Unpacking the Complex Determinants of the Performance of Accredited Social Health Activists in Bihar: A Qualitative Study

Abstract

The Accredited Social Health Activist (ASHA) programme has been associated with many improvements in health outcomes. However, the understanding of contextual performance constraints, particularly how these vary for different tasks, has been acknowledged as deficient. Relying on a means, motives and opportunity (MMO) framework, this article qualitatively explores the context-specific constraints on the performance of four ASHA tasks. We undertake qualitative research to unpack ASHA’s perspectives and conduct a thematic analysis of the interview data. We find that different combinations of MMO factors affect different services differently, although many affect all services. Immunisation day, survey and record-keeping duties and escorting for institutional deliveries were deemed ‘core’ deliverables due to the administrative focus, preference or the incentives tied to the task. Home visits for home-based newborn care (HBNC) were not preferred and were seen as effort-intensive. The rapidly evolving role of ASHAs in responding to evolving health system needs in Bihar demands special effort if the different factors are to be diagnosed. This article attempts to offer the various avenues to unlock ASHA performance and contributes to the current partial global evidence base on factors affecting the performance of community health workers (CHWs) in different contexts.