-19, India’s community health workers had been treated as quasi-volunteers and managed with suspicion and distrust. Data collected between November 2018 and March 2019 in the state of Bihar show that community health workers did not receive steady wages and were regularly “scolded” at management meetings (Figure 1).

In common parlance in India, this low effort among and trust in public service providers is referred to as problems of “the system.” Indeed, the majority of our survey respondents, across health cadres, from doctors with supervisory authority at the top of the cadres down to the community health workers at the bottom, agree with the statement: “Irrespective of my efforts, the system will not allow health outcomes to improve.” In economic theory this is referred to as an “equilibrium” in the game of the public sector, sustained by beliefs about how others are behaving.

This research takes economic theory seriously, using rich surveys and innovative modules to measure the variables that theory suggests are important (such as intrinsic motivation and peer norms). The survey provides evidence of the mismatch between actual policy practice and the insights from economic theory and offers ideas to policymakers to adopt a different approach to strengthening health systems using the current crisis as an opportunity.

Read the full article about community health workers by Stuti Khemani at Brookings.