Unpacking the Complex Determinants of the Performance of Accredited Social Health Activists in Bihar: A Qualitative Study

Abstract

The Accredited Social Health Activist (ASHA) programme has been associated with many improvements in health outcomes. However, the understanding of contextual performance constraints, particularly how these vary for different tasks, has been acknowledged as deficient. Relying on a means, motives and opportunity (MMO) framework, this article qualitatively explores the context-specific constraints on the performance of four ASHA tasks. We undertake qualitative research to unpack ASHA’s perspectives and conduct a thematic analysis of the interview data. We find that different combinations of MMO factors affect different services differently, although many affect all services. Immunisation day, survey and record-keeping duties and escorting for institutional deliveries were deemed ‘core’ deliverables due to the administrative focus, preference or the incentives tied to the task. Home visits for home-based newborn care (HBNC) were not preferred and were seen as effort-intensive. The rapidly evolving role of ASHAs in responding to evolving health system needs in Bihar demands special effort if the different factors are to be diagnosed. This article attempts to offer the various avenues to unlock ASHA performance and contributes to the current partial global evidence base on factors affecting the performance of community health workers (CHWs) in different contexts.

Keywords

Accredited Social Health Activist community health worker Bihar service delivery means motives opportunity

Background

Community health workers (CHWs) play a critical role in many existing and evolving public health objectives, including providing essential primary health care services, promoting behaviour change and service uptake and ensuring social mobilisation; thus, playing a crucial role in the achievement of universal health coverage. CHWs assume greater importance in low-resource settings like India, which typically face health-worker shortages and an increased burden on health facilities (Global Health Workforce Alliance, 2014; Haines et al., 2007; Narasimhan et al., 2004; Perry et al., 2014). Their role in achieving the Sustainable Development Goals is well established, and their importance has become more visible during COVID-19 (Black et al., 2017; Nanda et al., 2020).

One such CHW cadre is the Accredited Social Health Activists (ASHAs) in India. The ASHA cadre was established in 2005 by the country’s National Rural Health Mission (NRHM) to reduce infant and maternal mortality rates in rural areas. ASHAs are incentivised female volunteers chosen from within the community and are typically mapped to a population of 1,000 beneficiaries (NHM, n.d.). ASHAs are expected to deliver diverse tasks under three key roles: they act as healthcare facilitators, provide community care and serve as health activists (NRHM, 2005). ASHAs do not receive a salary and are entirely remunerated through performance-based incentives for different tasks.

The ASHA programme has been associated with improvements in coverage of services, behaviours and health outcomes. For example, exposure to ASHAs was correlated with improved utilisation of maternity (antenatal care, skilled birth attendance and institutional deliveries) and childcare services (Agarwal et al., 2019; Sundararaman et al., 2012). While ASHAs are vital to realising these gains, it is increasingly recognised that the coverage and quality of services delivered by ASHAs are highly variable, specifically in the coverage of home visits for home-based newborn care (HBNC), which has typically been low across several states (Neogi et al., 2016). A 21-state study finds that although ASHA’s deployment at the village level led to improved immunisation coverage, outcomes such as oral rehydration salts (ORS) disbursement and vitamin A supplementation appeared to remain unchanged (Wagner et al., 2018). Service delivery also varied on socio-economic grounds (Agarwal et al., 2019; Seth et al., 2017).

Studies have investigated this heterogeneity in service delivery by examining deficiencies in ASHA motivation (Abdel-All et al., 2019; Gopalan et al., 2012; Wahid et al., 2020), inconsistent knowledge levels (Shrivastava & Shrivastava, 2012; Singh et al., 2017), delays in compensation (Bhatia, 2014), and the absence of supportive supervision (Bajpai & Dholakia, 2011). Together, the studies point to a combination of factors that are also widely discussed in the larger CHW literature—the nature of the task (Kambarami et al., 2016), the task-performing context (Kok et al., 2015; Scott et al., 2018), and individual-level barriers (Gopalan et al., 2012) that prevent the delivery of specific services.

Global literature also illustrates how the constraints on performance are context specific, given that they operate at the interface of complex adaptive health systems and complex, heterogeneous community ecosystems (George et al., 2018; Kok et al., 2017). As such, designing policy improvements requires a deep, human-centred understanding of CHWs and the communities in which they operate.

This article explores the context-specific constraints on performance for ASHAs within the health system of Bihar and explores how these constraints vary for different tasks that ASHAs perform. We rely on a means, motives and opportunity (MMO) framework (John et al., 2019) to diagnose a combination of factors potentially influencing service delivery in four specific ASHA tasks: ensuring community mobilisation for attending the Village Health Nutrition and Sanitation Day (VHSND); promoting institutional deliveries; undertaking surveys and record keeping and making HBNC visits.

This article contributes to the evidence based on the contextual performance constraints on ASHAs, particularly on how these vary for different tasks, an understanding of which has been acknowledged as deficient (Wagner et al., 2018). This insight is crucial to recognising the various avenues to unlock ASHA performance, especially as ASHA roles are evolving alongside the programme (Scott et al., 2019). It also contributes to the currently partial global evidence base on the factors affecting the performance of CHWs in different contexts (Perry et al., 2014).

Conceptual Framework

The MMO framework has been developed to diagnose the constraints on the performance of CHWs in a particular context (John et al., 2019).

The framework articulates how CHW performance depends on an interaction between the motivations to perform and the constraints on doing so, both at the individual and the system level. Means refers to the CHW’s capability to perform, motives to the desire to perform, and opportunity to the chance to perform. The MMO framework was previously validated through its application in the context of Anganwadi Workers in Bihar and drew on existing research in India to examine the facilitators and binding constraints on CHW performance (John et al., 2020).

Together, the framework presents 14 interacting subcategories that potentially affect CHW performance to varying degrees, as shown in Figure 1.

Methods

We rely on an exploratory qualitative investigation undertaken in two blocks of Saharsa district in the state of Bihar, India. We conducted semi-structured, in-depth interviews with ASHAs using a grounded theory approach (Charmaz & Belgrave, 2007). The approach allowed us to gain a nuanced understanding of the experiences and perceptions of ASHAs.

Study Context

Bihar has reported maternal and infant mortality rates that are higher than the India average (Bhatia et al., 2019). The ASHA cadre has been active in the state of Bihar since 2005, with 88,331 ASHAs (as of January 2019) based in the rural areas of the state (NHSRC, 2019). Saharsa is one of the 38 districts in the state, in north-east Bihar, and is made up of 10 blocks.

Selection of Participants

The study blocks—Saur Bazaar and Sonbarsa—were identified based on their proximity to the district headquarters, with Saur Bazaar being the nearest and Sonbarsa being farther. Distance from the district headquarters has been identified in previous studies as affecting performance due to the level of supervisory visits required and the ease of communication with supervisors (John et al., 2020).

We collected the names and phone numbers of all 280 ASHAs in these two blocks. We contacted 60 ASHAs on this list, chosen at random, and asked for consent for interviews. This gave a total sample of 35 ASHAs across 25 villages. The average age was 35.4 years; the average experience was 6 years. 54% of the respondents reported agriculture as the source of livelihood, and 57% belonged to other backward classes caste.¹

Study Design

The interviews explored various factors that might influence ASHA performance of different activities, in line with the MMO framework, including ASHA motivations, preferences, support and workload. The interviews were conducted in September 2018 by a team of six trained social scientists. Each interview lasted for 45–75 min, was conducted in Hindi or Maithili, and was audio-recorded. The team was trained in undertaking the interviews, focusing on rapport building, posing non-leading questions, probing and ethics. Daily debriefing sessions with the interviewers allowed us to discuss key findings and revise our approach.

The interview audio was translated into English for analysis. An inductive approach with open coding was used to analyse the data manually (Strauss & Corbin, 1998). Each interview was read and coded independently. Multiple codes were regrouped based on similarity to identify emerging themes.

Ethics

We acquired prior approvals from the State Health Society in Bihar to undertake various rapid studies pertaining to health and nutrition in the state. Informed consent was sought from all the study participants, and the interviews could be conducted and recorded only upon receiving verbal consent. We took extensive steps to ensure the confidentiality of the participants at the transcription and analysis stages. Ethical clearance was received from the Sigma Institutional Review Board on the 9th of August 2016.

Findings

Four ASHA tasks were routinely discussed and are the focus of the findings presented below: mobilising attendance for VHSNDs; promoting institutional delivery; undertaking surveys and record-keeping and making HBNC home visits. The findings are presented according to the MMO framework. Only those MMO subcategories that were prominent in the analysis are discussed.

The details of these four tasks, district-specific coverage data from the National Family Health Survey-Round 5 (NFHS-5), are presented in Table 1. There is a wide variation in the effective coverage of these different tasks and the uptake of the services, and behaviours that ASHAs promote, which are further explored in the findings.

Table 1.

Description of Four Accredited Social Health Activist (ASHA) Tasks.

Task	Targeted at	Coverage in Saharsa as per NFHS-5	ASHA Role	Incentives Due for ASHAs
Mobilising attendance/supporting service delivery at VHSNDs/immunisation day MoHFW (2020), NHSRC (2019), NHM, MoHFW (n.d.))	Immunisation services for children under 3 years Antenatal checks for pregnant women Distribution of IFA tablets/other medicines Post-natal checks for lactating mothers	72.2% of the children in the age group of 12–23 months were fully vaccinated. 34.8% of mothers had an antenatal check-up in the first trimester. 11.7% of the mothers had at least four antenatal care visits. 4.4% of surveyed mothers consumed iron folic acid for 180 days or more when they were pregnant.	Mobilise attendance for the immunisation day Undertake health counselling and communication	Incentives are based on the percentage of eligible beneficiaries receiving immunisation and antenatal care services.
Promoting institutional delivery MoHFW (2020), MoHFW (2015, 2016)	Institutional births Reduced maternal and child mortality	70.4% of mothers chose institutional births.	Encourage institutional deliveries Escort pregnant women to give birth at either a government or accredited private health facility.	Entitled to an incentive of ₹600
Survey and record keeping MoHFW (2020), MoHFW (2023), NHM, MoHFW (n.d.)	Health Management Information System (HMIS) data to identify eligible beneficiaries Identify resource requirements Other documentation		Maintain different HMIS records (health, drug supply, immunisation and so on). The five broad categories of incentivised records via household surveys are:Line listing of households at beginning of the year (half-yearly basis) Maintaining the village health register (ongoing) Due list of children to be immunised (monthly basis) Due list of antenatal care (monthly basis) List of eligible couples (monthly basis)	Typically receives ₹1,500 for maintaining the five specific records. This incentive ranged from ₹100 to ₹150 for each register but was revised in 2018.
Undertaking home visits Care (2018), NHSRC 2019, NHM, MoHFW (n.d.), MoHFW (2025), MoHFW (2020)	Post-natal checks to monitor lactating mothers Newborn and under-five child health	In 2017, 48% of the children under two months of age in Bihar received at least one visit from a CHW; this number dropped to 20% for children aged 3–5 months, 6–9 months, 9–11 months. 49.4% of the children under age 6 months were exclusively breastfed. 10.3% of the children aged 6–23 months received an adequate diet. 18% of the children under 5 years were stunted, 20.5% were wasted, and 42.7% were underweight.	Expected to undertake 6–7 visits up until the 42nd day after a child’s birth under HBNC Visits to include counselling (newborn feeding practices) and information (birth spacing, childhood illness management) and product distribution. As per the Home-based Young Child Care (HBYC), ASHA is expected to undertake additional five visits after the 42nd day until the child completes 15 months of age.	Entitled to an ₹50 incentive for each visit under HBNC. ASHAs receive ₹250 incentive for the first 6/7 visits and a total ₹250/per child for making five visits under HBYC

Note: CHW: Community health worker; HBNC: Home-based newborn care; VHSNDs: Village Health Nutrition and Sanitation Days.

Means

Family Support

Family support in everyday work facilitates the ASHA’s performance. Male relatives assist ASHAs to undertake surveys, mobilise beneficiaries for immunisation days or escort them to and from the health facility. Numerate males often help with record-keeping due to the size of the workload and difficulties ASHAs (particularly with low education levels) have with completing them. Female family members in the family support in domestic roles, which allows ASHAs to pursue their professional roles. Therefore, the support of the family was important for all tasks but was particularly critical for the successful completion of the immunisation day, survey and record-keeping-related activities.

Self-efficacy

Many ASHAs seemed to have internalised the idea that they were poorly educated. As a result, many were found to have low self-efficacy, self-identifying that they had ‘no value’, and were self-conscious of their limited educational qualifications. This affected their delivery of the survey and record-keeping duties. The participants said that they were not sufficiently educated to carry out tasks that involved recording, maths or writing, reiterating that they were ‘illiterate’ or not educated enough, have not completed schooling—‘I’m only 7th Pass’ or ‘[I] don’t understand this work’. However, they still complied with their requirements without enthusiasm, or in a way that used the record-keeping to aid their service delivery through engaging with the data or using it for case management.

Knowledge

Gaps in knowledge also affected service delivery. This was most notably seen with regard to ASHA’s HBNC services, under which they are expected to make six or seven home visits to newborns. Many respondents had to be probed or reminded that they were also supposed to conduct home visits. Many were not aware of the danger signs to check for in HBNC and appeared to have a haphazard visit schedule. Few ASHAs recalled receiving recent training for home visits and HBNC.

Motives

Financial, Social and Moral Drivers

The idea of seva, or service, was reiterated as the basis for working as an ASHA, suggesting prosocial motives for taking on the role. However, this was a less powerful motive than the financial motive; ASHAs relied on the financial incentives provided by the role, given the lack of viable alternative livelihood options.

ASHAs typically belonged to socio-economically poorer sections and stated that financial pressures affected their decision to become an ASHA. The respondents spoke of selection into ASHA service, punctuating their experience with terms such as ‘needed money’ and ‘(money) was important’ to indicate the decision to become an ASHA. As one ASHA said of her decision:

When there were too many children at home, then we started facing financial issues. My husband used to earn and that was not enough, and I used to think that I am educated and should work. I have four daughters and I do not have anyone to help in their marriage. I thought that if I earn, I will be able to educate the children.

–A3, 36 years, Saur Bazaar, 12th pass

Further, incentives were also cues to prioritise certain tasks. Tasks such as institutional delivery and family planning (tubectomy operations) have higher incentives tied to them, and hence were a focus of task undertaken by the ASHAs. The ASHAs prioritised tasks with a higher incentive to maximise their income, but also because they perceived the tasks for which ASHAs received higher incentives as being more important.

Respondents reported discontent with the incentives received for the work performed. Incentives attached to immunisation and record keeping were considered too low in comparison to the effort invested, since each household had to be repeatedly visited. Long delays in receiving incentives were reported, which amplified discontent. ASHAs continued to work in the expectation of receiving future payments, and prioritised tasks where they had a higher expectation of receiving future payments, including immunisation. As an ASHA summarised,

I don’t get to know that when am I getting the money … They don’t give us all the amount at once and when they will give us the full amount, then only I will get to know.

–D6, 36 years, Sonbarsa, BA Pass

Remuneration was also tied to great legitimacy in the community. Respondents even claimed to lie to the community members when their services were dismissed as a nuisance. An ASHA said,

I have to lie that the government gives me 2,000 (rupees) to do this work (get the beneficiary ward immunised), only then they believe me.

–E7, 34 years, Sonbarsa, 12th pass

More fundamentally, incentive-based remuneration was perceived as unfair, whereas salaries were perceived to provide a legitimate standing in the community. Most ASHAs considered a full-time salary as the only way to satisfactorily reimburse them, given the substantive nature of their role. As one respondent said:

School teachers get paid regardless of whether there are students who attend the school. But I am working far more, and I have to wait for each beneficiary to get some money.

–C2, 34 years, Saur Bazaar, 10th pass

Incentive-based remuneration was perceived as unstable; the amount to be received was unpredictable and unbalanced across the months. This was because the incentives still relied on catchment areas, which varied significantly.

When the ASHA role was created, new ASHAs were promised ‘flexible’ work hours and a role focused on accompanying pregnant women to facilities. As the scope of the role has steadily increased, the perceived unfairness of incentive-based payments has grown. One of the reasons ASHAs stayed in the role is the hope that they would imminently become ‘government servants’ with a regularised tenure.

Provider and Beneficiary Preferences

ASHAs discussed an explicit preference for tasks with higher incentives and perceived ‘core’ tasks based on the original job description (institutional deliveries). On the other hand, ASHAs appeared not to prefer tasks with a higher dependence on numeracy skills (record keeping).

In terms of beneficiary preferences, the community appears to demand tangible product-oriented services (food supplies/monetary benefits). Hence, there is a relatively limited ‘active’ demand for certain information-oriented services, particularly home visits. In the absence of community demand, ASHAs were not motivated to continue to try to deliver certain services.

ASHAs also alter their service delivery based on the caste of beneficiaries, in nuanced ways related to the perceived differences in the preferences of groups. Some caste groups were perceived as ‘easier to convince’ for immunisation efforts, and hence were focused upon. Other groups were ‘difficult to convince’ for immunisation or ‘likely to have larger families’, so ASHAs focused more on delivery-based services and less on behavioural change communication. As one ASHA stated:

Musahar caste is there [in the village]. There delivery happens frequently … but they are reluctant to use family planning services.

–A2, 31 years, Saur Bazaar, 8th pass

System Reinforcement

ASHA’s supervisors deemed certain tasks to be core—VHSNDs or immunisation days—and consequently, ASHAs prioritised those over other services. Respondents claimed they are repeatedly reminded of the impending immunisation days during the monthly ASHA meetings; non-performance could potentially be met with a formal reprimand, in addition to implications for incentives. An ASHA stated that:

It’s mandatory for immunisation to be done every month. If a sudden delivery case comes up [on the VHSND], I attend to the delivery case also: I take them there [to the facility] and I tell the ANM [Auxiliary Nurse Midwife] to fill by due list register [at the VHSND] … I try to return immediately.

–A3, 36 years, Saur Bazaar, 12th Pass

System-wide focus to achieve immunisation targets saw supervisors, auxiliary nurse midwives (ANMs), Anganwadi Workers and ASHAs work together to reach ‘difficult’ households. As an ASHA pointed out:

For immunisation, two to three women don’t bring their children because of the fever they get (routine after certain vaccines). I know this, so I need to tell the facilitator that so-and-so person is not coming. Then the facilitator goes there to try and convince on her own.

−E6, 30 years, Sonbarsa, 8th Pass

This teamwork and focus were not reported for any other services.

Opportunity

Community

Strong community relationships were found to be a performance enabler. Embeddedness allows ASHAs to identify potential beneficiaries of services, leveraging their social networks to identify newlyweds and expectant mothers.

Conversely, many ASHAs did not enjoy strong legitimacy in their communities, which constrained service delivery and demotivated them. Many ASHAs reflected on how most beneficiaries thought of them as ‘idle’; they were seen as pressuring community members into service take-up for no benefit, and the rejection of ASHA services was uniformly reported. As an ASHA pointed out:

No one values us ASHAs in the area, they keep saying why do you keep roaming around, what is the purpose of your work?

–C3, 38 years, Saur Bazaar, 10th Pass

Furthermore, the community’s limited understanding of ASHA’s role affected their interactions with her. Many beneficiaries demanded that ASHAs provide them with financial support and food items, an area outside the ASHA’s jurisdiction. As an ASHA pointed out:

They [beneficiaries from a socio-economically poor locality/tola] say that you [the ASHA] do not give us rice and dal, you eat everything.

–D1, 31 years, Son Barsa, 10th Pass

Workload

The requirements for flexibility—to accompany women for deliveries or offer drugs or assistance at any time of day or night—were presented as a major challenge in ASHA’s routine.

The participants claimed that survey and record-keeping work were not something they should be expected to perform, as it had never been part of their initial job description. As one ASHA remarked:

Work has increased and now you can see that it started with [the] due list once a month. Then couples register and now we do the survey for everything. We go to each home and see how many five-year-olds there? How many 10-year-olds are there? And who has got what? I need to fill this information 20 times. The little I get for this is also delayed.

–E6, 30 years, Sonbarsa, 8th Pass

Workload was also viewed as an important deterrent in the performance of the home visits and HBNC-based activities. Given that it required repeated visits and effort to convince households to adopt specific childcare behaviours, ensuring that these behaviours were adopted was perceived as challenging. A respondent ASHA said:

We are supposed to visit the households on the seventh day but in between also, we have to go. If a woman does not understand, I’m sceptical that she might apply something on the umbilical cord [of a newborn]. Something might happen, and it would cause problem to me as well as to her too.

–E8, 43 years, Sonbarsa, 10th Pass

Immunisation days were also deemed challenging due to the effort involved in visiting families repeatedly to remind them to attend VHSNDs.

Resource Availability

Health system determinants—the availability of resources such as ambulances and safe spaces in facilities—were cited as challenges in the effective and prompt delivery of care. In the absence of ambulances or road connectivity, ASHAs were expected to pay ‘out of their own pockets’ to book transport to ensure that the patient reached the facility. In cases that took more time, the ASHA was expected to wait. In fact, many respondents avoided emergency cases that came up at night. This was partly because of the discomfort of going and staying at the public health centre (PHC). A respondent stated:

No one likes to stay there [PHC] … suppose, when I take the women there, they [the ANM and the beneficiary] say that you cannot go until it is done. There is so much problem in staying there … No arrangement to stay and I must stay with the patient. Because I have taken the patient there, I cannot make any excuse as well.

–D3, 38 years, Sonbarsa, 12th Pass

The ASHAs ability to perform is also affected by gaps in the supply of critical drugs such as ORS and paracetamol. The inability to provide medicines can also influence the credibility and trust in the ASHA, preventing the take-up of other ASHA services. As an ASHA remarked:

Everybody says that you only come here to write down things, but we don’t get any advantage of it as you don’t give us anything … They say that ‘you are not giving us tablet from so long’. But when medicines are available to us only then can we distribute to them.

–C3, 38 years, Saurbazaar, 10th Pass

Discussion

Nine of the 14 MMO subcategories were identified as influencing ASHA performance, with three related to each of MMO. Other subcategories did not arise in the interviews. Six of these nine subcategories have been previously identified in the literature on ASHAs. However, three (self-efficacy, system reinforcement and provider preferences) have been under-researched in ASHA literature, albeit acknowledged as important in the broader CHW literature (Abdel-All et al., 2019; Saprii et al., 2015; Sarin & Lunsford, 2017).

Under means, similar to previous investigations, we find that family support is crucial in the ASHA’s performance. This finding underpins the need to recognise the ASHA’s workload, which extends beyond a voluntary status, necessitating family support (Kawade et al., 2021; Manjunath et al., 2022). Further, studies from across the country have identified the impact of poor knowledge and skill levels of ASHAs on service delivery (Bansal et al., 2016; Kochukuttan et al., 2013). However, the effect of this on ASHAs’ self-efficacy and feelings of self-worth has not previously been identified.

Among motives, incentives are identified as a partial determinant of ASHA performance, as well as influencing provider preferences (Gopalan et al., 2012; Wahid et al., 2020). However, we find that ASHAs are not fully influenced by incentives—partly because of the complexity within the incentive system, and partly because of other drivers of performance (such as prioritising tasks that the ASHAs and system deem core). The belief that a salary would be fairer than incentives has been well documented in the literature (Bhatia, 2014). Studies situated in similar contexts have discussed beneficiaries’ preference for product-oriented services (John et al., 2020). However, few studies have discussed the role of system reinforcement towards specific tasks over others. This reinforcement also appears to affect ASHAs’ focus, which was targeted towards immunisations.

Within opportunities, embeddedness in the community allows ASHAs to perform better, as was also previously identified (Scott et al., 2018). Our findings further suggest that embeddedness allows ASHAs to expend targeted efforts through tailored messaging for institutional deliveries and other family planning services. We find that this curated service delivery reflects on the ASHAs’ agency and acute understanding of sociocultural dynamics (Kane et al., 2020). Other articles have identified this and advocated stronger ASHA communication skills training and have focused on targeted messaging (Sarin & Lunsford, 2017; Smittenaar et al., 2020). Other opportunity factors, such as community acceptance of ASHAs, were undermined by perceptions of low education and system-level constraints on service delivery (limited resources), which have been previously identified for Anganwadi Workers (John et al., 2020) in a similar context. The constraining influence of unrealistic workloads and limited resource availability has been routinely identified in the literature (Kawade et al., 2021; Scott et al., 2019). This potentially reflects a mismatch in ASHA roles, the means they have to deliver, and the expectations of the programme and the community.

Broadly, we find that means, motives and opportunities are interdependent and together act as a barrier to ASHA performance in line with the MMO diagnostic framework. We observe several interdependencies among the different factors affecting performance across the four tasks, also presented in Table 2. For example, low knowledge and self-efficacy also undermined community acceptance of the ASHAs and influenced provider preferences against tasks requiring numeracy and literacy, such as record keeping.

Table 2.

Summary of Identified Factors That Were Seen to Influence Accredited Social Health Activist’s (ASHA’s) Performance of Four Mandates Tasks.

MMO	Subcategories	Mobilising Attendance on Immunisation Day	Promoting Institutional Delivery	Survey and Record-keeping Duties	Undertaking Home Visits
Means	Knowledge and skills			Considered low
	Self-efficacy		Capable to carry out	Low self-worth
	Family support	Facilitates service	Facilitates service	Facilitates service
Motives	Financial, social and moral drivers	Incentives deemed low	Incentives deemed high		Incentives deemed low
	Provider preferences	Less inclined to deliver	Very inclined to deliver	Less inclined to deliver	Less inclined to deliver
	Beneficiary preferences System reinforcement	Less demandHigh		High	Less demandLow
Opportunities	Resource availability		Under-resourced health centres
	Workload	Considered time consuming		Effort-intensive	Existing workload is too high to deliver
	Community	Not seen to support

Source: Developed by authors by drawing on the domains and determinants of the MMO framework (as seen in John et al., 2019).

Immunisation day remained an administrative focus, with strong system reinforcement. Thus, it was prioritised by ASHAs despite being deemed under-incentivised and effort-intensive. Promoting institutional delivery also remains a focus. It was deemed an original part of the ASHA’s role, was also tied to higher incentives and thus ‘core’. However, poor overnight facilities at health centres were a barrier to delivery, and this merits policy attention. Survey and record-keeping duties were viewed as challenging, as ASHAs deemed themselves underequipped to deliver, and therefore had low self-efficacy. They also found it effort-intensive and under-incentivised. However, given its administrative focus, they maintained minimum, empty compliance with the task. This implies that core skill training (on numeracy and literacy) is important for ASHAs, as well as reviewing the levels of documentation and surveys they are expected to deliver. Home visits for HBNC were not prioritised by ASHAs due to the level of required effort in delivering them, low system reinforcement and low knowledge levels. The role of ASHAs in home visits and HBNC may need to be reconsidered. However, group-based approaches may be more realistic (Grantham-McGregor et al., 2020).

The differential effect of different MMO factors on different services is the major contribution of the article, alongside expanding the evidence base on contextual-level drivers of CHW performance, and the identification of self-efficacy, system reinforcement and provider preferences, which have not been previously well described in the ASHA literature.

It is also important to acknowledge a few limitations of this study. First, the findings are specific to four services, second, the findings exclusively focused on ASHA perceptions and hence aspects like coverage and fidelity of services fall outside the scope of our investigation.

Conclusion

This article discusses the many challenges that exist in ASHAs’ service delivery and points to prospects for assisting ASHAs in their performance. The rapidly evolving role of ASHAs in responding to evolving health system needs in Bihar demands a special effort to diagnose the different factors that influence service delivery. We find that different combinations of MMO factors affect different services differently, although many affect all services. This analysis is especially critical in the face of the growing role of ASHAs in non-communicable disease management and in pandemic response. Recent evidence indicates that many of the challenges faced by ASHAs have affected ASHAs’ role in the COVID-19 response, in addition to addressing nutrition and health-related challenges (‘ASHA Workers’ Struggle for Recognition’, 2021; Kapur et al., 2021; Nanda et al., 2020). As health systems continue to evolve to respond to changing health needs, ASHA’s roles and responsibilities are also changing. The programme design must learn from original pieces of work on ASHAs, to carefully consider the various aspects affecting ASHA performance across her many deliverables.

Footnotes

Acknowledgements

The authors would like to acknowledge Dr Priya Nanda and the Bill and Melinda Gates Foundation for supervision and feedback.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This study was funded under the Frontline Worker Knowledge Synthesis grant received by Oxford Policy Management from the Bill and Melinda Gates Foundation (BMGF) (OPP1194341).

Note

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