Assessing community health workers’ performance motivation: a mixed-methods approach on India's Accredited Social Health Activists (ASHA) programme

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.