Downloaded from http://bmjopen.bmj.com/ on November 30, 2015 - Published by group.bmj.com Open Access Research Assessing community health 102431 workers’ performance motivation: a mixed-methods approach on India’s Accredited Social Health Activists (ASHA) programme Saji Saraswathy Gopalan,1 Satyanarayan Mohanty,2 Ashis Das1 To cite: Gopalan SS, ABSTRACT Mohanty S, Das A. Assessing ARTICLE SUMMARY Objective: This study examined the performance community health motivation of community health workers (CHWs) and Article focus workers’ performance its determinants on India’s Accredited Social Health ▪ What is the current level of the performance motivation: a mixed-methods approach on India’s Activist (ASHA) programme. motivation of the community health workers? Accredited Social Health Design: Cross-sectional study employing mixed- ▪ What are the determinants of their performance Activists (ASHA) programme. methods approach involved survey and focus group motivation? BMJ Open 2012;2:e001557. discussions. ▪ What are the community health workers’ (CHWs) doi:10.1136/bmjopen-2012- Setting: The state of Orissa. perceptions and experiences on the current status 001557 Participants: 386 CHWs representing 10% of the total of the factors affecting their performance CHWs in the chosen districts and from settings selected motivation? ▸ Prepublication history and through a multi-stage stratified sampling. additional material for this Key messages Primary and secondary outcome measures: The paper are available online. To ▪ The CHWs are more motivated on the individual level of performance motivation among the CHWs, its view these files please visit and the community level factors than the health the journal online (http:// determinants and their current status as per the system determinants. perceptions of the CHWs. dx.doi.org/10.1136/bmjopen- ▪ The qualitative findings also support the survey out- 2012-001557). Results: The level of performance motivation was the comes that the healthcare delivery status and the highest for the individual and the community level factors human resource management modalities for CHW Received 24 May 2012 (mean score 5.94–4.06), while the health system factors are not satisfactory for them. Accepted 15 August 2012 scored the least (2.70–3.279). Those ASHAs who felt ▪ This study recommends that the CHW management having more community and system-level recognition needs changes to ensure adequate supportive This final article is available also had higher levels of earning as CHWs (p=0.040, supervision, skill and knowledge enhancement and for use under the terms of the Creative Commons 95% CI 0.06 to 0.12), a sense of social responsibility enabling working modalities. Attribution Non-Commercial (p=0.0005, 95% CI 0.12 to 0.25) and a feeling of self- 2.0 Licence; see efficacy (p=0.000, 95% CI 0.38 to 0.54) on their Strengths and limitations of this study http://bmjopen.bmj.com responsibilities. There was no association established ▪ This is a unique study exploring the performance between their level of dissatisfaction on the incentives motivation of the public sector CHW on one of the (p=0.385) and the extent of motivation. The inadequate largest CHW programmes in the world. The evi- healthcare delivery status and certain working modalities dence on CHWs’ performance motivation and that reduced their motivation. Gender mainstreaming in the of public sector CHW programmes are limited. The community health approach, especially on the demand- unique application of the mixed-methods approach side and community participation were the positive will enhance the generalisability of the study find- externalities of the CHW programme. ings. It helped in finding the causality between the Conclusions: The CHW programme could motivate and level of CHW’s motivation and its each determinant empower local lay women on community health largely. along with an understanding of how and why a The desire to gain social recognition, a sense of social CHW is motivated or demotivated. The study dis- responsibility and self-efficacy motivated them to perform. cussions are centred on comparable global experi- 1 The World Bank, NW The healthcare delivery system improvements might ences for relevant policy changes. Washington DC, USA further motivate and enable them to gain the community ▪ Among the study limitations, there could be a pos- 2 DCOR Consulting Pvt Ltd, trust. The CHW management needs amendments to sibility of CHWs’ responses complying with percep- Bhubaneswar, Orissa, India ensure adequate supportive supervision, skill and tions of what should be an acceptable answer. We knowledge enhancement and enabling working did not assess the actual level of performance of Correspondence to modalities. the CHWs and its effectiveness from the commu- Dr Saji Saraswathy Gopalan; sajisaraswathyg@gmail.com nity’s or the supervisors’ perspectives. Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 1 Downloaded from http://bmjopen.bmj.com/ on November 30, 2015 - Published by group.bmj.com CHWs ’ performance motivation and its determinants INTRODUCTION their job satisfaction derived from certain intrinsic and Globally, the intermediation of community health workers extrinsic motivators.6 However, the yardstick for their per- (CHWs) in healthcare delivery is widening as they are inev- formance motivation assessment should be different from itable to meet the universal healthcare provision and the usual health staffs particularly on three grounds; (1) many millennium development goals.1 The term ‘community CHWs are volunteers and not salaried staff, (2) they are lay health worker’ encompasses a wide variety of local health- workers without prior training on community health and care providers ranging from nurse-midwives to home-based (3) CHWs constitute the outreach workforce directly care givers and salaried-staffs to volunteers.2 The CHWs linking the community with the formal healthcare.7 enable access to and utilisation of health services, and Further, the approach to assess the public sector CHWs’ inculcate healthy behaviours among the communities.3 work motivation could be different from the private sector They are preponderantly deployed to cater to underutilised since they are more integrated with the formal healthcare services, unmet health behaviours and underserved popu- system and have wider responsibilities. The existing few lations.3 The CHW’s contributions to disease control, studies from Kenya, Vietnam, Bangladesh, Taiwan, etc immunisation and family planning programmes are have largely catered to the latter or omitted a ‘mixed already established.4 In the public sector, though the -methods approach’ by mostly employing the qualitative CHWs are primarily link-workers or motivators, yet they do tools.8–12 This paper explores one of the largest public undertake curative services for malaria, tuberculosis and sector community health worker initiatives in the world, elderly care.3 The spectrum of the CHW programmes namely the Accredited Social Health Activist (ASHA) varies across countries on their objectives, rollout and man- programme in India. This study had three objectives: agement. Their larger penetration and sustainability are (1) assessing the current level of performance motivation more observed with the public sector.5 Having identified among the ASHAs, (2) understanding the factors affecting the potential of women in community mediation, predom- their level of motivation and (3) their perceptions and inantly females constitute CHWs universally.2 experiences on the current status of the motivational determinants. Rationale The existing literature on CHWs’ performance motivation ASHA programme: an overview and its determinants are scanty. Similar to any other The ASHA is a female volunteer selected by the commu- health cadre, the performance of CHWs depends on nity, deployed in her own village (one in every 1000 Figure 1 Responsibilities of the Accredited Social Health Activist. 2 Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 Downloaded from http://bmjopen.bmj.com/ on November 30, 2015 - Published by group.bmj.com CHWs ’ performance motivation and its determinants population) after a short training on community parameters and under each a set of questions explored health.13 She is preferred to be between 25 and 45 years their level of motivation on a Likert scale of 1 (strongly old, with a minimum formal education of 8 years and disagree) to 5 (strongly agree). The construct of the demonstrable leadership qualities.13ASHAs are not salar- questions were balanced with both positive and negative ied and they belong to the voluntary cadre of health staffs directions to prevent similar responses. The composite as they get fixed activity-based incentives. Started in 2006, score of all questions decided the level of motivation currently the ASHA programme has spread across the under each parameter. A CHW was considered as moti- country with 820 000 women trained and deployed.14 vated on a particular parameter if her mean score was Their responsibilities range from health education to above 3. At the health system level, the exploration was on diagnosis of health conditions ( figure 1). Each state over- the organisation and management of the healthcare sees the programme confining to the guidelines of the delivery system (eg, availability of services and commod- National Rural Health Mission (NRHM). ities, incentives, monitoring and training of CHWs, interaction with supervisors, peers and grass roots non- governmental organisations (NGOs)). The community METHODS level parameters consisted of community response, recog- Conceptual framework nition of CHW and participation in activities. At the indi- The concept of ‘performance motivation’ is complex and vidual level, abilities, inducements to perform, job can be defined contextually. The study defined it as the satisfaction, family support, etc were explored. The CHW’s degree of interest and willingness to undertake focus group discussions (FGDs) explored CHWs’ current and improve upon an allotted responsibility towards com- experiences and perceptions on the factors affecting munity health.8 We used a customised framework adapted their performance motivation. Their suggestions to from the existing literature.8–12 15 16 The motivation improve upon the existing situations were also probed. factors were broadly classified into individual and environ- mental. The latter was further divided into health system and community level factors ( figure 2). Further, 16 parameters Sampling and recruitment were considered (identified from the literature and self- The study settings were selected through a multistage validated by the CHWs through group discussions) stratified sampling. First, Orissa was selected randomly together under the above broad classifications, that is, indi- among the high-focus states of NRHM. Then, the dis- vidual, health system and community levels (table 2). tricts of Angul and Mayurbhanj were selected represent- ing the state based on its administrative division. Finally, Assessment tools 25% of the rural administrative blocks from each district This cross-sectional study conducted during 2010 were randomly selected. employed a mixed-methods approach, that is, a combin- The survey purposively targeted 10% (n=434) of the ation of qualitative and quantitative techniques. It existing number of ASHAs (n=4342) together from both employed both survey and focus groups discussions the districts.7 Thus, it planned to interview 55 ASHAs among the CHWs. The survey tool constituted 16 from each of the eight rural administrative blocks. Figure 2 Community health worker’s performance motivation assessment framework. Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 3 Downloaded from http://bmjopen.bmj.com/ on November 30, 2015 - Published by group.bmj.com CHWs ’ performance motivation and its determinants conducted in the local language Oriya. The participants Table 1 Background characteristics of the CHWs were informed about this study through local village Characteristics Percentage (n/386) leaders and women’s groups a week prior to the study. Age (years) A written informed consent was obtained from each 25–30 45.60 (176) CHW after explaining the study objectives and the 31–35 32.64 (126) intended use of the information. The participation was 36–40 17.88 (69) completely voluntary and the respondents had the >41 3.88 (15) choice of not answering any question or withdrawal Education (years) from the study at any time. The confidentiality of the 5–7 14.25 (55) 8–10 85.75 (331) participants was maintained throughout the study. The Marital status interviews were conducted at a convenient location and Married 70.47 (272) refreshments were provided to the participants. In each Widowed 17.88 (69) district, the survey and the FGDs were performed by five Separated 3.88 (15) locally based researchers, who were social science bache- Unmarried 4.92 (19) lors. The entire data collection process took 3 months. Divorced 2.85 (11) A predesigned protocol guided the conduct of the data Poverty status collection and further, it was supervised by one of the Below poverty line 70.98 (274) coauthors. We could not initiate for ethical approval as Above poverty line 29.02 (112) there was no such specific entity in the state providing Monthly household income in INR (US$) ethical approval on this kind of research. 1000–2000 (22.21–44.44) 21.51 (83) 2001–3000 (44.46–66.65) 43.26 (167) >3000 (66.67) 35.23 (136) Data analysis Caste The quantitative information was analysed through Scheduled caste* 29.02 (112) STATA. Linear and multivariate regression tests Scheduled tribe* 36.01 (139) explored the association between the level of perform- Others 34.97 (135) ance motivation and the predictors at different levels Monthly earning as CHW in INR (US$) along with the CHWs’ background characteristics. The <500 (11.13) 2.07 (8) qualitative data were transcribed verbatim and trans- 500–1000 (11.13–22.21) 14.77 (57) lated to English by the researchers themselves who con- 1001–1500 (22.24–33.33) 83.16 (321) Sources of earning ducted the interviews. These translations were verified Only as CHW 91.97 (355) by the coauthors who are proficient in the local lan- Other sources 8.03 (31) guage. The translated transcripts were coded and ana- Years of experience as ASHA lysed through NVivo. The analysis was both inductive <2 17.10 (66) and deductive and relevant themes were indexed 2–5 82.90 (320) under the individual, health system and community-level Number of trainings undergone aspects. They were further classified as the enabling <5 73.06 (282) and the demotivating factors for the CHW’s perform- 6–10 26.94 (104) ance. The qualitative findings were triangulated with *Scheduled caste and tribe are communities that receive special the survey findings confining to the conceptual frame- privileges from the Government of India based on relatively weaker socio-economic status. work of the study. ASHA, Accredited Social Health Activist; CHWs, community health workers; INR, Indian rupees. RESULTS The survey consisted of 386 CHWs (table 1), of which However, only 386 ASHAs could be interviewed consid- the majority were below poverty line (71%), married ering their availability and willingness during the study (70.47%) and scheduled tribes (36%). Most of them period. Each survey on an average took about had 8 years of formal education (85.75%), experience of 30–45 min. 2–5 years as CHW (82.9%). The majority had under- There were 11 FGDs for 78 CHWs and each consti- gone a minimum five trainings (73.06%), earned US tuted 7–10 participants. There were mixed groups of $22.24–33.33/month as a CHW (83.16%). Further, most ASHAs from different socio-economic and demographic of them did not have any other personal sources of backgrounds. Each FGD took between 45 and 60 min earning (91.97%). and interviews were conducted till the data saturation. An FGD guide with broad themes and specific probes Level of performance motivation among the CHWs directed the discussions. The FGDs were conducted first, The level of motivation was the highest on the intrinsic followed by the survey. job satisfaction on various job-related achievements (mean The local women’s groups mobilised the CHWs for 4.30; 68.4% of CHWs). The self-efficacy or the perceived the surveys and the FGDs. The interviews were abilities on job scored a mean score of 4.27 (69.7%). 4 Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 Downloaded from http://bmjopen.bmj.com/ on November 30, 2015 - Published by group.bmj.com CHWs ’ performance motivation and its determinants Table 2 Level of performance motivation among the community health workers (CHWs) (N=386) Motivated* Variable Mean 95% CI n (%) Health system level Nature of responsibilities: level of interest in the responsibilities 4.18 4.09 to 4.27 256 (66.3) and confidence to execute them Workload: time to complete daily tasks, able to spend time with f 2.96 2.90 to 3.02 34 (8.8) amily and flexibility in work schedule Incentive: adequacy of financial and non-financial incentives and their 3.07 2.97 to 3.17 64 (16.6) pattern of payment Healthcare infrastructure: satisfaction on the quality of existing infrastructure, 2.83 2.78 to 2.89 26 (6.7) communication options and commodities Work modality: satisfaction on hierarchy, participatory approach, 3.18 3.13 to 3.24 68(17.6) recording and reporting Training: level of knowledge and skills imparted through trainings, and timing and 3.78 3.72 to 3.85 281 (72.8) organisation of training Supportive supervision: help, monitoring, and supervision to execute r 3.28 3.23 to 3.32 47 (12.2) esponsibilities and solve issues Peer support: moral support, advice and learning from peers 4.04 3.95 to 4.14 298 (77.2) Community level Community participation: level of community’s interest, acceptance and 4.05 3.96 to 4.16 244 (63.2) participation in activities Community opinion on public healthcare system: on quality of care, availability of 2.70 2.65 to 2.75 4 (1.0) healthcare and community programmes Individual level Social responsibility and altruism: interest in social work when existing 4.12 4.04 to 4.20 255 (66.1) social norms adversely impact community health, and sense of social responsibility Intrinsic job satisfaction: chance for better use of abilities and time, feeling of 4.30 4.24 to 4.36 264 (68.4) accomplishment, awards, career enhancement, advancement in employability, knowledge, communication skills, managerial skills and overall happiness being on job Self-efficacy: able to handle tough situations, solve problems, feel emotionally and 4.27 4.20 to 4.33 269 (69.7) physically perfect on work Self-motivation: working with a sense that the job is important and is not for 4.07 4.05 to 4.10 327(84.7) avoiding blame from others and gaining money alone Individual+community+health system level Recognition: acceptance of CHWs’ performance, its value, and talents by family, 3.96 3.90 to 4.02 214 (55.4) community and system Autonomy: freedom to move in the community, express opinion and execute 3.96 3.90 to 4.02 233 (60.4) responsibilities *Motivated if mean score >3. The nature of the job responsibilities positioned at the modality (3.18; 17.6%) and the incentives (3.07; 16.6%) third with a mean score of 4.18 (66.3%), followed by the also scored a moderate mean. social responsibility and altruism (4.12; 66.1%). The mean A large proportion of the ASHAs (n=327; 84.72%) scores were 4.07 for the self-motivation (84.7%), 4.06 for were self-motivated. If we look at the individual scores the community participation in activities (63.2%) and 4.04 for each parameter, the question on community for the peer support (77.2%). acceptance, that is, the community accepts my activities as The degree of motivation was the least on the commu- I intend to secured the highest mean score at 4.64 nity opinion on the healthcare delivery system (2.7; 1%), fol- (n=366). Second, a self-efficacy-related question (I can lowed by their satisfaction on the level of healthcare always manage to solve dif ficult problems if I try hard infrastructure (2.83; 6.7%). The ASHAs were also less enough) scored at 4.58 (n=350). Further, the probe on motivated on their work load (2.96; 8.8%). They had a the intrinsic job satisfaction (I am satisfied that I accomplish moderate level of motivation (mean 3–4) on enjoying something worthwhile in this job) received a mean score the autonomy to move, express opinions and execute the of 4.54 (n=336). responsibilities (3.96; 60.4%). The recognition from the As per the Cronbach’s α test, the internal consistency community, family and health system scored moderately of the scale was adequate. The consistency coefficient (3.96; 55.4%). The training (3.78; 72.8%), the type of was 0.78, 0.79 and 0.84 for the community, health system supportive supervision received (3.28; 12.2%), the work and the individual scales, respectively. Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 5 Downloaded from http://bmjopen.bmj.com/ on November 30, 2015 - Published by group.bmj.com CHWs ’ performance motivation and its determinants Determinants of the level of performance motivation community recognition and intrinsic job satisfaction. The The ASHA’s earning as a CHW ( p<0.05, 95% CI 0.06 to demotivation on the work modality and the healthcare infra- 0.12), sense of social responsibility and altruism ( p<0.01, structure were positively related to a lesser intrinsic job sat- 95% CI 0.12 to 0.25) and feeling of self-efficacy ( p<0.01, isfaction. Their perceptions on the incentives did not 95% CI 0.38 to 0.54) in undertaking responsibilities affect the level of motivation on any of the community, influenced her recognition at the health system, commu- individual or health system parameters (table 3). nity and family (not mentioned in the tables). Other socio-economic characteristics were not significant in this regard. Prevailing scenario of the factors affecting the performance motivations: experiences of the ASHAs How does the healthcare delivery system impact on the Enabling factors CHW’s level of motivation? The better use of time (91%), lack of alternative job We explored how significantly the level of motivation on opportunities (76%) and a sense of social responsibility the health system factors influenced their motivation at (68%) were the reasons to become a CHW and everyone the individual and the community levels. This exploration wanted to continue as ASHA. They considered perform- was prompted by the fact that the CHWs were more ance motivation as an encouragement (45%) or some- demotivated on the status of the former (table 2 and thing which makes their performance better (62%). figure 3). The peer support induced for a higher level of Their prior involvement in women’s groups improved satisfaction on the community participation, recognition, self- their sense of altruism. Working with the community as efficacy and intrinsic job satisfaction. On the contrary, the CHW and empowering them, especially women, inspired dissatisfaction on the workload also led to a higher level many. They felt women to be more receptive to their of dissatisfaction on the above aspects. The dissatisfied health advices and engage in community activities com- CHWs on the supportive supervision had reported a lesser pared to men. Figure 3 Healthcare delivery system vis-à-vis the community health workers’ performance motivation. 6 Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 Downloaded from http://bmjopen.bmj.com/ on November 30, 2015 - Published by group.bmj.com CHWs ’ performance motivation and its determinants Table 3 Influence of the healthcare delivery system on the community health workers’ (CHWs) performance motivation Dependent variable Independent variable Coefficient SE p Value 95% CI R2 Community participation Work load −0.065 0.028 <0.05 −0.12 to −0.01 0.069 Work autonomy 0.062 0.026 <0.01 0.01 to 0.11 Peer support 0.139 0.049 <0.001 0.04 to 0.24 Community recognition Work load −0.215 0.077 <0.001 −0.37 to −0.06 0.223 Work autonomy 0.165 0.039 <0.001 0.08 to 0.24 Peer support 0.089 0.040 <0.05 0.01 to 0.17 Supportive supervision −0.19 0.096 <0.05 −0.38 to −0.00 Social prestige Work autonomy 0.153 0.032 <0.001 0.09 to 0.22 0.124 Self-efficacy Workload −0.204 0.082 <0.01 −0.37 to 0.04 0.436 Work autonomy 0.185 0.042 <0.001 0.10 to 0.27 Peer support 0.089 0.040 <0.05 0.01 to 0.17 Relatedness Work autonomy 0.238 0.036 <0.001 0.17 to 0.31 0.276 Intrinsic job satisfaction Workload −0.097 0.039 <0.01 −0.18 to −0.02 0.510 Work autonomy 0.215 0.020 <0.001 0.17 to 0.25 Healthcare infrastructure −0.145 0.049 <0.001 −0.24 to −0.05 Work modality −0.063 0.030 <0.05 −0.12 to 0.05 Training 0.327 0.038 <0.001 0.25 to 0.40 Supportive supervision −0.229 0.079 <0.001 −0.38 to −0.07 Peer support 0.131 0.045 <0.001 0.04 to 0.22 We have more support from our Didis and women’s the planning of service delivery to incorporate commu- groups are now more enthusiastic and capable in com- nity’s felt needs, as often they were given only the munity activities. Our social cohesion is improving options to deliver services than planning. further. [CHW, #4] Supporting the survey data, many reported enhance- Very often what the programme wants and people want ment in their family and social status, and personal from me are different. I feel whatever issues I raise on autonomy attributing to the role of CHW. They felt behalf of the community during the health centre meet- empowered through the acquisition of knowledge and ings are not addressed timely. [CHW# 74] skills on community health through training, designated stature in the community and the personal autonomy to Many posed concern on the community’s lack of trust work. Peer support and healthy competition among the on the public healthcare system. There were instances of ASHAs seemed to have enhanced their enthusiasm to care seeking from the private informal providers, despite perform well and achieve progressive community health. the availability of drugs with the CHWs. This community They enjoyed the job autonomy to perform the desig- behaviour was built on the instances of them not getting nated duties. drugs from the CHWs due to unavailability. Their activ- ities were limited by the frequent stock-out of drugs and Now I have a say in my neighborhood. I am being invited commodities and the communication gap at different to sit in community meetings and I represent my village in health centre meetings. [CHW# 28] levels of their supervision. They also reported to have an inadequate level of We meet during trainings and meetings and share a lot knowledge, skills and supportive supervision to perform with each other. Since we have the same kind of work, optimally. Their performances were monitored through learning from each other has increased our problem- the self-recording of activities, supplemented with solving skills. [CHW # 41] random visits by the multipurpose female health workers and other supervisors. They found it difficult to Demotivating factors monitor community health through surveys as it was On the contrary, the CHWs had certain dissatisfactions time consuming and tricky to record, with their low level on certain health system aspects limiting their perform- of education. Most of them expected to have routine ance motivation at the individual and the community supportive supervision of their activities and the levels. Excessive workload, frequent refresher trainings grass-roots level organisations’ cooperation to enable and meetings at health centres and travel to remote improved performances. habitations took away their personal time. They some- times felt having limited autonomy at work to perform We would like to have an integrated approach with the their social responsibilities beyond the specified guide- women’s group, the NGOs and the village health com- lines. The CHWs solicited their active involvement in mittee to share and solve local issues. [CHW# 13] Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 7 Downloaded from http://bmjopen.bmj.com/ on November 30, 2015 - Published by group.bmj.com CHWs ’ performance motivation and its determinants Often, I communicate timely on drug stock-outs to sub- healthcare system. This will be relevant for those coun- centre, but the primary health centres tell that they are tries trying to reduce the poor people’s dependency on not aware of this. I feel my concerns and issues are not the private sector.1 Peer support and cross-learning from spelled out at the higher level properly, though I share peers were potential ways of inspiration, apart from the everything with my supervisors. I am also not given timely support of many community-based organisations. The instruction on my roles on many activities [CHW #53] involvement of locally based NGOs and community- They demanded for more flexibility in organising based organisations needs to be promoted to empower meetings at convenient locations to give more time for and support the CHWs.23 However, the NGOs need to the community and their personal life. Although CHWs be a complimentary mechanism and should not under- received honorarium for trainings and meetings, they mine the CHWs’ efficiency as health workers.24 did not prefer frequently attending them. They were Above all, a sense of intrinsic motivation was the confident to execute the responsibilities, still desired underlying factor for the CHWs’ performance. For knowledge and skill enhancement to convince the com- instance, their urge for community interactions pre- munity and gain community acceptance. They seemed vented them from attending the meetings and training, to be less confident on curative skills and urged for despite the scope of receiving honoraria in such events. more system thrust and training in this regard. The local cultural traits of solidarity, hospitality and pro- viding social support lifted their enthusiasm.25 These I want to be with the community more than the meet- behavioural traits could be exploited positively with ings. We wait for longer time, even for four hours at the providing more public recognition to the CHWs. The health centres for a one hour meeting [CHW# 29] events of ‘public honoring’, involvement in public meet- ings and appreciation in their group meetings would be Some of them were disgruntled on the level of the an impetus for their social commitment. Kenya also monetary and ours non-monetary incentives received, reported on CHWs’ strong preference for community yet they did not want to underperform. The ASHAs acceptance compared to the supervisor’s recognition.5 often had to expend on mother’s consumables and In this study, the CHWs’ dissatisfaction on remuneration spare on an average 30 hours on escorting mothers for was not associated with their level of earning. This implies child birth. However what they receive was lesser consid- that remuneration through incentivising each activity ering their actual spending and the time cost. They seems to have motivated performance despite their denied having any opportunity for informal payments, feeling of under-remunerated. Yet, care should be taken to but admitted to have received occasional incentives for ensure that the CHWs perform equally on all the responsi- escorting mothers without actually doing so. bilities despite the incentives varying on each responsibil- ity. Further, they should be remunerated adequately I often spend out-of-pocket on mother’s consumables at considering the time cost and the market rate. hospitals and what I receive is quite less in return. Still, I want to support mothers as I feel they are like my sisters What discourages the CHWs and the consequences? and I am obliged to support them. [CHW#69] The study found a strong nexus between the healthcare delivery system’s status and the CHW’s level of perform- DISCUSSION ance motivation. As demonstrated in similar settings, What prompts the CHWs to perform and its externalities resource constraints such as limited transportation to on community health? escort mothers and stock-outs of commodities hindered The rural women consider becoming a CHW as a mag- the community’s trust on them.26 The communication nificent opportunity to empower themselves socially, per- gap among different actors led to delay in receiving the sonally and financially.16 Empowering rural women as stocks and non-clarity on the responsibilities among CHWs, who do not have alternate job opportunities can CHWs. This weak supportive system to CHWs concerns be a replicable and sustainable model on community many other countries also as it might lead to the exclu- health management.17 In this study, the level of motiv- sion of the poorest of the poor from appropriate health ation was directly related to self-efficacy, yet socio- services.1 economic status did not influence the latter. This The CHWs demanded for regular supportive supervi- implies that with proper selection, orientation and train- sion and streamlining of responsibilities. However, in ing, the lay women can be organised for community resource-constraint settings, identifying and training health activities.18–21 more experienced volunteers for CHW’s supervision will They displayed a strong commitment towards empower- be a challenge. This concern should be addressed ing women as women were more receptive to their advices. through leveraging some of the grass-roots level public The higher level of health awareness and adherence to health managers or NGOs in a systematic manner. More healthy practices among women compared to men might involvement of grass-roots entities like women’s groups justify this village-level social network among women.22 could inculcate a sense of collective accountability and The identity with the government motivated them to learning. Nigeria reported village health committee be a bridge between the community and the public (VHC) supporting CHWs.27 Since India’s VHCs are still 8 Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 Downloaded from http://bmjopen.bmj.com/ on November 30, 2015 - Published by group.bmj.com CHWs ’ performance motivation and its determinants evolving, CHW’s monitoring can be designed as one of supportive supervision, skill and knowledge enhance- its roles in future.19 ment and enabling working modalities. The CHWs’ increasing work load with more and more Acknowledgements We are thankful to all the community health workers, community-based health programmes produced a participated in the study. We also thank the women’s groups, who mobilised feeling of ‘overburdened’. Without proper orientation, the study participants. We are grateful to the editorial board and the reviewers monitoring of many community health initiatives, espe- for their comments on an earlier version of the manuscript. cially surveys will be difficult for them, considering their Contributors All authors took part in the conceptualisation, design of tools low level of formal education.28 29 Though the current and writing of manuscript. SSG analysed the data and wrote the first draft of pattern of incentivising does not appear to bring in less the manuscript. SNM enabled the data collection. All authors read and performance, India could experiment with preferential approved the final version. treatment on social securities and public privileges to Competing interests None. the CHWs and their households as demonstrated in Patient consent Obtained. Guatemala and Nepal.27 Provenance and peer review Not commissioned; externally peer reviewed. In India, the ASHAs are more indentified as ‘link- workers’ or facilitators for appropriate care and the com- Data sharing statement We declare that all the raw data are available with the primary authors on the published information for public sharing. munity has less acceptance for their curative role.7 The CHWs are less confident on their curative care skills and Declaration The opinions expressed in this paper are exclusively of the authors and not of their organizations they are currently affiliated with. the supply constraints induce the community’s non- confidence on them.30–32In future, the CHWs’ could be leveraged intensively on diagnosing health conditions to REFERENCES promote a comprehensive community health manage- 1. World Health Organization. Health systems financing—the path to ment approach. This will be relevant for elderly care universal coverage. Geneva: World Health Report, 2010. 2. Lehmann U, Sanders D. Community health workers: what do we know and settings with increasing chronic disease burden to about them? The state of the evidence on programmes, activities, offer a cost-effective care.19 33–35 costs an impact on health outcomes of using community health workers. Geneva: The World Health Organization, 2007. 3. Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community health care for maternal and child health Strengths and limitations of the study and the management of infectious diseases. Cochrane Database We employed a mixed-methods approach and it helped Syst Rev 2010;(3): CD004015. 4. Shrestha R, Baral K, Weir N. Community ear care delivery by us in two ways. First, to understand the extent of causal- community ear assistants and volunteers: a pilot programme. ity between the CHW’s level of motivation and each of J Laryngol Otol 2003;115:869–73. 5. Lewin SA, Dick J, Pond P, et al. Lay health workers in primary and its determinant. Second, to assess how, why and under community health care. Cochrane Database Syst Rev 2005;(1): what condition a CHW is motivated or demotivated. The CD004015. study depended on a ‘relativist’ approach to trigger the 6. Glenton C, Inger BS, Pradhan S, et al. The female community health volunteer programme in Nepal: Decision makers’ perceptions of policy processes on streamlining the motivating factors volunteerism, payment and other incentives. Soc Sci Med for the CHW’s performance motivation. Further, the 2010;70:1920–7. 7. Government of India. ASHA the way forward: evaluation of ASHA FGD responses were used to verify the survey responses program. NRHM New Delhi: The National Health System Resource and thereby enhance the generalisability of the study Center, 2011. outcomes. There could be a possibility of the CHWs’ 8. Dieleman M, Cuong PV, Anh LV, et al. Identifying factors for job motivation of rural health workers in North VietNam. Hum Resour responses complying with the perceptions of what Health 2003;1:10. should be an acceptable answer. We did not assess the 9. Mbindyo P, Gilson L, Blaauw D, et al. Contextual influences on health worker motivation in district hospitals in Kenya. Implement Sc actual level of performance of the CHWs and its effect- 2009;4:43; doi:10.1186/1748-5908-4-43. iveness from the community’s or supervisors’ perspec- 10. Darmstadt GL, Baqui AH, Choi Y, et al. Validation of community health workers’ assessment of neonatal illness in rural Bangladesh. tives. Despite this, these study revelations on the CHW Bull World Health Organ 2009;87:12. programme add to the rare global evidence base for 11. Rahman SM, Ali NA, Jennings L, et al. Factors affecting recruitment relevant policy changes, specifically on the CHW man- and retention of community health workers in a newborn care intervention in Bangladesh. Hum Resour Health 2010;8:12 http:// agement and the retention. www.human-resources-health.com/content/8/1/12 (accessed on 24th November 2011). 12. Li I-C, Lin M-C, Chen C-M. Relationship between personality traits, job satisfaction, and job involvement among Taiwanese community health CONCLUSION volunteers. Public Health Nurs 2007;24:274–82. 13. Government of India. Accredited Social Health Activist (ASHA) The CHW programme could motivate and empower the guidelines, National Rural Health Mission. New Delhi: Ministry of local lay women on community health largely. The Health and Family Welfare, 2005. 14. Government of India. Annual report: 2009–10. New Delhi: Ministry of desire to gain social recognition, a sense of social Health and Family Welfare, 2010. http://mohfw.nic.in/Health% responsibility and self-efficacy enhances their motivation. 20English%20Report.pdf (accessed on 11th July 2011). Linking the incentive directly with each activity ensures 15. Manongi RN, Marchant TC, Bygbjerg IBC. Improving motivation among primary health care workers in Tanzania: a health worker performances of the CHWs. The healthcare delivery perspective. Hum Resour Health 2006;4:6; doi:10.1186/ system improvement might further enhance their motiv- 1478-4491-4-6. 16. Willis-Shattuck M, Bidwell P, Thomas S, et al. Motivation and ation and enable them to gain the community trust. The retention of health workers in developing countries: a systematic CHW management needs to change with adequate review. BMC Health Serv Res 2008;8:247. Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 9 Downloaded from http://bmjopen.bmj.com/ on November 30, 2015 - Published by group.bmj.com CHWs ’ performance motivation and its determinants 17. Willis-Shattuck M, Bidwell P, Thomas S, et al. Motivation and 27. Bhattacharya K, Winch P, LeBan K, et al. Community health worker retention of health workers in developing countries: a systematic incentives and disincentives: how they affect motivation, retention review. BMC Health Serv Res 2008;8:247. and sustainability. Basics II 2001;2:1–68. 18. Scott K, Shanker S. Tying their hands? Institutional obstacles to the 28. Abbatt F. Scaling up health and education workers: community success of the ASHA community health worker programme in rural health workers: a literature review. London: DFID Health Systems north India. AIDS Care 2010;22:1606–12. Resource Centre, 2005. 19. Kane SS, Gerretsen B, Scherpbier R, et al. A realist synthesis of 29. Henderson L, Tulloch J. Incentives for retaining and motivating health randomised control trials involving use of community health workers workers in Pacific and Asian countries. Hum Resour Health 2008;6:18. for delivering child health interventions in low and middle income 30. Wendy Gidman W, Ward P, McGregor L. Understanding public trust countries. BMC Health Serv Res 2010;10:286. in services provided by community pharmacists relative to those 20. Daniels K, Van Zyl HH, Clarke M, et al. Ear to the ground: listening provided by general practitioners: a qualitative study. BMJ Open to farm dwellers talk about the experience of becoming lay health 2012;2:e000939; doi:10.1136/bmjopen-2012-000939. workers. Health Policy 2005;73:92–103. 31. Nyanzi S, Manneh H, Walraven G. Traditional birth attendants in 21. George A. Nurses, community health workers, and home carers: rural Gambia: beyond health to social cohesion. Afr J Reprod Health gendered human resources compensating for skewed health 2007;11:43–56. systems. Glob Public Health 2008;3:75–89. 32. Khan SH, Chowdhury AM, Karim F, et al. Training and retaining 22. Gopalan SS. Report on health equity. Bhubaneswar: Government of Shasthyo Shebika: reasons for turnover of community health Orissa, DoHFW, 2009. workers in Bangladesh. Health Care Superv 1998;17:37–47. 23. Gray HH, Ciroma J. Reducing attrition among village health workers 33. Palmas W, Teresi JA, Findley S, et al. Protocol for the Northern in rural Nigeria. Soc Econ Plann Sci 1988;22:39. Manhattan Diabetes Community Outreach Project. A randomised 24. Kironde S, Klaasen S. What motivates lay volunteers in high burden trial of a community health worker intervention to improve diabetes but resource-limited tuberculosis control programmes? Perceptions care in Hispanic adults. BMJ Open 2012;2:e001051; doi:10.1136/ from the Northern Cape province, South Africa. Int J Tubercul Lung bmjopen-2012-001051. Dis 2002;6:104. 34. Macinko J, De Fátima Marinho de Souza M, Guanais FC, et al. 25. Robinson SA, Larsen DE. The relative influence of the Going to scale with community-based primary care: an analysis of community and the health system on work performance: a case the family health program and infant mortality in Brazil, 1999e2004. study of community health workers in Colombia. Soc Sci Med Soc Sci Med 2007;65:2070–2080. 1990;30:1041. 35. Robert J, Blendon RJ, Benson JM, , et al A four-country survey of 26. Baker B, Benton D, Friedman E, et al. Systems support for task public attitudes towards restricting healthcare costs by limiting the shifting to community health workers. Geneva: The Global Health use of high-cost medical interventions. BMJ Open 2012;2:e001087; Alliance, 2007. doi:10.1136/bmjopen-2012-001087. 10 Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 Downloaded from http://bmjopen.bmj.com/ on November 30, 2015 - Published by group.bmj.com Assessing community health workers' performance motivation: a mixed-methods approach on India's Accredited Social Health Activists (ASHA) programme Saji Saraswathy Gopalan, Satyanarayan Mohanty and Ashis Das BMJ Open 2012 2: doi: 10.1136/bmjopen-2012-001557 Updated information and services can be found at: http://bmjopen.bmj.com/content/2/5/e001557 These include: References This article cites 25 articles, 3 of which you can access for free at: http://bmjopen.bmj.com/content/2/5/e001557#BIBL Open Access This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode. Email alerting Receive free email alerts when new articles cite this article. Sign up in the service box at the top right corner of the online article. Topic Articles on similar topics can be found in the following collections Collections Evidence based practice (397) Global health (256) Health policy (380) Health services research (783) Public health (1259) Notes To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/