How can community workers improve the health system? 

Boosting the effectiveness of frontline health workers

Around the world, frontline health workers are often the backbone of health systems. They serve the communities in which they live and play an essential role in connecting families to the formal health system. In rural India, where medical facilities are often few and far between, the government relies on trained community volunteers called ASHAS (accredited social health activists) to visit families to encourage them to seek care when needed, and to talk about healthy behaviors.

The 150,000 ASHAs in Uttar Pradesh, India’s most populous state, are asked to perform a wide range of tasks, though most focus on reproductive, maternal and child health. Even within that area, they tend to concentrate on registering pregnancies, ensuring antenatal care, encouraging women to give birth at a health facility, and motivating parents to have their children immunized.

ASHAs have had a positive influence on these behaviors but they tend to give far less attention to other crucial aspects of maternal and newborn care, such as encouraging women to stay in hospital for up to 48 hours after birth, providing postnatal care, and offering information on family planning. What can be done to ensure that community health workers like ASHAs are as efficient and effective as possible in providing vital frontline care?

Surgo Foundation tackled this question from a number of angles, using a framework we have developed to systematically analyze community health workers’ practices. Our framework examines ASHAs’ behavior by exploring both internal drivers (such as beliefs, motivations, and decision-making processes) and external factors (such as the availability, accessibility, and quality of health services, and community norms and expectations). We analyzed quantitative data from community tracking surveys, and worked with our partners to design and implement new qualitative and quantitative studies, based on behavioral science principles, to identify behavioral drivers.

We learned that while many ASHAs are motivated and knowledgeable about a wide range of health issues, in general they only focus on some parts of their role. Our research suggested several possible reasons for this “know-do” gap. On the contextual side, there is an insufficient number of ASHAs (given the high fertility rate in Uttar Pradesh) and a striking discord exists between the expectations of the government and the limited time that ASHAs have as volunteers. ASHAs lack tools to work more efficiently, and their incentive payment structures are hard to understand. Community members also have limited understanding and expectations of the ASHA’s role. This is crucial, as ASHAs often choose to do only those tasks that the community expects. Further, ASHAs themselves underestimate the importance of some health behaviors and risk factors during pregnancy such as anemia. They also have low status within the health system, lack confidence in their abilities, and receive minimal feedback and supervision that may not take into account their particular needs and motivations.

Our initial findings point toward several potential solutions that could be explored by the government and other partners. Boosting the number of ASHAs, improving selection criteria, and limiting their role to areas where they can have high impact would increase the quantity and quality of their contacts with households. Building community expectations of the ASHA’s role could drive demand for more comprehensive services. Equipping ASHAs with tools to help them provide messages tailored to the family’s context will make them more efficient and effective. Finally, more frequent and individually designed supervision, and simplified incentive structures, could boost ASHAs’ motivation and confidence in their ability to ensure essential basic care, especially for expectant mothers and newborns.