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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
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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
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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
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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%).

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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.

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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.

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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]

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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
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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
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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

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