Remuneration systems of community health workers in India and promoted maternal health outcomes: a cross-sectional study (original) (raw)

Background: This study assessed the association of remuneration systems of paid-for-performance Accredited Social Health Activists (ASHAs) and salaried Anganwadi workers (AWWs) on seven maternal health outcomes in four states in India: Andhra Pradesh (AP), Chhattisgarh, Odisha (Orissa), and Uttar Pradesh (UP). Methods: The cross-sectional study surveyed mothers of children aged 6-23 months. A total of 3,455 mothers were selected via multistage cluster sampling. The seven health outcomes related to the community health worker (CHW) visits were: institutional delivery, complete immunization, exclusive breastfeeding for six months, timely introduction of complementary feeding, continued breastfeeding during child's illness, handwashing, and awareness of Nutrition and Health Days (NHDs). Results: The results varied by state. Mothers who received ASHA visits were signi cantly less likely to have an institutional delivery, timely introduction of complementary feeding, awareness of Nutrition and Health Days (NHDs), proper handwashing, and exclusive breastfeeding for the rst six months in at least one of the four states. Conversely, AWW's home visits were positively predictive of the following health outcomes in certain states: complete immunization for index child, continued breastfeeding during the child's illness, handwashing, and awareness of NHDs. Conclusions: ASHAs' home visits were not more strongly associated with health outcomes for which they were paid than outcomes for which they were unpaid. AWWs' home visits were positively associated with awareness of NHDs, and associations varied for other recommended health behaviors. Further research could elucidate the causes for successes and failures of CHW programs in different states of India. link the community to public health care to promote maternal and child health in their communities [4]. Each rural village in India is supposed to have an ASHA and an AWW [5]. ASHAs are selected by their communities and receive one month of training. Their role is to provide health promotion, speci cally regarding nutrition, sanitation and hygiene, birth preparedness and safe delivery, immunizations, breastfeeding, complementary feeding, and prevention of common infections. While they are considered unpaid volunteers, ASHAs receive performance-based incentives for facilitating institutional deliveries and immunizations of children in addition to receiving compensation for their training days and attending monthly meetings. ASHAs receive approximately 10forfacilitatinganinstitutionaldeliveryand10 for facilitating an institutional delivery and 10forfacilitatinganinstitutionaldeliveryand3 for facilitating a child's immunization session, though compensation varies by state [6, 7]. AWWs are also selected by the community. They receive two to three months of training, and their role is to provide health information, medicine, and nutritional supplementation to children under six years old, adolescent girls, and pregnant and lactating women [5, 6]. AWWs receive a monthly stipend of approximately $25 and qualify for a government life insurance scheme [6]. There are some con icting results on the nancial incentives received by ASHAs. A mixed-method study of ASHAs in Orissa (now Odisha) found that ASHAs were more motivated by the social recognition, a sense of social responsibility, and self-e cacy to perform their responsibilities than by their incentives [8]. Other researchers have shown that the performance-based incentives may be a key factor to an ASHAs' performance [9], which can lead to ASHAs focusing more on the activities for which they are paid than unfunded activities [10]. However, there is scarce evidence of the effects of home visits conducted by the two types of workers on maternal and children health outcomes. The purpose of this study is to determine, using data from four Indian states, 1) whether ASHAs' home visits are more predictive of institutional deliveries and children's complete immunization, for which they are paid, than of ve unpaid, but important health practices: exclusive breastfeeding for the rst six months of the child's life, timely introduction of complementary feeding, continued breastfeeding during the child's illness, proper handwashing, and awareness of Nutrition and Health Days (NHDs); 2) whether visits from AWWs are more predictive of certain health outcomes than other health outcomes. Methods Data This analysis used the secondary quantitative survey data from the 2011 CARE endline evaluation of USAID's Food for Peace (FFP) projects in four states in India: Andhra Pradesh (AP), Chhattisgarh, Odisha, and Uttar Pradesh (UP). The 2011 survey used multistage cluster sampling using random selection with probability proportional to size. Randomly selected Anganwadi Centers (AWC) from a list of centers in each state in districts with a CARE program were used to identify catchment areas. The study team conducted a census in each selected catchment area and identi ed households with children under two