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Assessing community health
workers’performance motivation: a
mixed-methods approach on India’s
Accredited Social Health Activists
(ASHA) programme
Saji Saraswathy Gopalan,
1
Satyanarayan Mohanty,
2
Ashis Das
1
To cite: Gopalan SS,
Mohanty S, Das A. Assessing
community health
workers’performance
motivation: a mixed-methods
approach on India’s
Accredited Social Health
Activists (ASHA) programme.
BMJ Open 2012;2:e001557.
doi:10.1136/bmjopen-2012-
001557
▸Prepublication history and
additional material for this
paper are available online. To
view these files please visit
the journal online (http://
dx.doi.org/10.1136/bmjopen-
2012-001557).
Received 24 May 2012
Accepted 15 August 2012
This final article is available
for use under the terms of
the Creative Commons
Attribution Non-Commercial
2.0 Licence; see
http://bmjopen.bmj.com
1
The World Bank, NW
Washington DC, USA
2
DCOR Consulting Pvt Ltd,
Bhubaneswar, Orissa, India
Correspondence to
Dr Saji Saraswathy Gopalan;
sajisaraswathyg@gmail.com
ABSTRACT
Objective: This study examined the performance
motivation of community health workers (CHWs) and
its determinants on India’s Accredited Social Health
Activist (ASHA) programme.
Design: Cross-sectional study employing mixed-
methods approach involved survey and focus group
discussions.
Setting: The state of Orissa.
Participants: 386 CHWs representing 10% of the total
CHWs in the chosen districts and from settings selected
through a multi-stage stratified sampling.
Primary and secondary outcome measures: The
level of performance motivation among the CHWs, its
determinants and their current status as per the
perceptions of the CHWs.
Results: The level of performance motivation was the
highest for the individual and the community level factors
(mean score 5.94–4.06), while the health system factors
scored the least (2.70–3.279).Those ASHAs who felt
having more community and system-level recognition
also had higher levels of earning as CHWs (p=0.040,
95% CI 0.06 to 0.12), a sense of social responsibility
(p=0.0005, 95% CI 0.12 to 0.25) and a feeling of self-
efficacy (p=0.000, 95% CI 0.38 to 0.54) on their
responsibilities. There was no association established
between their level of dissatisfaction on the incentives
(p=0.385) and the extent of motivation. The inadequate
healthcare delivery status and certain working modalities
reduced their motivation. Gender mainstreaming in the
community health approach, especially on the demand-
side and community participation were the positive
externalities of the CHW programme.
Conclusions: The CHW programme could motivate and
empower local lay women on community health largely.
The desire to gain social recognition, a sense of social
responsibility and self-efficacy motivated them to perform.
The healthcare delivery system improvements might
further motivate and enable them to gain the community
trust. The CHW management needs amendments to
ensure adequate supportive supervision, skill and
knowledge enhancement and enabling working
modalities.
ARTICLE SUMMARY
Article focus
▪What is the current level of the performance
motivation of the community health workers?
▪What are the determinants of their performance
motivation?
▪What are the community health workers’(CHWs)
perceptions and experiences on the current status
of the factors affecting their performance
motivation?
Key messages
▪The CHWs are more motivated on the individual
and the community level factors than the health
system determinants.
▪The qualitative findings also support the survey out-
comes that the healthcare delivery status and the
human resource management modalities for CHW
are not satisfactory for them.
▪This study recommends that the CHW management
needs changes to ensure adequate supportive
supervision, skill and knowledge enhancement and
enabling working modalities.
Strengths and limitations of this study
▪This is a unique study exploring the performance
motivation of the public sector CHW on one of the
largest CHW programmes in the world. The evi-
dence on CHWs’performance motivation and that
of public sector CHW programmes are limited. The
unique application of the mixed-methods approach
will enhance the generalisability of the study find-
ings. It helped in finding the causality between the
level of CHW’s motivation and its each determinant
along with an understanding of how and why a
CHW is motivated or demotivated. The study dis-
cussions are centred on comparable global experi-
ences for relevant policy changes.
▪Among the study limitations, there could be a pos-
sibility of CHWs’responses complying with percep-
tions of what should be an acceptable answer. We
did not assess the actual level of performance of
the CHWs and its effectiveness from the commu-
nity’s or the supervisors’perspectives.
Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 1
Open Access Research
INTRODUCTION
Globally, the intermediation of community health workers
(CHWs) in healthcare delivery is widening as they are inev-
itable to meet the universal healthcare provision and the
millennium development goals.
1
The term ‘community
health worker’encompasses a wide variety of local health-
care providers ranging from nurse-midwives to home-based
care givers and salaried-staffs to volunteers.
2
The CHWs
enable access to and utilisation of health services, and
inculcate healthy behaviours among the communities.
3
They are preponderantly deployed to cater to underutilised
services, unmet health behaviours and underserved popu-
lations.
3
The CHW’s contributions to disease control,
immunisation and family planning programmes are
already established.
4
In the public sector, though the
CHWs are primarily link-workers or motivators, yet they do
undertake curative services for malaria, tuberculosis and
elderly care.
3
The spectrum of the CHW programmes
varies across countries on their objectives, rollout and man-
agement. Their larger penetration and sustainability are
more observed with the public sector.
5
Having identified
the potential of women in community mediation, predom-
inantly females constitute CHWs universally.
2
Rationale
The existing literature on CHWs’performance motivation
and its determinants are scanty. Similar to any other
health cadre, the performance of CHWs depends on
their job satisfaction derived from certain intrinsic and
extrinsic motivators.
6
However, the yardstick for their per-
formance motivation assessment should be different from
usual health staffs particularly on three grounds; (1) many
CHWs are volunteers and not salaried staff, (2) they are lay
workers without prior training on community health and
(3) CHWs constitute the outreach workforce directly
linking the community with the formal healthcare.
7
Further, the approach to assess the public sector CHWs’
work motivation could be different from the private sector
since they are more integrated with the formal healthcare
system and have wider responsibilities. The existing few
studies from Kenya, Vietnam, Bangladesh, Taiwan, etc
have largely catered to the latter or omitted a ‘mixed
-methods approach’by mostly employing the qualitative
tools.
8–12
This paper explores one of the largest public
sector community health worker initiatives in the world,
namely the Accredited Social Health Activist (ASHA)
programme in India. This study had three objectives:
(1) assessing the current level of performance motivation
among the ASHAs, (2) understanding the factors affecting
their level of motivation and (3) their perceptions and
experiences on the current status of the motivational
determinants.
ASHA programme: an overview
The ASHA is a female volunteer selected by the commu-
nity, deployed in her own village (one in every 1000
Figure 1 Responsibilities of the Accredited Social Health Activist.
2Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557
CHWs’performance motivation and its determinants
population) after a short training on community
health.
13
She is preferred to be between 25 and 45 years
old, with a minimum formal education of 8 years and
demonstrable leadership qualities.
13
ASHAs are not salar-
ied and they belong to the voluntary cadre of health staffs
as they get fixed activity-based incentives. Started in 2006,
currently the ASHA programme has spread across the
country with 820 000 women trained and deployed.
14
Their responsibilities range from health education to
diagnosis of health conditions (figure 1). Each state over-
sees the programme confining to the guidelines of the
National Rural Health Mission (NRHM).
METHODS
Conceptual framework
The concept of ‘performance motivation’is complex and
can be defined contextually. The study defined it as the
CHW’s degree of interest and willingness to undertake
and improve upon an allotted responsibility towards com-
munity health.
8
We used a customised framework adapted
from the existing literature.
8–12 15 16
The motivation
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
were considered (identified from the literature and self-
validated by the CHWs through group discussions)
together under the above broad classifications, that is, indi-
vidual,health system and community levels (table 2).
Assessment tools
This cross-sectional study conducted during 2010
employed a mixed-methods approach, that is, a combin-
ation of qualitative and quantitative techniques. It
employed both survey and focus groups discussions
among the CHWs. The survey tool constituted 16
parameters and under each a set of questions explored
their level of motivation on a Likert scale of 1 (strongly
disagree) to 5 (strongly agree). The construct of the
questions were balanced with both positive and negative
directions to prevent similar responses. The composite
score of all questions decided the level of motivation
under each parameter. A CHW was considered as moti-
vated on a particular parameter if her mean score was
above 3. At the health system level, the exploration was on
the organisation and management of the healthcare
delivery system (eg, availability of services and commod-
ities, incentives, monitoring and training of CHWs,
interaction with supervisors, peers and grass roots non-
governmental organisations (NGOs)). The community
level parameters consisted of community response, recog-
nition of CHW and participation in activities. At the indi-
vidual level, abilities, inducements to perform, job
satisfaction, family support, etc were explored. The
focus group discussions (FGDs) explored CHWs’current
experiences and perceptions on the factors affecting
their performance motivation. Their suggestions to
improve upon the existing situations were also probed.
Sampling and recruitment
The study settings were selected through a multistage
stratified sampling. First, Orissa was selected randomly
among the high-focus states of NRHM. Then, the dis-
tricts of Angul and Mayurbhanj were selected represent-
ing the state based on its administrative division. Finally,
25% of the rural administrative blocks from each district
were randomly selected.
The survey purposively targeted 10% (n=434) of the
existing number of ASHAs (n=4342) together from both
the districts.
7
Thus, it planned to interview 55 ASHAs
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
CHWs’performance motivation and its determinants
However, only 386 ASHAs could be interviewed consid-
ering their availability and willingness during the study
period. Each survey on an average took about
30–45 min.
There were 11 FGDs for 78 CHWs and each consti-
tuted 7–10 participants. There were mixed groups of
ASHAs from different socio-economic and demographic
backgrounds. Each FGD took between 45 and 60 min
and interviews were conducted till the data saturation.
An FGD guide with broad themes and specific probes
directed the discussions. The FGDs were conducted first,
followed by the survey.
The local women’s groups mobilised the CHWs for
the surveys and the FGDs. The interviews were
conducted in the local language Oriya. The participants
were informed about this study through local village
leaders and women’s groups a week prior to the study.
A written informed consent was obtained from each
CHW after explaining the study objectives and the
intended use of the information. The participation was
completely voluntary and the respondents had the
choice of not answering any question or withdrawal
from the study at any time. The confidentiality of the
participants was maintained throughout the study. The
interviews were conducted at a convenient location and
refreshments were provided to the participants. In each
district, the survey and the FGDs were performed by five
locally based researchers, who were social science bache-
lors. The entire data collection process took 3 months.
A predesigned protocol guided the conduct of the data
collection and further, it was supervised by one of the
coauthors. We could not initiate for ethical approval as
there was no such specific entity in the state providing
ethical approval on this kind of research.
Data analysis
The quantitative information was analysed through
STATA. Linear and multivariate regression tests
explored the association between the level of perform-
ance motivation and the predictors at different levels
along with the CHWs’background characteristics. The
qualitative data were transcribed verbatim and trans-
lated to English by the researchers themselves who con-
ducted the interviews. These translations were verified
by the coauthors who are proficient in the local lan-
guage. The translated transcripts were coded and ana-
lysed through NVivo. The analysis was both inductive
and deductive and relevant themes were indexed
under the individual, health system and community-level
aspects. They were further classified as the enabling
and the demotivating factors for the CHW’sperform-
ance. The qualitative findings were triangulated with
the survey findings confining to the conceptual frame-
work of the study.
RESULTS
The survey consisted of 386 CHWs (table 1), of which
the majority were below poverty line (71%), married
(70.47%) and scheduled tribes (36%). Most of them
had 8 years of formal education (85.75%), experience of
2–5 years as CHW (82.9%). The majority had under-
gone a minimum five trainings (73.06%), earned US
$22.24–33.33/month as a CHW (83.16%). Further, most
of them did not have any other personal sources of
earning (91.97%).
Level of performance motivation among the CHWs
The level of motivation was the highest on the intrinsic
job satisfaction on various job-related achievements (mean
4.30; 68.4% of CHWs). The self-efficacy or the perceived
abilities on job scored a mean score of 4.27 (69.7%).
Table 1 Background characteristics of the CHWs
Characteristics Percentage (n/386)
Age (years)
25–30 45.60 (176)
31–35 32.64 (126)
36–40 17.88 (69)
>41 3.88 (15)
Education (years)
5–7 14.25 (55)
8–10 85.75 (331)
Marital status
Married 70.47 (272)
Widowed 17.88 (69)
Separated 3.88 (15)
Unmarried 4.92 (19)
Divorced 2.85 (11)
Poverty status
Below poverty line 70.98 (274)
Above poverty line 29.02 (112)
Monthly household income in INR (US$)
1000–2000 (22.21–44.44) 21.51 (83)
2001–3000 (44.46–66.65) 43.26 (167)
>3000 (66.67) 35.23 (136)
Caste
Scheduled caste* 29.02 (112)
Scheduled tribe* 36.01 (139)
Others 34.97 (135)
Monthly earning as CHW in INR (US$)
<500 (11.13) 2.07 (8)
500–1000 (11.13–22.21) 14.77 (57)
1001–1500 (22.24–33.33) 83.16 (321)
Sources of earning
Only as CHW 91.97 (355)
Other sources 8.03 (31)
Years of experience as ASHA
<2 17.10 (66)
2–5 82.90 (320)
Number of trainings undergone
<5 73.06 (282)
6–10 26.94 (104)
*Scheduled caste and tribe are communities that receive special
privileges from the Government of India based on relatively
weaker socio-economic status.
ASHA, Accredited Social Health Activist; CHWs, community
health workers; INR, Indian rupees.
4Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557
CHWs’performance motivation and its determinants
The nature of the job responsibilities positioned at the
third with a mean score of 4.18 (66.3%), followed by the
social responsibility and altruism (4.12; 66.1%). The mean
scores were 4.07 for the self-motivation (84.7%), 4.06 for
the community participation in activities (63.2%) and 4.04
for the peer support (77.2%).
The degree of motivation was the least on the commu-
nity opinion on the healthcare delivery system (2.7; 1%), fol-
lowed by their satisfaction on the level of healthcare
infrastructure (2.83; 6.7%). The ASHAs were also less
motivated on their work load (2.96; 8.8%). They had a
moderate level of motivation (mean 3–4) on enjoying
the autonomy to move, express opinions and execute the
responsibilities (3.96; 60.4%). The recognition from the
community, family and health system scored moderately
(3.96; 55.4%). The training (3.78; 72.8%), the type of
supportive supervision received (3.28; 12.2%), the work
modality (3.18; 17.6%) and the incentives (3.07; 16.6%)
also scored a moderate mean.
A large proportion of the ASHAs (n=327; 84.72%)
were self-motivated. If we look at the individual scores
for each parameter, the question on community
acceptance, that is, the community accepts my activities as
Iintendtosecured the highest mean score at 4.64
(n=366). Second, a self-efficacy-related question (Ican
always manage to solve difficult problems if I try hard
enough) scored at 4.58 (n=350). Further, the probe on
the intrinsic job satisfaction (I am satisfied that I accomplish
something worthwhile in this job) received a mean score
of 4.54 (n=336).
As per the Cronbach’sαtest, the internal consistency
of the scale was adequate. The consistency coefficient
was 0.78, 0.79 and 0.84 for the community, health system
and the individual scales, respectively.
Table 2 Level of performance motivation among the community health workers (CHWs) (N=386)
Variable Mean 95% CI
Motivated*
n (%)
Health system level
Nature of responsibilities: level of interest in the responsibilities
and confidence to execute them
4.18 4.09 to 4.27 256 (66.3)
Workload: time to complete daily tasks, able to spend time with f
amily and flexibility in work schedule
2.96 2.90 to 3.02 34 (8.8)
Incentive: adequacy of financial and non-financial incentives and their
pattern of payment
3.07 2.97 to 3.17 64 (16.6)
Healthcare infrastructure: satisfaction on the quality of existing infrastructure,
communication options and commodities
2.83 2.78 to 2.89 26 (6.7)
Work modality: satisfaction on hierarchy, participatory approach,
recording and reporting
3.18 3.13 to 3.24 68(17.6)
Training: level of knowledge and skills imparted through trainings, and timing and
organisation of training
3.78 3.72 to 3.85 281 (72.8)
Supportive supervision: help, monitoring, and supervision to execute r
esponsibilities and solve issues
3.28 3.23 to 3.32 47 (12.2)
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
participation in activities
4.05 3.96 to 4.16 244 (63.2)
Community opinion on public healthcare system: on quality of care, availability of
healthcare and community programmes
2.70 2.65 to 2.75 4 (1.0)
Individual level
Social responsibility and altruism: interest in social work when existing
social norms adversely impact community health, and sense of social responsibility
4.12 4.04 to 4.20 255 (66.1)
Intrinsic job satisfaction: chance for better use of abilities and time, feeling of
accomplishment, awards, career enhancement, advancement in employability,
knowledge, communication skills, managerial skills and overall happiness being on job
4.30 4.24 to 4.36 264 (68.4)
Self-efficacy: able to handle tough situations, solve problems, feel emotionally and
physically perfect on work
4.27 4.20 to 4.33 269 (69.7)
Self-motivation: working with a sense that the job is important and is not for
avoiding blame from others and gaining money alone
4.07 4.05 to 4.10 327(84.7)
Individual+community+health system level
Recognition: acceptance of CHWs’performance, its value, and talents by family,
community and system
3.96 3.90 to 4.02 214 (55.4)
Autonomy: freedom to move in the community, express opinion and execute
responsibilities
3.96 3.90 to 4.02 233 (60.4)
*Motivated if mean score >3.
Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 5
CHWs’performance motivation and its determinants
Determinants of the level of performance motivation
The ASHA’searning as a CHW (p<0.05, 95% CI 0.06 to
0.12), sense of social responsibility and altruism ( p<0.01,
95% CI 0.12 to 0.25) and feeling of self-efficacy (p<0.01,
95% CI 0.38 to 0.54) in undertaking responsibilities
influenced her recognition at the health system, commu-
nity and family (not mentioned in the tables). Other
socio-economic characteristics were not significant in
this regard.
How does the healthcare delivery system impact on the
CHW’s level of motivation?
We explored how significantly the level of motivation on
the health system factors influenced their motivation at
the individual and the community levels. This exploration
was prompted by the fact that the CHWs were more
demotivated on the status of the former (table 2 and
figure 3). The peer support induced for a higher level of
satisfaction on the community participation,recognition,self-
efficacy and intrinsic job satisfaction. On the contrary, the
dissatisfaction on the workload also led to a higher level
of dissatisfaction on the above aspects. The dissatisfied
CHWs on the supportive supervision had reported a lesser
community recognition and intrinsic job satisfaction. The
demotivation on the work modality and the healthcare infra-
structure were positively related to a lesser intrinsic job sat-
isfaction. Their perceptions on the incentives did not
affect the level of motivation on any of the community,
individual or health system parameters (table 3).
Prevailing scenario of the factors affecting the
performance motivations: experiences of the ASHAs
Enabling factors
The better use of time (91%), lack of alternative job
opportunities (76%) and a sense of social responsibility
(68%) were the reasons to become a CHW and everyone
wanted to continue as ASHA. They considered perform-
ance motivation as an encouragement (45%) or some-
thing which makes their performance better (62%).
Their prior involvement in women’s groups improved
their sense of altruism. Working with the community as
CHW and empowering them, especially women, inspired
many. They felt women to be more receptive to their
health advices and engage in community activities com-
pared to men.
Figure 3 Healthcare delivery system vis-à-vis the community health workers’performance motivation.
6Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557
CHWs’performance motivation and its determinants
We have more support from our Didis and women’s
groups are now more enthusiastic and capable in com-
munity activities. Our social cohesion is improving
further. [CHW, #4]
Supporting the survey data, many reported enhance-
ment in their family and social status, and personal
autonomy attributing to the role of CHW. They felt
empowered through the acquisition of knowledge and
skills on community health through training, designated
stature in the community and the personal autonomy to
work. Peer support and healthy competition among the
ASHAs seemed to have enhanced their enthusiasm to
perform well and achieve progressive community health.
They enjoyed the job autonomy to perform the desig-
nated duties.
Now I have a say in my neighborhood. I am being invited
to sit in community meetings and I represent my village
in health centre meetings. [CHW# 28]
We meet during trainings and meetings and share a lot
with each other. Since we have the same kind of work,
learning from each other has increased our problem-
solving skills. [CHW # 41]
Demotivating factors
On the contrary, the CHWs had certain dissatisfactions
on certain health system aspects limiting their perform-
ance motivation at the individual and the community
levels. Excessive workload, frequent refresher trainings
and meetings at health centres and travel to remote
habitations took away their personal time. They some-
times felt having limited autonomy at work to perform
their social responsibilities beyond the specified guide-
lines. The CHWs solicited their active involvement in
the planning of service delivery to incorporate commu-
nity’s felt needs, as often they were given only the
options to deliver services than planning.
Very often what the programme wants and people want
from me are different. I feel whatever issues I raise on
behalf of the community during the health centre meet-
ings are not addressed timely. [CHW# 74]
Many posed concern on the community’s lack of trust
on the public healthcare system. There were instances of
care seeking from the private informal providers, despite
the availability of drugs with the CHWs. This community
behaviour was built on the instances of them not getting
drugs from the CHWs due to unavailability. Their activ-
ities were limited by the frequent stock-out of drugs and
commodities and the communication gap at different
levels of their supervision.
They also reported to have an inadequate level of
knowledge, skills and supportive supervision to perform
optimally. Their performances were monitored through
the self-recording of activities, supplemented with
random visits by the multipurpose female health
workers and other supervisors. They found it difficult to
monitor community health through surveys as it was
time consuming and tricky to record, with their low level
of education. Most of them expected to have routine
supportive supervision of their activities and the
grass-roots level organisations’cooperation to enable
improved performances.
We would like to have an integrated approach with the
women’s group, the NGOs and the village health com-
mittee to share and solve local issues. [CHW# 13]
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 R
2
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
Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557 7
CHWs’performance motivation and its determinants
Often, I communicate timely on drug stock-outs to sub-
centre, but the primary health centres tell that they are
not aware of this. I feel my concerns and issues are not
spelled out at the higher level properly, though I share
everything with my supervisors. I am also not given timely
instruction on my roles on many activities [CHW #53]
They demanded for more flexibility in organising
meetings at convenient locations to give more time for
the community and their personal life. Although CHWs
received honorarium for trainings and meetings, they
did not prefer frequently attending them. They were
confident to execute the responsibilities, still desired
knowledge and skill enhancement to convince the com-
munity and gain community acceptance. They seemed
to be less confident on curative skills and urged for
more system thrust and training in this regard.
I want to be with the community more than the meet-
ings. We wait for longer time, even for four hours at the
health centres for a one hour meeting [CHW# 29]
Some of them were disgruntled on the level of the
monetary and ours non-monetary incentives received,
yet they did not want to underperform. The ASHAs
often had to expend on mother’s consumables and
spare on an average 30 hours on escorting mothers for
child birth. However what they receive was lesser consid-
ering their actual spending and the time cost. They
denied having any opportunity for informal payments,
but admitted to have received occasional incentives for
escorting mothers without actually doing so.
I often spend out-of-pocket on mother’s consumables at
hospitals and what I receive is quite less in return. Still, I
want to support mothers as I feel they are like my sisters
and I am obliged to support them. [CHW#69]
DISCUSSION
What prompts the CHWs to perform and its externalities
on community health?
The rural women consider becoming a CHW as a mag-
nificent opportunity to empower themselves socially, per-
sonally and financially.
16
Empowering rural women as
CHWs, who do not have alternate job opportunities can
be a replicable and sustainable model on community
health management.
17
In this study, the level of motiv-
ation was directly related to self-efficacy, yet socio-
economic status did not influence the latter. This
implies that with proper selection, orientation and train-
ing, the lay women can be organised for community
health activities.
18–21
They displayed a strong commitment towards empower-
ing women as women were more receptive to their advices.
The higher level of health awareness and adherence to
healthy practices among women compared to men might
justify this village-level social network among women.
22
The identity with the government motivated them to
be a bridge between the community and the public
healthcare system. This will be relevant for those coun-
tries trying to reduce the poor people’s dependency on
the private sector.
1
Peer support and cross-learning from
peers were potential ways of inspiration, apart from the
support of many community-based organisations. The
involvement of locally based NGOs and community-
based organisations needs to be promoted to empower
and support the CHWs.
23
However, the NGOs need to
be a complimentary mechanism and should not under-
mine the CHWs’efficiency as health workers.
24
Above all, a sense of intrinsic motivation was the
underlying factor for the CHWs’performance. For
instance, their urge for community interactions pre-
vented them from attending the meetings and training,
despite the scope of receiving honoraria in such events.
The local cultural traits of solidarity, hospitality and pro-
viding social support lifted their enthusiasm.
25
These
behavioural traits could be exploited positively with
providing more public recognition to the CHWs. The
events of ‘public honoring’, involvement in public meet-
ings and appreciation in their group meetings would be
an impetus for their social commitment. Kenya also
reported on CHWs’strong preference for community
acceptance compared to the supervisor’s recognition.
5
In this study, the CHWs’dissatisfaction on remuneration
was not associated with their level of earning. This implies
that remuneration through incentivising each activity
seems to have motivated performance despite their
feeling of under-remunerated. Yet, care should be taken to
ensure that the CHWs perform equally on all the responsi-
bilities despite the incentives varying on each responsibil-
ity. Further, they should be remunerated adequately
considering the time cost and the market rate.
What discourages the CHWs and the consequences?
The study found a strong nexus between the healthcare
delivery system’s status and the CHW’s level of perform-
ance motivation. As demonstrated in similar settings,
resource constraints such as limited transportation to
escort mothers and stock-outs of commodities hindered
the community’s trust on them.
26
The communication
gap among different actors led to delay in receiving the
stocks and non-clarity on the responsibilities among
CHWs. This weak supportive system to CHWs concerns
many other countries also as it might lead to the exclu-
sion of the poorest of the poor from appropriate health
services.
1
The CHWs demanded for regular supportive supervi-
sion and streamlining of responsibilities. However, in
resource-constraint settings, identifying and training
more experienced volunteers for CHW’s supervision will
be a challenge. This concern should be addressed
through leveraging some of the grass-roots level public
health managers or NGOs in a systematic manner. More
involvement of grass-roots entities like women’s groups
could inculcate a sense of collective accountability and
learning. Nigeria reported village health committee
(VHC) supporting CHWs.
27
Since India’s VHCs are still
8Gopalan SS, Mohanty S, Das A. BMJ Open 2012;2:e001557. doi:10.1136/bmjopen-2012-001557
CHWs’performance motivation and its determinants
evolving, CHW’s monitoring can be designed as one of
its roles in future.
19
The CHWs’increasing work load with more and more
community-based health programmes produced a
feeling of ‘overburdened’. Without proper orientation,
monitoring of many community health initiatives, espe-
cially surveys will be difficult for them, considering their
low level of formal education.
28 29
Though the current
pattern of incentivising does not appear to bring in less
performance, India could experiment with preferential
treatment on social securities and public privileges to
the CHWs and their households as demonstrated in
Guatemala and Nepal.
27
In India, the ASHAs are more indentified as ‘link-
workers’or facilitators for appropriate care and the com-
munity has less acceptance for their curative role.
7
The
CHWs are less confident on their curative care skills and
the supply constraints induce the community’s non-
confidence on them.
30–32
In future, the CHWs’could be
leveraged intensively on diagnosing health conditions to
promote a comprehensive community health manage-
ment approach. This will be relevant for elderly care
and settings with increasing chronic disease burden to
offer a cost-effective care.
19 33–35
Strengths and limitations of the study
We employed a mixed-methods approach and it helped
us in two ways. First, to understand the extent of causal-
ity between the CHW’s level of motivation and each of
its determinant. Second, to assess how, why and under
what condition a CHW is motivated or demotivated. The
study depended on a ‘relativist’approach to trigger the
policy processes on streamlining the motivating factors
for the CHW’s performance motivation. Further, the
FGD responses were used to verify the survey responses
and thereby enhance the generalisability of the study
outcomes. There could be a possibility of the CHWs’
responses complying with the perceptions of what
should be an acceptable answer. We did not assess the
actual level of performance of the CHWs and its effect-
iveness from the community’s or supervisors’perspec-
tives. Despite this, these study revelations on the CHW
programme add to the rare global evidence base for
relevant policy changes, specifically on the CHW man-
agement and the retention.
CONCLUSION
The CHW programme could motivate and empower the
local lay women on community health largely. The
desire to gain social recognition, a sense of social
responsibility and self-efficacy enhances their motivation.
Linking the incentive directly with each activity ensures
performances of the CHWs. The healthcare delivery
system improvement might further enhance their motiv-
ation and enable them to gain the community trust. The
CHW management needs to change with adequate
supportive supervision, skill and knowledge enhance-
ment and enabling working modalities.
Acknowledgements We are thankful to all the community health workers,
participated in the study. We also thank the women’s groups, who mobilised
the study participants. We are grateful to the editorial board and the reviewers
for their comments on an earlier version of the manuscript.
Contributors All authors took part in the conceptualisation, design of tools
and writing of manuscript. SSG analysed the data and wrote the first draft of
the manuscript. SNM enabled the data collection. All authors read and
approved the final version.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement We declare that all the raw data are available with the
primary authors on the published information for public sharing.
Declaration The opinions expressed in this paper are exclusively of the
authors and not of their organizations they are currently affiliated with.
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