The survey consisted of 386 CHWs (), of which the majority were below poverty line (71%), married (70.47%) and scheduled tribes (36%). Most of them had 8 years of formal education (85.75%), experience of 2–5 years as CHW (82.9%). The majority had undergone a minimum five trainings (73.06%), earned US$22.24–33.33/month as a CHW (83.16%). Further, most of them did not have any other personal sources of earning (91.97%).
Background characteristics of the CHWs
Level of performance motivation among the CHWs
The level of motivation was the highest on the intrinsic job satisfaction on various job-related achievements (mean 4.30; 68.4% of CHWs). The self-efficacy or the perceived abilities on job scored a mean score of 4.27 (69.7%). The nature of the job responsibilities positioned at the third with a mean score of 4.18 (66.3%), followed by the social responsibility and altruism (4.12; 66.1%). The mean scores were 4.07 for the self-motivation (84.7%), 4.06 for the community participation in activities (63.2%) and 4.04 for the peer support (77.2%).
The degree of motivation was the least on the community opinion on the healthcare delivery system (2.7; 1%), followed by their satisfaction on the level of healthcare infrastructure (2.83; 6.7%). The ASHAs were also less motivated on their work load (2.96; 8.8%). They had a moderate level of motivation (mean 3–4) on enjoying the autonomy to move, express opinions and execute the responsibilities (3.96; 60.4%). The recognition from the community, family and health system scored moderately (3.96; 55.4%). The training (3.78; 72.8%), the type of supportive supervision received (3.28; 12.2%), the work modality (3.18; 17.6%) and the incentives (3.07; 16.6%) also scored a moderate mean.
A large proportion of the ASHAs (n=327; 84.72%) were self-motivated. If we look at the individual scores for each parameter, the question on community acceptance, that is, the community accepts my activities as I intend to secured the highest mean score at 4.64 (n=366). Second, a self-efficacy-related question (I can always manage to solve difficult problems if I try hard enough) scored at 4.58 (n=350). Further, the probe on the intrinsic job satisfaction (I am satisfied that I accomplish something worthwhile in this job) received a mean score of 4.54 (n=336).
As per the Cronbach's α test, the internal consistency of the scale was adequate. The consistency coefficient was 0.78, 0.79 and 0.84 for the community, health system and the individual scales, respectively.
Determinants of the level of performance motivation
The ASHA's earning as a CHW (p<0.05, 95% CI 0.06 to 0.12), sense of social responsibility and altruism (p<0.01, 95% CI 0.12 to 0.25) and feeling of self-efficacy (p<0.01, 95% CI 0.38 to 0.54) in undertaking responsibilities influenced her recognition at the health system, community and family (not mentioned in the tables). Other socio-economic characteristics were not significant in this regard.
How does the healthcare delivery system impact on the CHW's level of motivation?
We explored how significantly the level of motivation on the health system factors influenced their motivation at the individual and the community levels. This exploration was prompted by the fact that the CHWs were more demotivated on the status of the former ( and ). The peer support induced for a higher level of satisfaction on the community participation, recognition, self-efficacy and intrinsic job satisfaction. On the contrary, the dissatisfaction on the workload also led to a higher level of dissatisfaction on the above aspects. The dissatisfied CHWs on the supportive supervision had reported a lesser community recognition and intrinsic job satisfaction. The demotivation on the work modality and the healthcare infrastructure were positively related to a lesser intrinsic job satisfaction. Their perceptions on the incentives did not affect the level of motivation on any of the community, individual or health system parameters ().
Healthcare delivery system vis-à-vis the community health workers’ performance motivation.
Influence of the healthcare delivery system on the community health workers’ (CHWs) performance motivation
Prevailing scenario of the factors affecting the performance motivations: experiences of the ASHAs
The better use of time (91%), lack of alternative job opportunities (76%) and a sense of social responsibility (68%) were the reasons to become a CHW and everyone wanted to continue as ASHA. They considered performance motivation
as an encouragement (45%) or something which makes their performance better (62%). Their prior involvement in women's groups improved their sense of altruism. Working with the community as CHW and empowering them, especially women, inspired many. They felt women to be more receptive to their health advices and engage in community activities compared to men.
We have more support from our Didis and women's groups are now more enthusiastic and capable in community activities. Our social cohesion is improving further. [CHW, #4]
Supporting the survey data, many reported enhancement in their family and social status, and personal autonomy attributing to the role of CHW. They felt empowered through the acquisition of knowledge and skills on community health through training, designated stature in the community and the personal autonomy to work. Peer support and healthy competition among the ASHAs seemed to have enhanced their enthusiasm to perform well and achieve progressive community health. They enjoyed the job autonomy to perform the designated duties.
Now I have a say in my neighborhood. I am being invited to sit in community meetings and I represent my village in health centre meetings. [CHW# 28]
We meet during trainings and meetings and share a lot with each other. Since we have the same kind of work, learning from each other has increased our problem-solving skills. [CHW # 41]
On the contrary, the CHWs had certain dissatisfactions on certain health system aspects limiting their performance motivation at the individual
and the community levels
. Excessive workload, frequent refresher trainings and meetings at health centres and travel to remote habitations took away their personal time. They sometimes felt having limited autonomy at work to perform their social responsibilities beyond the specified guidelines. The CHWs solicited their active involvement in the planning of service delivery to incorporate community's felt needs, as often they were given only the options to deliver services than planning.
Very often what the programme wants and people want from me are different. I feel whatever issues I raise on behalf of the community during the health centre meetings are not addressed timely. [CHW# 74]
Many posed concern on the community's lack of trust on the public healthcare system. There were instances of care seeking from the private informal providers, despite the availability of drugs with the CHWs. This community behaviour was built on the instances of them not getting drugs from the CHWs due to unavailability. Their activities were limited by the frequent stock-out of drugs and commodities and the communication gap at different levels of their supervision.
They also reported to have an inadequate level of knowledge, skills and supportive supervision to perform optimally. Their performances were monitored through the self-recording of activities, supplemented with random visits by the multipurpose female health workers and other supervisors. They found it difficult to monitor community health through surveys as it was time consuming and tricky to record, with their low level of education. Most of them expected to have routine supportive supervision of their activities and the grass-roots level organisations’ cooperation to enable improved performances.
We would like to have an integrated approach with the women's group, the NGOs and the village health committee to share and solve local issues. [CHW# 13]
Often, I communicate timely on drug stock-outs to sub-centre, but the primary health centres tell that they are not aware of this. I feel my concerns and issues are not spelled out at the higher level properly, though I share everything with my supervisors. I am also not given timely instruction on my roles on many activities [CHW #53]
They demanded for more flexibility in organising meetings at convenient locations to give more time for the community and their personal life. Although CHWs received honorarium for trainings and meetings, they did not prefer frequently attending them. They were confident to execute the responsibilities, still desired knowledge and skill enhancement to convince the community and gain community acceptance. They seemed to be less confident on curative skills and urged for more system thrust and training in this regard.
I want to be with the community more than the meetings. We wait for longer time, even for four hours at the health centres for a one hour meeting [CHW# 29]
Some of them were disgruntled on the level of the monetary and ours non-monetary incentives received, yet they did not want to underperform. The ASHAs often had to expend on mother's consumables and spare on an average 30 hours on escorting mothers for child birth. However what they receive was lesser considering their actual spending and the time cost. They denied having any opportunity for informal payments, but admitted to have received occasional incentives for escorting mothers without actually doing so.
I often spend out-of-pocket on mother's consumables at hospitals and what I receive is quite less in return. Still, I want to support mothers as I feel they are like my sisters and I am obliged to support them. [CHW#69]