This analysis shows that visits by ASHAs did not demonstrate a stronger relationship with the health outcomes for which they were paid (institutional delivery and complete immunizations) than with outcomes for which they were not explicitly paid (exclusive breastfeeding for the first six months, timely introduction of complementary feeding, continued breastfeeding during the child’s illness, handwashing, and awareness of NHDs). With few exceptions, ASHA visits did not show a significant positive impact on these health behaviors, and in some instances showed a negative association. The analysis also demonstrates that visits from AWWs were more predictive of mothers adopting certain health behaviors (complete immunizations for the index child and continued breastfeeding during the child’s illness in Chhattisgarh, handwashing in Odisha, and awareness of NHDs in all four states). Visits by other CHWs and multiple visits by different types of CHWs were not predictive of any of the health outcomes in any of the four states. The study also ran a model (data not shown) with an interaction term between visits from ASHAs and AWWs, to see if visits from one worker reinforced or otherwise affected the effect of visits from the other, but no significant effects were observed.
Table 3 shows that a mother in AP is less likely to have an institutional delivery after being visited by an ASHA. The reported odds ratio may be misleading, however. Only 42 mothers in AP were visited by ASHAs – a very small number compared to other types of CHW visits (AWWs 520 and Other CHWs 520) – and these mothers may be anomalous in other, unmeasured ways. Of those 42 mothers, over 71% had an institutional delivery. The same issue of minimal ASHA visits in AP applies to the statistically significant but possibly misleading results for having an ASHA worker visit reduce the odds of a mother introducing complementary feeding as recommended and being aware of NHDs.
Similarly, the impact of a visit from an AWW in Chhattisgarh may not be as extreme as the odds ratio implies. A visit from an AWW statistically increased the likelihood of an index child being completely immunized, but only 22 children in the state had complete immunizations out of 692, suggesting that the positive impact of an AWW visit is overstated in the statistical results, and that CHW visits, in fact, did not achieve the goal of universal complete immunization.
Some studies have shown that more than 60% (689/1141) of institutional deliveries in India can be attributed to the motivation of ASHAs [4]. Similarly, a recent study showed that exposure to ASHA services was associated with a 28% increase in facility births [13]. However, Wagner and his colleagues did not find a significant relationship between ASHA placement in a community and institutional delivery [14]. Rather than motivation, exposure to services, or ASHA placement, our study used ASHA home visits as a primary independent variable and found no positive association with institutional deliveries, which is likely a key reason for the difference in findings compared to other research.
Bellows and his colleagues reported that ASHAs focused more on the health practices for which they were paid at the expense of other important but unpaid activities [10], which is not supported by the results of this analysis. A qualitative study by Saprii L. and colleagues in 2015 found that ASHAs relied on the incentives provided from institutional deliveries and referrals of pregnancy cases, but that other activities were poorly incentivized [15]. However, ASHAs in remote villages found it more difficult to rely on the incentives provided from pregnancy referrals and institutional deliveries because there were too few pregnancy cases in their communities [15]. In 2010, Scott K. and Shanker S. also reported that ASHAs were limited by the performance-based payments and delayed incentives [16]. Some ASHAs have campaigned to change their payment method to a regular salary-based system rather than the unstable performance-based incentives, but this has not been approved by the NRHM [17]. Differences in the compensation system within states, variability in pregnancy cases within communities, and ability to rely on the incentives provided to ASHAs were not controlled for in this analysis but may all affect the results presented above.
Another explanation for the statistically insignificant association between ASHA visits and the promoted maternal health outcomes may be that the ASHA program was established in 2005, whereas the AWW program has been in place since 1975. Within the six years between the start of the ASHA program and the survey reported here, the GOI may not have fully developed the capability to support the ASHAs. Consistent with this, Paul et al. also stated that the Indian primary health care system lacks sufficient ASHA training, supervision, and monitoring, both nationally and at the state level [18]. Without sufficient support from the government and health system, ASHA workers may not have received the necessary resources for their work, which could account for the low rates of ASHA home visits revealed in this analysis.
Given the low percentage of households that received an ASHA visit, it is possible that these households have other characteristics associated with the outcomes measured. Although we controlled for possible confounders in multivariate analysis, unobserved or unmeasured differences between households that received an ASHA visit and those that did not could have contributed to the results reported here.
Future studies could employ a cluster randomized design in which workers are assigned to be paid according to one or the other compensation method and evaluate whether a hybrid compensation model may achieve superior positive impacts on maternal and child health outcomes in India. CHWs could be salaried and also have the opportunity to receive performance-based incentives such as those currently given to ASHAs. The stability of a salaried remuneration system could attract the most qualified CHWs, while offering the performance-based incentives may encourage the CHWs to prioritize key outcomes.
Study limitations and implications
The Tufts University study team replicated the FFP projects’ quantitative endline evaluation surveys in 2011 for CARE. The researchers consequently did not have control over the questionnaire design and were unable to control for useful factors such as information about home visits, state-level incentives, or adequacy of trainings of AWWs and ASHAs. The survey question, “Has a (specify the type of CHW) met you at home in the last 1-month to talk to you about the care and feeding of your child?” may also have been overly specific. It is possible that some mothers did not report a visit by a CHW because the CHW who visited them did not discuss the care and feeding of their children, but may have discussed other important health outcomes, such as proper handwashing practices. Finally, because analyzing outcomes based on home visits from different types of CHWs was the purpose of our analysis, this study could have benefited from having data on the number of home visits by various CHWs.
Due to the diverse results across states in this analysis, we suggest further research on this topic that includes variables related to the implementation of the ASHA program, inclusive of incentives being paid out by state and the number of active ASHAs, in order to identify possible reasons why ASHA visits are lower in some states and higher in others. It would be useful to identify the factors underlying the successes and challenges of the various CHWs’ performance and compare the AWW and ASHA programs order to provide recommendations to improve the impact of the ASHAs on the health and nutrition outcomes of their beneficiaries.