Effects of Various Financial and Non-financial Incentives on the Performance of Accredited Social Health Activist: Evidence from Two Selected Districts of Odisha

Abstract

Introduction:

The performance of Accredited Social Health Activists (ASHAs) is crucial for the achievement of the ‘health for all’ goal in India. The performance and motivation of workforce are dependent on various financial and non-financial incentives. This study analyses the linkage of current incentive practices and perceived rewards/sanctions, with the motivation and performance of ASHA.

Methods:

Cross-sectional qualitative approach and interpretive structural modelling (ISM).

Results:

The motivation and performance of ASHAs were driven by various inter-related factors. The predominant rewarding factors identified were: monetary incentives, awards, and support and respect of the community towards the ASHAs. Dissatisfaction was fuelled by factors, such as sense of underpayment, comparison with peers and the community cadres of other departments, erratic duty hours, scarce disbursement of resources, financial insecurity post-retirement, difficulty in reading or writing, unavailability of health services and medicines in the nearby healthcare facilities.

Conclusions:

For a sustained advance in motivation and performance of ASHAs, the public health systems’ focus needs to be oriented on: capacity building; optimal resource allocation, rationalised payoffs to the ASHAs working in difficult terrains and improving availability of healthcare services in primary healthcare facilities.

Keywords

CHW ASHA incentive motivation performance ISM

Introduction

The World Health Organization (WHO) states that community health workers (CHWs) ‘should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organisation, and have shorter training than professional workers’ (WHO Study Group, 1989).

CHWs play a pivotal role in achieving public health goals in low- and middle-income countries (LMICs), particularly in improving maternal and child health (MCH) outcomes in resource scarce settings (Gilmore & Mcauliffe, 2013). In this context, India has tried several ways of engaging CHWs over a period of time. In 2005, the Union Government introduced the Accredited Social Health Activist (ASHA) initiative under the aegis of the National Rural Health Mission (NRHM)—now, the National Health Mission (NHM)—to engage CHWs in the architecture of an inclusive and equitable public health system for the country. The primary aim of the ASHA programme was to provide a trained health activist at the community level who would serve as the first point of contact between the community and health system. ASHAs provide basic, yet significant health information and services to the community (Agarwal et al., 2019). It has been suggested in some recent studies that although ASHAs are contributing considerably towards strengthening MCH and reproductive healthcare in India, their role as social health activists is reducing, gradually (Saprii et al., 2015). With this background, the ASHAs’ performance becomes crucial for the success of NHM and achievement of ‘health for all’ goal in India.

The quest for linking human resource management (HRM) practices and performance has been underway for the past several decades (Boxall et al., 2009; Guest, 2011).Studies suggest that the adoption of appropriate HRM interventions, such as incentives (both financial and non-financial) can improve health workforce performance (Armstrong, 2014; Delery & Doty, 1996; Guest, 2011). Most of the health sector-related literature in LMICs describe what works but there is little knowledge available on the mechanisms through which the HRM practices influence the health workforce performance in a given context (Dieleman et al., 2009; Kadam, 2020; Rowe et al., 2005). This study analyses the linkages of HRM practices related to the financial and non-financial incentives with health workforce performance, especially, in the context of the Indian public health system.

Objectives

The specific objective of the study is to assess the effects of current financial and non-financial incentives on the performance and motivation of ASHAs in terms of intrinsic and extrinsic HRM outcomes.

Methodology

Study Approach

A qualitative cross-sectional approach was used to understand the effect of financial and non-financial incentives on the performance of ASHAs. The effects in terms of intrinsic and extrinsic outcomes leading to job satisfaction as HRM outcomes were analysed using a theoretical framework (Figure 1).

Figure 1.

Source: Based on Vroom’s expectancy theory and description of Open University (1997).

The framework is based on the Vroom’s expectancy theory (Gibson et al., 2012) and it precisely summarises the linkages between effort, performance and rewards (awards/sanctions)—also called outcomes. The basic assumption is that the employee will put in more effort, if there are higher chances of effort resulting in performance that will lead to financial and non-financial rewards which are perceived to be fair. To transform effort into better performance, employees need clear directions about the job, enough competencies to undertake the job and adequate resources required to accomplish it. Moreover, the employee’s performance is linked with rewards that may be intrinsic (e.g., sense of accomplishment) or extrinsic (e.g., monetary incentives). Employees will judge whether these rewards/sanctions are fair enough to satisfy them. Based on this job satisfaction, they will decide whether or not to put in effort. Thus, the whole model is probabilistic, such as what is the probability that extra effort will lead to improved performance, and improved performance will lead to rewards/sanctions that are fair to employees’ expectation.

Study Setting

The study was conducted in two purposively selected districts, namely, Balasore and Rayagada in Odisha to represent the plains and hard-to-reach terrain, respectively. In each district, two community development (CD) blocks were selected purposively on the basis of their locations and distance from the district headquarter (DHQ)—one neighbouring/nearer block and another distant/ further block. It was assumed that the motivation and performance of ASHA might be influenced by different geographical terrains because of the diverse working contexts.

Study Participants

The following three categories of respondents were purposively selected with an assumption that they can better explain the mechanism through which intrinsic and extrinsic outcomes affect the performance: (a) ASHAs, (b) auxiliary nurse midwives (ANM)—the immediate supervisors to ASHAs and (c) block and district levels managers—associated with the management and planning of activities and incentive disbursement process for the ASHAs.

The block-level informants included: Block Programme Manager (BPM)–NHM, Block Accounts and Data Assistant (BADA)–NHM, and Public Health Extension Officer (PHEO)–Health and Family Welfare Department, Government of Odisha. The district-level informants included: District Programme Manager (DPM)–NHM and District ASHA Coordinator–NHM.

Data Collection and Analysis

The study was conducted between December 2020 and May 2021. Primary qualitative data were collected through in-depth interviews (IDIs) of the selected respondents/informants. Separate interview schedules were used for different groups of participants, developed in an iterative manner with piloting and contextualisation. The interviews were conducted in the local language, that is, Odia, with prior informed consent from the respondents. In total, 56 IDIs were planned, of which 54 IDIs were conducted.

A thematic framework approach was followed to analyse and interpret the primary qualitative data with the help of ATLAS.ti 8 package. The steps involved: data familiarisation, coding, identification of themes, charting and interpretation.

Further, interpretive structural modelling (ISM) (Ahmad et al., 2019; Attri et al., 2013; Mabrouk & Ibrahim, 2021) technique was applied to synthesise mental models to depict the structural relationship and flow of factors leading to ‘content’ and ‘discontent’ in ASHAs that ultimately affects performance. In addition, MICMAC analysis (explained later in this article) was used to determine the driving and dependence power of different factors leading to ‘content’ and ‘discontent’. The modelling exercise involved the following steps:

Identification of factors associated with content and discontent in ASHAs: From the analysis of IDIs, relevant factors or variables leading to content and discontent in ASHAs were identified and extracted.

Structural self-interaction matrix (SSIM): The SSIM shows whether a specific factor leads to another or not and vice versa. The causal links between the factors were examined through brainstorming; taking views of the thematic experts, such as health systems researchers, and scoping literature review. Conventionally, four symbols are used to determine the relationship between any two factors, such as F1 and F2:

O—none of the variables lead to no other variables (neither F1 leads to F2 nor F2 leads to F1).

V—forward/unidirectional (e.g., F1 leads to F2, but F2 does not lead to F1).

A—backward/unidirectional (e.g., F1 does not lead to F2, but F2 leads to F1).

X—bidirectional: both variables lead to each other (e.g., F1 leads to F2 and F2 leads to F1).

Reachability matrix: The SSIM was converted to an initial reachability matrix (IRM) in binary terms by replacing the causal relationship between factors with 0 or 1 as per the rule for transformation (Table 1). After obtaining the IRM, the property of transitivity was checked to generate the final reachability matrix (FRM). The transitivity was checked for the condition: if (F1, F2) = 1 and (F2, F3) = 1, then (F1, F3) is also = 1.

Table 1.

Rules for Transformation of SSIM to IRM.

If the (F1, F2) relationship in SSIM is:	Entry IRM
If the (F1, F2) relationship in SSIM is:	(F1, F2)	(F2, F1)
O	0	0
V	1	0
A	0	1
X	1	1

Source: The authors.

Note: IRM, initial reachability matrix; SSIM, structural self-interaction matrix.

Level partitions: It refers to the partitioning of FRM into different levels. For each factor in the FRM, the antecedent and reachability factors were identified and segregated. The ‘reachability set’ for any specific factor included the factor itself and other factors it may affect. The ‘antecedent set’ comprised the factor itself and other factors that may lead to it. Subsequently, the intersection of antecedent and reachability for all factors was derived and level of each factor determined. The factor for which the reachability and the intersection sets was the same was given the first level in the model. Then, this factor was separated from the other factors for the next-level iteration process. The same process was repeated to find the next-level factors, and continued until all factors were segregated appropriately to their respective levels in the model.

The digraph: Following the level partition, an initial model for the ISM was developed with regard to the transitivity. Then, the final version of diagraph was sketched by removing the transitivity of nodes. In the digraph, the elements were presented in terms of nodes and edges on the basis of their interdependencies.

The MICMAC analysis: The MICMAC is an abbreviation for Matrice d’Impacts Croises Multiplication Appliques a un Classement—a process to analyse the driving and dependence power of factors. The MICMAC analysis was conducted by dividing factors into four clusters with respect to the driving and dependence powers of the factors:

Autonomous factors (cluster I): Factors having lower or no dependence and driving powers. These factors have least influence on other factors;

Dependent factors (cluster II): Factors having higher dependency and lower or no driving power. These are the top-level factors and affected by other factors;

Linkage factors (cluster III): Factors having higher dependency and driving powers. These factors are usually unstable and act as links between the dependent and independent factors;

Independent factors (cluster IV): Factors having lower dependency but higher driving power. These factors have lower influence from others factors, but influence other factors the most.

Ethical Considerations

Necessary clearance was obtained from the Research and Ethics Committee, Directorate of Health Services, Department of Health and Family Welfare, Government of Odisha (Letter No. 25332/MS-2-IV-04/2020).

Results

Directions

The key informants working at block and district levels perceived ASHAs as an integral part of the rural healthcare delivery system and acknowledged their significance and contributions towards achieving the NHM goals. ASHAs being affiliated to the community, hold a strategic position to serve as a reliable source of health related information for the community and the public health system. Over the years, their roles and responsibilities have increased substantially and currently, they are directed to carry out 53 community-level activities.

ASHAs viewed whatever they are doing as part of their duty, which is appreciated above any personal discretions. They keep constant communication with the ANMs and follow their directions and suggestions to undertake activities. They get support from peers, ANMs, ASHA Sathis (only in few areas), supervisors, community processes (CPs) nodal persons, BADA, BPM and medical officers (MO) of the respective community health centres (CHCs).

The supervision system for the ASHAs is largely dependent on the ANM. The ANM visits tagged villages to oversee the activities of ASHAs and to ensure the general well-being of mothers, pregnant women and children in the villages. The ANM not only assumes a supervisory role, but also directs and helps ASHAs to learn and understand the intricacies of community-based health activities and associated incentives.

Despite the cohesive work culture of ASHAs with the ANMs, it was observed that every third ASHA lacks comprehensive understanding on the complete array of activities, and her roles and responsibilities. These issues were more prevalent in Rayagada than Balasore. The block- and district-level informants attributed the problem to the low literacy level of ASHAs in tribal and hard-to-reach pockets.

We do whatever we are asked to do by ANM, on the day of VHND, we go to the Anganwadi centre early in the morning and arrange for water, sweep and mop the centre, arrange everything and once ANM comes, we go and call the children and weigh them and do everything. (An ASHA, Rayagada)

If you talk about awareness, then because the literacy rate in our area is low, we cannot refute the fact that we have a smaller number of literate ASHAs, we are also constantly putting efforts to make them aware about the activities and incentives. (A district level management personnel, Rayagada)

Competencies

Most respondents believed that the workload on ASHAs has increased manifold. The programme was initiated with nine activities, and now it has reached 53. New activities were being added each year with the commencement of new national or state-specific programmes.

The ASHAs seemed competent and confident in carrying out their routine activities related to MCH and reproductive health interventions, such as Village Health Sanitation and Nutrition Day (VHSND), immunisation, antenatal check-up (ANC), registration of pregnancy, and home-based new-born care (HBNC) visits. However, a few respondents were hesitant to undertake activities in which they needed to travel out of their villages; writing and compilation of reports or records; and persuading beneficiaries, such as ensuring regular consumption of medicines for leprosy and TB patients, sputum collection for testing for probable and confirmed TB cases, ensuring adherence to the use of mosquito nets in the community and persuading eligible couples to adopt family planning measures.

Training is an essential part of the ASHA programme. ASHAs undergo a 20-day induction training soon after joining, and thereafter, various other trainings from time to time as per the requirements of various health programmes, such as polio, TB, leprosy, HBNC, home-based care for young children (HBYC), non-communicable diseases (NCDs), malaria and most recently added training on COVID-19.

Most respondents felt that they did not need any new training, but required recurrent refresher trainings to brush-up skills. However, a few showed interest in learning new skills, such as blood pressure measurement and giving intramuscular/intravenous (IM/IV) injections. The diseases and health programmes are changing rapidly, so that, updating knowledge on recent developments are essential, said a few respondents. A few others emphasised the need for raising the quality of trainings.

Other than the writing, we are able to do all other work. We are not able to do the documentation work much. I have studied only till 5^th standard and that also years back, so you can imagine, how difficult it would be for me to undertaking the documentation work, that needs us to write. (An ASHA, Rayagada)

Every day, the diseases are evolving and their symptoms are changing. Now, if a disease has this symptom, next year there will be some other symptoms, so we should be aware about that. Hence, refresher trainings are very important. (An ASHA, Balasore)

Training on measuring BP, and if we could be given opportunity to give injections, it would have been better; I have learnt how to give injections, but because I haven’t received the training, I am not giving injections. If we will be, then it would be helpful for the elderly in the village, because they are unable to go to hospital. (An ASHA, Balasore)

Resources

The government has provisioned many resources for ASHAs, for the convenience of performing routine activities. Some materials are given once and some are given on contingency basis, from time to time. The ASHAs received a cupboard (or money to buy), carry bag, torch light, footwear, umbrella, dress, bicycle (or money to buy), water bottle, raincoats, mobile SIM card, HBNC kits, weighing scale for the new-borns, registers and diary (each year as per requirement). Additionally, they received some medicines and consumables, such as paracetamol, metronidazole and oral rehydration salts to serve the community at the time of need. The government pays the premium amount (₹12 + ₹330) for PMSBY and PMJJBY insurance schemes, each year for the ASHAs. Recently, the government deemed ASHAs as ‘COVID Warriors’, which makes them eligible for ₹5 million insurance, in case of death in the line of duty.

ASHAs felt that they did not need additional resources but the materials in HBNC kit should be replaced timely as some of them become unusable after a certain time period. A few others suggested that there should be more supply of medicines for minor ailments, as the community demands such services frequently. In addition, many respondents felt the need of mobile phones with camera facility as they had to send photos of field-level activities to the ANMs.

For every work that we do, we are asked to give proof. Earlier they were seeing paper work, but now they are asking us to send photos in WhatsApp. But we don’t have a smart phone and we have to depend on our husband, son or someone else for that. (An ASHA, Balasore)

Intrinsic Outcomes

The prevailing intrinsic outcomes were: sense of satisfaction from serving the community and contributing towards lowering maternal and child death in the community in which they work; the acknowledgement and respect of the community; and sense of contributing to the well-being of beneficiaries.

ASHAs seemed happy and socially content, as they got the opportunity to work for the community where they live. Whenever they helped a needy person or family they got a sense of satisfaction. They realised that they are contributing to reducing maternal and child mortality in their area and supporting the well-being of individuals. For this, they were able to earn respect of the community. The ASHA programme has created social recognition and many of them valued the social recognition above other incentives. Some respondents said that the ASHA programme had brought financial and social independence to them.

I was restricted to my home; Now, I could get opportunity to visit other places, I could interact with other women, I could connect with people of 3- 4 villages, I could be a part of their sad and happy moments; I am feeling happy because we are able to save women and children life. (An ASHA, Rayagada)

We are able to help women, child & our community people. We also attend people suffering from diarrhoea, fever, vomiting; if anybody had an accident, we help them; we support as much as we can. It is not just for incentives. Otherwise, we wouldn’t have attended accident cases. We go because we feel we are helping our own brothers and sisters by standing with them. (An ASHA, Rayagada)

Extrinsic Outcomes

The basic extrinsic outcome was cash incentives. Earlier, the ASHAs were getting around ₹250–300 incentive per month. Gradually, with the increase of activities the monetary incentives also increased. Now, the ASHAs are getting incentives for two segments of activities. The first segment comprises 13 activities for which an ASHA can get maximum ₹3,500 incentive per month—also called the assured financial incentives. However, if someone fails to complete the listed activities, then she would not get the full amount, but there would be deductions as per the actual tasks performed. These 13 activities are not dependent on the population, and thus, the ASHAs have equal scope to achieve this target by carrying out all 13 activities. The second segment comprises 40 activities aligned with various health programmes and provides scope to the ASHAs to earn beyond ₹3,500 per month. The incentive for this segment may vary for individuals as some of the activities are dependent upon population and numbers of households. It was observed that the ASHAs receiving high incentives were mostly from the densely populated areas, whereas the ASHAs receiving fewer incentives were often from large geographical areas with sparse population.

Nearly, all the respondents did not remember the whole range of incentives against all 53 activities. Some of them were aware about the assured-incentive for all 13 activities. In the second segment, the majority of the respondents were not aware about nearly half of the activities. It was observed that most respondents were more aware about the activities and incentives where the amount of incentive was considerably higher.

All respondents opined that the amount of incentive was not proportional to the amount of efforts ASHAs were putting into their work. They felt that they were grossly underpaid for the activities they perform.

Perceived Fairness of Awards and Sanctions Leading to Job Satisfaction/Dissatisfaction

The respondents identified many awards and sanctions affecting their motivation and performance. A majority of the respondents perceived the cash incentivisation of activities as one of the most compelling incentives for the ASHAs to perform. In addition, factors, such as: satisfaction from the services rendered to the community; awards and accolades; respect and support of the community; support of the supervisors and peers; availability of health services, provision of medicines and consumables to serve the community; provision of trainings and resources, were responsible for a sense of reward among the ASHAs.

The factors (sanctions) leading to dissatisfaction in the job were: disrespect and misunderstanding from the community; perception of underpayment against some of the activities; undue delay in the payments; erratic work schedule; increasing workload; unavailability of health services and medicines and consumables; lack of cooperation from the peers and supervisors; financial insecurity post-retirement; competition and comparison with peers and community cadres of other departments, such as Anganwadi workers (AWWs); unwarranted behaviour of hospital staff; compulsion to travel out of the block; poor conveyance and safety issues; caste barriers and poor literacy level (difficulties in reading and writing).

The primary aim of the performance-based incentives system was that with improved performance comes the increased incentives, which was not uniformly applicable across regions. The blanket incentivisation of services seemed unfair to many respondents. They felt that ASHAs serving in hard-to-reach areas had to endure more difficulties than those serving in the plains. In addition, in the hard-to-reach areas the population was sparsely distributed and the tagged villages were scattered. Therefore, the ASHAs received less incentives against the hard work. These factors ultimately lead to demotivation and dissatisfaction in job. For some ASHAs, limited provisions for financial security for aged/retiring ASHAs affected their motivation level.

Activities which require greater time commitments need to be compensated accordingly with higher incentives. There were some activities, such as mobilising and accompanying target groups for immunisation and VHSND that require more involvement. For instance, the ASHAs had to visit households to inform them about a scheduled activity. On the event day, they had to accompany the beneficiaries. This might require less time, but in total, a commitment of two days was required for the whole process. They get ₹75 to mobilise children for immunisation against the efforts of two days, thus they felt underpaid. Similarly, there were many activities, such as Janani Suraksha Yojana (JSY), VHSND, HBNC, community based assessment checklist (CBAC), sector meetings, training programmes, survey and mass drug administration (MDA) campaign, which the respondents felt had unfair payoffs.

The disbursement of incentives usually does not get delayed. However, the incentives under few programmes, such as TB and leprosy are paid from the district level and are often delayed. Some ASHAs said that their TB incentives were pending for last three years. Such delays in payments were demotivating for them.

The lack of availability of certain health services, such as: prompt ambulance services; specialist services, particularly paediatric and gynaecology services at the nearest CHC; medicines for the beneficiaries at the CHC; basic medications with ASHAs and hectic official processes like in case of issuance of birth and death certificates at the CHC, negatively affected the motivation level of ASHAs.

While prizes and accolades motivated the workers, irrational distribution often proved to be counterproductive. In some blocks there were provisions to award the best performing ASHA. However, this awarding system seemed irrational to a few as the parameter set to receive award was monetary incentive. Higher the incentive, higher was the chance of getting awarded. ASHAs working in hard-to-reach areas or having low target population did not get the chance to earn higher incentives and were thus excluded from a fair competition for awards. This often demotivated the ASHAs working in areas with lower population.

If an ASHA in the hard-to-reach area would receive equal or less incentives than an ASHA from the plains area, definitely she will feel bad. For example, see our health sub-centres and headquarter. The one who is in headquarter can easily get vehicle to reach to the hospital for delivery, but will so many be able to reach from hard to reach areas? So definitely, they will get less, and thus get demotivated! (A district level management personnel, Rayagada)

We are paid very less as compared to the amount of work we do. For immunisation, first we have to go and call them, then we have to be present during the session day, and then we have to go to the village and check for adverse events on the next day; but we get only INR 75 for that; hence, that needs to be increased. (An ASHA, Balasore)

We have scarcity of ambulance services. The entire area is hard to reach; we have very less coverage of 102 and 108 (ambulance services); they aren’t available on time, and the CUG mobile connections given to ASHAs have connectivity issues. So all these factors combined, demotivates the ASHAs! (A block level management personnel, Rayagada)

Structural Relationship between Factors Leading to ‘Content’ and ‘Discontent’

Two models were generated through the ISM exercise to establish flow of factors leading to ‘content’ and ‘discontent’ in ASHAs. The factors affecting performance and motivation of ASHAs were identified from the analysis of interviews. The factors were scrutinised and finally, 11 and 20 variables were considered for the ISM exercise to depict the mental model for ‘content’ and ‘discontent’, respectively.

The variables cited in Table 2 represent the factors associated with ‘content’.

Table 2.

Factors considered for the ISM for ‘Content’ in ASHAs.

Sl. No.	Variables/Factors
C1	Content/satisfaction
C2	Satisfaction from the services rendered to the community
C3	Motivation
C4	Performance
C5	Awards and accolades
C6	Respect and support of the community
C7	Monetary incentives
C8	Support of the supervisors and peers
C9	Availability of health services, medicines and consumables
C10	Trainings
C11	Resources

Source: The authors.

The digraph/model presented in Figure 2 suggested that the outcome variable ‘Content’ in ASHAs was driven by operational factors, such as motivation and performance and other inter-related factors, such as monetary incentives; awards and accolades; and support and respect of the community. There were some independent factors that acted as drivers for the operational factors, and thus affected the outcome variable, indirectly.

Figure 2.

Source: The authors.

Figure 3 represented the MICMAC analysis, exhibiting the driving and dependency power of the factors leading to content in ASHAs.

Figure 3.

Source: The authors.

The variables cited in Table 3 represented the factors associated with ‘Discontent’ in ASHAs.

Table 3.

Factors considered for the ISM for ‘Discontent’ in ASHAs.

Sl. No.	Variables/Factors
D1	Demotivation
D2	Poor performance
D3	Discontent/dissatisfaction
D4	Irrational awarding to the peers
D5	Disrespect and misunderstanding from the community
D6	Underpayment against the activities
D7	Undue delay in payment of incentives
D8	Erratic work schedule
D9	Increasing workload
D10	Unavailability of health services and medicines and consumables
D11	Scarce disbursement of resources
D12	Lack of co-operation from the peers and supervisors
D13	Financial insecurity post-retirement
D14	Competition & comparison with peers and the community cadres of other departments, such as AWW
D15	Unwarranted behaviour of hospital staff
D16	Compulsion to travel out of the block
D17	Poor conveyance and safety issues
D18	Caste barriers
D19	Poor literacy level (difficulty in reading/writing)
D20	Delay in payment of financial benefits to the beneficiaries (Ex. JSY, TB, etc.)

Source: The authors.

Figures 4 and 5 represented the diagraph—model of ‘Discontent’ and the MICMAC analysis for dependency and driving power of the factors leading to discontent, respectively.

Figure 4.

Source: The authors.

Figure 5.

Source: The authors.

The model shown in Figure 4 for ‘discontent’ was an intricate model which showed that the outcome variables discontent (D3), demotivation (D1) and poor performance (D2) were influenced by some operational factors acting at different levels in a more complex way. The perception of underpayment (D6); and competition and comparison with peers and the community cadres of other department (D14) factors were acting as linkage between the independent and outcome variables.

The independent variables, such as: undue delay in payments (D7), erratic work schedule (D8), increasing workload (D9), scarce disbursement of resources (D11), lack of co-operation from the peers and supervisors (D12), financial insecurity post-retirement (D13), unwarranted behaviour of hospital staff (D15), compulsion to travel out of the block (D16), poor conveyance and safety issues (D17) and poor literacy level—difficulty in reading/writing (D19) were indirectly affecting the outcome variable ‘discontent’. In addition, a single factor—unavailability of health services and medicines (D10)—was acting at the lowest level of the model with highest driving power, posed to affect the outcome variables the most.

The autonomous factors, such as irrational awarding system (D4), disrespect and misunderstanding from the community (D5), caste barriers (D18) and delay in payment of financial benefits to the beneficiaries (D20), were found to have low level of dependency and driving power and thus might not impact the outcomes in the model.

Discussion

In this study, a mixed-method approach was followed to investigate the possible linkages between financial and non-financial incentives with performance and motivation in ASHAs. The data were analysed and interpreted through a theoretical framework, based on which, the directions, competencies, resources, rewards/outcomes (extrinsic and intrinsic), perceived fairness of awards/sanctions affecting performance and motivation of ASHAs under a given context have been described. The framework is based on Vroom’s expectancy theory that holds widespread applicability in HRM research and practices and thus, used in various studies aimed at understanding the performance and motivation of personnel engaged in various sectors (Leonina-Emilia et al., 2013; Parijat & Bagga, 2014; Simone, 2015).

Furthermore, the ISM technique was applied to develop models depicting the factors leading to content and discontent in ASHAs. In several studies, researchers have used this technique to describe convoluted underlying mechanism of specific behavioral patterns, social and organisational issues including HRM practices (Ajmera & Jain, 2019; Guo et al., 2012; Karamat et al., 2018; Poduval et al., 2015; Rostami et al., 2020).

Clear cut directions to the workforce about their duties are essential in successful programme implementation (Rennie et al., 2007). In this study, it was observed that the managers and supervisors were making efforts to sensitise ASHAs about their roles and responsibilities. The ASHAs and ANMs were extremely interconnected, particularly, in manoeuvring field-level activities. Collaborative engagement of CHWs not only ensures flexibility in end-mile service delivery, but also makes them confident, and eventually improves their performance (Bhutta et al., 2010). In contrast, confusion regarding the duties may lead to poor performance (Kok et al., 2015). There was lack of clarity on the roles and responsibilities among some ASHAs, particularly, in Rayagada which could be ascribed to the lower literacy level of the workers operating in hard-to-reach areas. A study conducted in Rajasthan reported that lower level of education in ASHAs limit their capacities and knowledge thus, affecting their performance (Sharma et al., 2014). Considering the significance of literacy, the government may bring innovations to capacitate the ASHAs working in hard-to-reach areas and enable them to be fluent at reading and writing, which would ultimately encourage them to perform better.

No organisation can ever thrive without continuous capacity-building efforts for its employees (Wassem et al., 2019). ASHAs begin their service with an induction training, which serves as a backbone of knowledge for them. Furthermore, the public health system involves the ASHAs in several capacity-building initiatives, periodically. The respondents emphasised the need for frequent refresher trainings for the ASHAs, so that, they would feel confident and become competent in undertaking their routine activities. Nevertheless, to succeed in the demanding context of public health, the workforce needs to be informed about emerging issues and evolving practices to serve the community optimally. A study from Afghanistan deliberated on the significance of capacity enhancement of frontline workers and suggested that the health systems must invest in capacity building of the frontline workers to augment their performance for efficient end-mile service delivery (Edward et al., 2015). Most ASHAs participating in this study appeared stranded when it came to the matter of applying interpersonal skills to ensure beneficiaries’ compliance. Productive interpersonal skills in CHWs is central to community engagement and flow of information which lead to the success of community-based social and health interventions (LeBan et al., 2021). Therefore, provision of trainings on inter-personal communication skills including emerging health issues may become a prolific add-on for the ASHAs.

A wide array of factors including allocation of resources impact the working condition of the health workers, thus affecting their motivation and performance (Nguyen et al., 2015). This study observed that irregular supply of registers and forms; scarce supply of medicine for the community to be given during minor ailments and failure in timely replacement or replenishment of materials in HBNC kits, demotivate the ASHAs. Under a resource-scarce setting, the health system has to ensure rational distribution of available resources.

The two models developed thorough the ISM exercise and the MICMAC graph helped to develop a subtle understanding about the intrinsic and extrinsic rewards and sanctions for ASHAs, which in turn impact job satisfaction/dissatisfaction and performance. The causal linkage between different factors responsible for ‘content’ in ASHAs produced a fundamentally simple model in which four factors: support from supervisors and peers, availability of health services and medicines in nearby hospitals, capacity-building activities and timely supply of adequate resources to help ASHA in her day-to-day work, operate independently in relation to other factors in the model. These factors are embedded with the highest driving power in the model, thus, maximum importance needs to be given to them at the time of designing policy interventions to enhance performance of ASHAs under the given context. The linkage variables including monetary incentives, awards, respect of the community and sense of gratification from the services rendered to the community, exhibit high dependence and driving power and thus are highly unstable. Any change in context with respect to the linkage variables would result in sudden change in performance with feedback effects. Accumulation of factors in the linkage quadrant of the MICMAC graphs for ‘content’ in ASHAs indicates, the performance-motivation dynamics in ASHAs under the given context is at its nascent phase, and the current, financial and non-financial incentives would take time to mature in order to get reflected in the performance of ASHAs.

In contrast to the simplicity of the model for ‘content’, the model for ‘discontent’ in ASHA appeared complex with respect to its dynamics and flow of factors. With multiple levels in the model, the factor which is highly independent of other factors but with strong driving power—unavailability of health services, medicines and consumables at the nearby hospitals—takes the lowest level in the model, and irrespective of the model dynamics, it is affecting the ultimate outcome—discontent—intensely. It might not surface as a problem in the implementation of ASHA programme, but it is certainly affecting performance of ASHAs in the given context. Similarly, there are many other independent factors, such as: erratic work schedule; increasing workload; sense of financial insecurity post-retirement; unwarranted behaviour of hospital staff; and compulsion to travel out of the block; and difficulties in reading and writing, affecting job satisfaction among ASHAs negatively. Alongside the motivational provisions, the government has to give ample attention to such factors.

The sense of underpayment is the one of the linkage factors with high driving and dependency powers. Actions aimed at attenuating the negative consequences in this regard would result in sudden changes in the model dynamics.

Factors including: irrational awarding to the peers; disrespect and misunderstanding from the community, caste barriers and delays in payment of financial benefits to the beneficiaries being placed in the autonomous quadrant of the MICMAC graph for discontent signifies that these factors have appeared in the model owing to some isolated events, thus, they are not cardinal features of the model.

This study bears synchronous views with several other studies, which mentioned similar motivating/demotivating factors affecting the performance of CHWs. A qualitative study from Swaziland underlined the prominence of increased monetary compensation, adequate supply of resources and provision for additional training for the improved performance of CHWs (Geldsetzer et al., 2017). Another study from Manipur (India) explained how unavailability of healthcare services and medicines at the nearest healthcare facility poses risk to the success of the ASHA programme. A poorly functioning healthcare facility in the community often drives the beneficiaries to cast doubt on ASHAs credibility and trust in the health system (Saprii et al., 2015). A systematic review (Scott et al., 2018) looking at evidence to understand the factors instrumental in the success of CHW interventions found that level of education of CHWs, supportive supervision, rational monetary incentive, adequate supply of resources, clarity on the roles and responsibilities, effective training, collaborative engagement of CHW and community embeddedness of CHW interventions enable positive outcomes.

Conclusion

Financial and non-financial incentive systems are not only important for meeting individual aspirations, but also effective tools for strategic workforce management. The cash incentivisation approach to motivate ASHAs remains dominant in HRM policies of the health system, and how far the current incentive provisions have addressed the demotivation in ASHAs dwells in uncertainty. This study generated evidence on specific factors leading to motivation and performance in ASHAs in Rayagada and Balasore districts of Odisha. Because of the robust methods and consultative processes adopted in the study, policies developed as a result of this study would hopefully have a high degree of acceptability among the concerned stakeholders.

Points of action have been indicated for decision-makers to focus on capacity building, optimal resource allocation and rationalised payoffs for ASHAs dealing with scattered areas or deployed in hard-to-reach pockets, and improving healthcare services in the health facilities at community level, which would gradually but certainly impact the motivation and performance of ASHAs.

Limitations

Because of the time and procedural constraints, the perspectives of state-level managers could not be captured. Moreover, we did not consider the existing differences in the study participants arising due to the variability in age, gender, communities and socio-cultural predispositions, at the time of data analysis, which could result in more discerning insights.

Supplemental Material

Supplemental material for this article is available online.

Supplemental Material for Effects of Various Financial and Non-financial Incentives on the Performance of Accredited Social Health Activist: Evidence from Two Selected Districts of Odisha by Saumya Ranjan Pani, Srinivas Nallala, Sarit Kumar Rout, Shyama Sundari, Maulik Chokshi, Tushar Mokashi, Arun Nair and Shridhar M. Kadam, in Journal of Health Management

Footnotes

Acknowledgement

We would like to acknowledge all the state health agencies, programme managers and primary stakeholders—the ASHAs—for their supports and participation. We would like to thank Access Health International Inc., for all the financial and administrative support.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This research study was funded by a grant from the Bill and Melinda Gates Foundation to the ACCESS Health International, Inc. (Grant number: INV-007165).

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