Analysing performance of community health workers

Community Health Workers (CHWs) are a critical component of the health system and serve as a crucial link between the formal health system and the communities they serve. CHWs are essential to the delivery of reproductive, maternal, newborn and nutrition interventions at the community level, in particular through three cadres of government CHWs in India – Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs) and outreach-focused Auxiliary Nurse Midwives (ANMs).

The coverage and quality of essential services at the community level in many states in India remains low and stagnant. In 2018, we received a grant from the Bill & Melinda Gates Foundation to explore the causes of this, and generate and strengthen evidence on what it would take to improve service delivery.

CHWs operate in a challenging role, navigating complex health systems and complex communities. Using novel conceptual frameworks and human-centred research techniques, and inspired by latest global thinking on CHWs, we have identified the binding constraints to CHW performance in different contexts. We have used this to identify a new generation of potential solutions, some of which we are testing in path-breaking pilots.

Challenges

We developed an analytical framework to identify the binding constraints and facilitators to CHW performance in ensuring effective coverage. The Means, Motives and Opportunity (MMO) framework , subsequently published in BMJ Global Health, presents three interdependent domains that identify whether an individual is capable of performing (means), wants to perform (motives) and has the chance to perform (opportunities).

On applying the MMO framework to the performance of ASHA and Anganwadi workers, we found that:

• A lack of means was a barrier to performance: CHWs have limited levels of technical knowledge scoring, on average, a third in a basic knowledge test. This has serious implications for services like newborn care counselling that require high degrees of knowledge.
• We did not find evidence that motives were a binding constraint. In general, CHWs are poor women with limited alternative livelihood options and their desire to keep their job (along with other moral and social motivators) ensures compliance to the current system.
• Opportunity constraints were the major impediments to improved coverage and quality of services. These are external to the individual and linked to system-level factors. For example, 20% of Anganwadi Centres are not operational, and the remaining 80% suffer from chronic deficiencies in infrastructure and supplies.

Overall, the analysis suggests that CHWs have limited agency over the factors that act as binding constraints to their performance. Yet policy levers tend to target motives – with strict monitoring and a reliance on incentives – which does not fit the problem diagnostic.

Our approach

Based on our findings, we identified priority solution areas that may support improved CHW performance. These have been identified based on experience from other contexts, and their congruence with the problem diagnostic, yet there is a limited evidence base on their potential effectiveness in India. Some of these are now being piloted to generate evidence.

1. Supportive supervision

Formative research shows that the supervision of CHWs is demotivating and counterproductive. Supervision tends to be delivered in a punitive manner, relying on auditing compliance and checking registers and not focused on mentoring and coaching. Emerging global evidence indicates that training and mentoring of supervisors can reverse these behaviours and make supervision more supportive, improving CHWs’ skills and performance.

2. Investing in transferable skills

Current in-service training for CHWs tend to rely on didactic, classroom-based approaches and are overly focused on technical knowledge rather than transferable skills (communication, teamwork, etc). We hypothesize that the system should increase its focus on transferable skills as it will enable CHWs to build trusting relationships with community members.

 3. Participatory Learning and Action (PLA)

The PLA uses CHWs to facilitate community groups to discuss and engage in participatory decision-making to address local problems. Pioneered in India by the NGO Ekjut, evidence suggests that PLA can improve health-seeking behaviour and reduce neonatal mortality. Further, repositioning the ASHA as a convenor and mobiliser can improve her relationships with the community, improving her overall effectiveness.

Outcomes

Our approach is in line with the broader global literature that advocates for empowering CHWs to perform by investing in their ability to forge trust-based relationships with their communities.

Implementation research conducted through a pilot implementation of the supportive supervision approach will focus on the changes in performance, positionality (vis-à-vis the community), and motivation of the CHW as a consequence of a more enabling work environment. We are also documenting promising and effective innovations in the space of soft-skill training of ASHAs from across the country to inform ASHA training approaches.

We collaborated with Women in Global Health India (WGHI) to anchor the CHW: Frontiers of Thinking and Evidence Webinar Series. Each webinar in the series focussed on a dedicated theme, involving multiple stakeholders to discuss the relevance, application, and implications of existing evidence on CHWs in India to identify gaps in evidence and potential ways forward. The aim of the webinar series was to share and generate practical solutions to the key challenges that CHWs face.

Webinar #1 theme: How can CHWs feel empowered? 

[button-link text="Watch recording" link="https://youtu.be/rZP6nWcu0v8"]

Webinar #2 theme: From Community Health Workers to Community Health Systems: Unpacking Complexities

[button-link text="Watch recording" link="https://youtu.be/lxYdF6bIyEk"]

Webinar #3 theme: Leveraging digital technologies for transforming CHW work

[button-link text="Watch recording" link="https://youtu.be/Gg-WXUnKujw"]

Webinar #4 theme: Role of Community Health Workers in Building Resilient Health Systems: Learnings from Covid-19

[button-link text="Watch recording" link="https://youtu.be/VccF4Cdd_jk"]

Webinar #5 theme: Supportive Supervision of CHWs: Improving Management Practices at the Frontlines of India's Health System

[button-link text="Watch recording" link="https://youtu.be/8w63WkK-e8g"]

Webinar #6 theme: Universal Health Coverage in India: Critical Areas of Policy Reforms and Research for Better CHW Engagement

[button-link text="Watch recording" link="https://youtu.be/HjriUKKru4c"]

The results from our research will aim to inform the state health policy and Bill & Melinda Gates Foundation about innovative solutions towards strengthening CHW performance and service delivery.