Facilitating behavioral change: A comparative assessment of ASHA efficacy in rural Bihar

Abstract

Community health worker (CHW) programs are essential for expanding health services to many areas of the world and improving uptake of recommended behaviors. One of these programs, called Accredited Social Health Activists (ASHA), was initiated by the government of India in 2005 and now has a workforce of about 1 million. ASHAs primarily focus on improving maternal and child health but also support other health initiatives. Evaluations of ASHA efficacy have found a range of results, from negative, to mixed, to positive. Clarity in forming a general impression of ASHA efficacy is hindered by the use of a wide range of evaluation criteria across studies, a lack of comparison to other sources of behavioral influence, and a focus on a small number of behaviors per study. We analyze survey data for 1,166 mothers from Bihar, India, to assess the influence of ASHAs and eight other health influencers on the uptake of 12 perinatal health behaviors. We find that ASHAs are highly effective at increasing the probability that women self-report having practiced biomedically-recommended behaviors. The ASHA’s overall positive effect is larger than any of the nine health influencer categories in our study (covering public, private, and community sources), but their reach needs to be more widely extended to mothers who lack sufficient contact with ASHAs. We conclude that interactions between ASHAs and mothers positively impact the uptake of recommended perinatal health behaviors. ASHA training and program evaluation need to distinguish between individual-level and program-level factors in seeking ways to remove barriers that affect the reach of ASHA services.

Association between the use of Accredited Social Health Activist (ASHA) services and uptake of institutional deliveries in India

“…ASHAs operate under a performance-based incentive program, linking monetary rewards to measurable tasks. Given their crucial role, it is essential to provide them with fair pay and conducive work environments to maintain the quality-of-service provision by ASHAs and for overall health system robustness and resilience [ 39 , 40 ]. To achieve Universal Health Care where “no one is left behind”, the role of ASHAs in India is indispensable [ 41 ].…”

“…Recent evaluations of the ASHA program highlight operational challenges, including insufficient contact with healthcare-seeking women, high workload, inadequate training, PLOS GLOBAL PUBLIC HEALTH supervision gaps, and low, uneven compensation [39,40]. ASHAs operate under a performance-based incentive program, linking monetary rewards to measurable tasks.…”

Evolution of community health workers: the fourth stage

“…The Indian ASHA ( 36 ) is an example of a CHW functioning at this stage. In the Indian case, even though the overall program has not been very effective ( 37 , 38 ), there is evidence that whenever the ASHA has engaged with households, she has had a significant impact on their behaviors ( 39 ). Among the more successful health messengers are the Health-Development-Army volunteers in Ethiopia ( 40 ).…”