|Year : 2016 | Volume
| Issue : 4 | Page : 309-315
An assessment of bicycle intervention to improve service delivery by accredited social health activists in selected blocks of West Champaran district of Bihar
Jyoti Sharma1, Preeti Negandhi1, Monika Chauhan2, Ghanashyam Sethy3, Siddharth Reddy4, Sutapa B Neogi5
1 Associate Professor, Indian Institute of Public Health-Delhi, Public Health Foundation of India, India
2 Project Associate, Indian Institute of Public Health-Delhi, Public Health Foundation of India, India
3 Health Specialist, Maternal and Newborn Health, UNICEF, Bihar, India
4 Health Officer, Maternal and Newborn Health, UNICEF, Bihar, India
5 Additional Professor, Indian Institute of Public Health-Delhi, Public Health Foundation of India, India
|Date of Web Publication||15-Dec-2016|
Indian Institute of Public Health-Delhi, Public Health Foundation of India, Plot No. 47, Sector 44, Gurgaon, Delhi-NCR, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Several programmatic and logistic issues affect the overall performance of Accredited Social Health Activists (ASHAs). Bihar Government provided bicycles to ASHAs in West Champaran district for increasing coverage of services by improving their mobility. Objective: To assess the use of bicycles by ASHAs and it's effect on service delivery. It also captures the perspectives of ASHAs in terms of its utilization for performing tasks. Methods: A community-based quasi-experimental study was undertaken during March-May 2016. Proportion of newborn babies visited within 24 h of birth was the primary outcome. Data were collected from two intervention blocks (West Champaran district) and a control block from the neighboring East Champaran district. A total of 323 (177 from intervention blocks and 146 from control block) mothers having children <3 years of age and who had delivered at home were interviewed. Besides, 88 ASHAs working in intervention blocks were also interviewed. Results: Significantly higher proportion of mothers and newborn babies (44%) received postnatal care within 24 h of delivery in intervention blocks as compared to the control block (16%, P < 0.001). Nearly 73.1% of ASHAs were using the bicycle themselves. ASHAs were twice more likely to visit a newborn on the day of delivery if she was provided with mobility support. However, the likelihood of continuing visits after the 1st day was not statistically significant. Conclusion: The intervention demonstrated the potential of ASHAs to improve their functioning at the grass-root level. The scale-up of bicycle intervention should be supplemented with reforms in financial incentives disbursement and better system support.
Keywords: Accredited Social Health Activist, incentive, link worker, mobility, service delivery
|How to cite this article:|
Sharma J, Negandhi P, Chauhan M, Sethy G, Reddy S, Neogi SB. An assessment of bicycle intervention to improve service delivery by accredited social health activists in selected blocks of West Champaran district of Bihar. Indian J Public Health 2016;60:309-15
|How to cite this URL:|
Sharma J, Negandhi P, Chauhan M, Sethy G, Reddy S, Neogi SB. An assessment of bicycle intervention to improve service delivery by accredited social health activists in selected blocks of West Champaran district of Bihar. Indian J Public Health [serial online] 2016 [cited 2020 May 30];60:309-15. Available from: http://www.ijph.in/text.asp?2016/60/4/309/195865
| Introduction|| |
Since the inception of National Rural Health Mission in 2005, inclusion of Accredited Social Health Activists (ASHA) as link workers was introduced as a key component of the community-based programs. ASHA is a community worker selected by Gram Panchayats, to generate awareness on health issues and act as an interface between community and health workforce. They have played a critical role in improving coverage of health services in rural areas across the country. Over a decade, this program emerged as the largest community health worker program globally, enabling community participation in health.,
The primary role of the ASHAs is to promote uptake of antenatal care services, skilled birth attendance, and provide home-based postnatal care services to the mother and newborn., Each ASHA is meant to cover a population of 1000 and receive performance and service-based compensation for facilitating immunization, referral, and escort services for institutional deliveries and make home visits to promote essential newborn care, identify illness, and refer infants if needed. Studies and evaluation carried out in various parts of the country demonstrated that ASHAs' motivation and performance are influenced by a variety of complex contextual factors. These include various personal, professional, and organizational factors along with those emerging from external environment.,,,,
Despite having ASHAs in every village, the coverage of home-based newborn care (HBNC) was dismal. Although the exact reasons are not documented, there was a presumption that mobility of ASHAs was a hurdle. To aid the ASHAs in delivering their assigned tasks more effectively and efficiently, a readily available mode of transport (bicycle) was provided to them by the Department of Health, Government of Bihar in 2013 in few select districts including West Champaran. Initially, only ASHA facilitators in West Champaran district were provided with the bicycle to assist them in the supportive supervision of ASHAs. Later, bicycles were distributed to all the ASHAs in the district to help them render their services to the community.
The present study assessed the outcome of the use of bicycles in terms of service delivery by ASHAs in West Champaran district. The study also assessed perspectives of ASHAs on bicycle intervention in terms of convenience of use and its utilization for performing tasks.
| Materials and Methods|| |
This was a community-based quasi-experimental study undertaken in March–May 2016. Data were collected from two selected blocks of intervention area (West Champaran district) and one block from the neighboring East Champaran district that served as the control. The blocks in the intervention area were selected purposively since majority of the ASHAs in these blocks were reported to have received the bicycle, whereas no ASHAs had received the bicycle in the control block. The participants interviewed were mothers of children <3 years of age in both intervention and control areas, to assess the delivery of postnatal services by ASHAs. In addition, ASHAs from the intervention area were interviewed to study their perceptions about the use of the bicycle.
Sampling and sample size calculation: The primary outcome considered was the proportion of home-delivered newborn babies visited within 24 h of birth after the delivery. Since ASHAs are invariably expected to be present during all institutional deliveries and these newborn babies receive postnatal care in hospitals, these were not considered. The HMIS reports indicated that proportion of newborns visited within 24 h of home delivery was approximately 30% during 2014–2015. The minimum required sample size was calculated based on the assumption that bicycle introduction would increase this proportion to at least 50% for home-delivered newborns. With 95% confidence interval and 80% power, the estimated sample size was 94 mothers (OpenEpi, 2015, OpenEpi development was supported in part by a grant from the Bill and Melinda Gates Foundation to Emory University, Rollins School of Public Health.) in each arm. Additional 5% to the calculated sample size was included to compensate for the loss due to refusals. Thus, a minimum sample of 198 mothers (99 in each arm) was estimated. Since multistage sampling method was employed, a design effect of 1.5 was considered, thereby estimating the sample size at 147 (~150) in each arm.
In the intervention area, out of 40 subcenters, 15 were randomly selected in the first stage, and in the second stage, 5 villages were selected randomly from each of these 15 subcenters. Thus, 75 villages were selected for the mothers' interviews. From every village, every eligible and consenting mother was supposed to be included in the sample. It was presumed that approximately 2 such mothers would be available in each village on an average. A detailed listing was carried out to generate a roster of eligible mothers having home-delivered children <3 years of age in both intervention and control blocks. In addition, in these 75 villages, the respective ASHAs were also interviewed. Similar multistage sampling was done in the adjoining control block for the selection of mothers.
A data collection tool was developed, translated into local language, and pilot-tested by the research team before data collection. Questions were asked with the objective of assessing the coverage of services provided by ASHAs to the mothers of children <3 years of age. In case, a woman had 2 children <3 years of age; the younger one was considered for the questioning. The questions included services provided to mothers during pregnancy, childbirth, and postnatal period and to their newborn children. Data on ASHAs' perceptions were also gathered to understand the outcome of bicycle intervention on their performance.
Data were collected by a team of 8 local interviewers, who were trained by the research team for this purpose. Monitoring was done by the research team to ensure quality. Data were collected on paper forms, entered electronically, and exported to SPSS version 21 IBM Corporation, Armonk, NY, USA for analyses. Descriptive as well as analytical statistical tests were applied to correlate the intervention with the outcomes. Factors significantly different (P < 0.05) in intervention and control blocks on bivariate analyses were subjected to multivariable logistic regression analysis. Ethics clearance for the study was obtained from the Institutional Ethics Committee of Indian Institute of Public Health Delhi for undertaking the project on interventions related to the newborn care at the outset.
| Results|| |
A total of 323 (177 from intervention blocks and 146 from control block) mothers having children <3 years of age and who had delivered at home were interviewed for the study. Besides, 88 ASHAs working in interventions blocks were also interviewed.
Respondents in the intervention and control districts had similar religious and educational backgrounds [Table 1]. Mean age of mothers was significantly higher in control area than intervention area (28.1 years vs. 26.5 years). Similarly, mean age of the children was significantly higher in control district (21.4 months) than intervention district (16.2 months).
|Table 1: Profile of beneficiaries (mothers of children <3 years of age and their children)|
Click here to view
Effect of bicycle intervention on services delivery
Improving skilled birth attendance is one of the major outcomes expected from ASHAs. However, as shown in [Table 1], in the intervention block, the largest proportion of home deliveries (38.4%) was reported as being conducted by ASHAs, whereas in the control block, the proportion of home deliveries conducted by them was the least (11.6%), despite ASHAs not being skilled birth attendants themselves. Among the other attendants, majority of deliveries (58% in intervention blocks and 72% in control block) were conducted either by other community members or by family members. The proportion of births conducted by auxiliary nurse midwife (ANM) was low (3.4%) in the intervention block, but it was significantly higher (P < 0.001) in the control block (15.8%).
Proportion of mothers who had registered themselves in the antenatal period was similar in intervention and control blocks (>90%), and majority of the respondents reported that ASHAs had contacted them during pregnancy.
Postnatal checkup of both mothers and newborn babies during first 24 h after delivery is crucial to save life. Almost 48% mothers in intervention blocks reported that an ASHA visited them on the day of delivery, whereas only 33% mothers in control block reported that ASHA visited on the 1st day of delivery [Table 2]. It was reported by most mothers (71% in intervention block and 93% in control block) that they were visited by the ASHA for the first time a week after delivery. However, a significantly higher proportion of mothers was visited during the first 72 h of birth which is the most crucial postnatal period. It is important to note that proportion of all home visits was significantly higher in intervention block as compared to control block.
|Table 2: Home visits by Accredited Social Health Activist after delivery in intervention and control blocks|
Click here to view
The association between the ASHA visit and the bicycle intervention remained significant after having adjusted for respondent's education, caste, birth order, pregnancy registration, and contact with ASHA during pregnancy [Table 3]. ASHAs were twice more likely to visit a newborn on the day of delivery if she was provided with a mobility support. However, the likelihood of visits after 1st day was not statistically significant.
|Table 3: Correlates of home visits by Accredited Social Health Activists in intervention and control blocks|
Click here to view
Effect of bicycle intervention in terms of performance of Accredited Social Health Activists other than service delivery
In addition to the beneficiaries, 88 ASHAs in the intervention blocks were interviewed to gather their perspectives regarding their performance with respect to the bicycle intervention. [Table 4] gives the detailed profile of ASHAs working in the intervention area during the study period. Most of the ASHAs had been working since a long time (mean duration of service - 8.9 years). Majority (72.7%) of ASHAs were catering to one village; only one ASHA reported that she covered three villages. The mean distance traveled between two villages was reported to be 5.25 km for those who were covering more than one village. The mean distance between village and Health Sub Centre (HSC) was reported to be approximately 2 km and distance from Primary Health Centre (PHC) was reported to be approximately 10 km. Sixty-seven out of 88 (76%) ASHAs reported that they received bicycle during year 2013. The others (24%) never received a bicycle.
|Table 4: Profile of Accredited Social Health Activists included in the study (n=88) from the intervention block|
Click here to view
Those ASHAs who received bicycle were further interviewed to get their opinions and perceptions regarding utility of bicycle and their experiences of using a bicycle in the field. The opinions of respondents were very positive. More than 73% (n = 49) of those who received the bicycle were using it themselves, and they felt that receiving a bicycle was better than getting cash to buy it. However, about 27% respondents felt that they face difficulty in riding bicycle in their uniform, a saree (a traditional Indian cotton garment elaborately draped around the body). A noteworthy observation was that only one respondent expressed that she faced social hindrance in riding a bicycle; however, details of the kind of difficulty could not be obtained. The bicycle intervention proved to be beneficial for the respondents in many other ways; 91% of them reported a reduction in expenses and improvement in their performance. A few of the respondents reported that bicycle helped them in improving their self-esteem and with this, they could go anywhere independently. Most of the respondents were using a bicycle for HBNC-related activities (including home visits) and to visit the PHC/Community Health Centre for immunization, etc.
| Discussion|| |
The State Government of Bihar is investing efforts on several fronts with an aim to improve the maternal and child health indicators. Our study was an assessment of the outcome of a pilot initiative within the health system to provide bicycles as a nonfinancial incentive to ASHAs for improving their work performance. The study captured the effect of bicycle intervention at two levels; first on the coverage of postnatal care of home-delivered newborn babies, as well as ASHAs' opinions and perceptions regarding this intervention.
The effect of the intervention reflected positively at the community level with significantly higher proportion of mothers and newborn babies receiving home visits within 24 h of delivery in intervention block as compared to the control block. ASHAs were twice more likely to visit a newborn on the day of delivery if she was provided with a mobility support. Furthermore, overall, the ASHAs seemed to be satisfied with the intervention; they felt that providing them with a bicycle eased their work and it was more convenient for them to provide services in the village.
The intervention demonstrated the potential of ASHAs as link workers to improve their functioning at the grass-root level by providing a suitable means of transportation to improve the coverage of services. Our study findings also demonstrated that approximately 75% ASHAs were using the bicycle themselves and the intervention was well accepted among them. An evaluation study conducted by National Health Systems Resource Centre reported that even in the best of situations, up to 11% of potential beneficiaries are being missed by the ASHA. The distance needed for them to travel and geographical dispersion of the population were found to be major determinants for coverage of services. The bicycle initiative may have helped the ASHAs to improve their outreach in the villages and pro-actively participate in their duties. The bicycles provided to them would be beneficial, as maneuvering them even in the narrow lanes within villages was easy, as compared to other larger and wider vehicles. With the bicycle, they were able to travel to health-care facilities for attending meetings, accompanying beneficiaries for checkups even to the remote areas, travelling to offices for claim settlements, etc. The recurrent travel expenses, which would otherwise have been incurred, were also reduced substantially as bicycle is a low-maintenance vehicle, thereby making it ASHA-friendly. Systemic issues such as delay in transfer of incentives and payment of claims used to be a common feature of the ASHA program in many states, which would no longer be an issue in the areas where bicycles are provided. Moreover, this initiative can prove to be cost-effective for the State in terms of saving long-term costs of transportation for the field functionaries.
The importance of ASHAs as link workers in the community is being increasingly understood., However, unlike other health-care workers, ASHAs do not receive a fixed monthly income. Instead, they receive performance-based incentives for their activities. These incentives, if received timely and regularly, can prove to be extremely motivating for their performance. ASHAs continue to receive other nonfinancial support from time to time, such as training and supportive supervision, job aids and kits, cooperation from other health-care workers (ANMs and Anganwadi workers). The addition of transportation as an incentive, as was seen in our study, can definitely help further since it has a direct implication on their outreach and coverage of services.
Incentives for ASHAs and their responsibilities as community link workers have always been a debatable issue since financial incentivization has often been linked to empowerment and independence, besides support to the family income. Hence, such incentives are far more lucrative as compared to the nonfinancial ones. In a study conducted in two North Indian districts, the rates of incentives being given to the ASHAs were not proportionate to the level of efforts being put in by them to complete their responsibilities. This led to a sense of motivation and inspiration as well as a cause of dissatisfaction among ASHAs and their families. While financial incentives are often a source of motivation to work harder, nonfinancial incentives have their own role and importance in contributing to the ASHAs' performance. In a study conducted in 2015, it was observed that in addition to the financial incentives, some nonfinancial support such as uniforms, identity cards, CUG sim card, radio, and ASHA awards are being distributed to the ASHAs in some states, and these improve their motivation and social recognition.
This study has several limitations which should be considered while interpreting findings. Due to long recall period, mothers might have failed to accurately recall some information on ASHA visits. However, to minimize the recall bias, mothers were requested to recall their experiences regarding the ASHA visits when their youngest child was born. Performance of ASHA was not assessed in terms of knowledge and skills; therefore, it would not be possible to comment on quality of services delivered with higher coverage in some villages. The study was of quantitative nature; therefore, the issues related to job satisfaction, community acceptance, and other problems could not be explored in detail. This would have helped in exploring the performance-related issues of ASHA at a deeper level. Furthermore, we did not assess the perceptions and opinion of program managers, trainers, and supervisors; this could have provided useful insights about program management and its scale up. Nonetheless, this study attempted to evaluate the outcome of providing a nonfinancial incentive (bicycle) to ASHAs, an important aspect of strengthening the health system. While there are many studies which provide results of the evaluation of financial incentives, there are very few published studies which have evaluated the outcome or impact of a nonfinancial incentive, and our study has succeeded in this regard.
| Conclusion|| |
It is well understood that the functioning of a public health system of a vast country such as India mandates the support of health-care workers who can mobilize the community and strengthen the bridge between the health-care workforce and the general population. Hence, it is very important to motivate these link workers for long-term health-care gains. To achieve positive changes in ASHA functioning and outreach of the maternal and newborn care services, scaling up of bicycle intervention and other such incentives would be useful. However, these would require to be supplemented with reforms in incentive disbursement mechanism, improvements in quality of training and supervision, adequate job aids, and better system support.
The research team acknowledges the contribution of field investigators of Sarvodaya Vikas Samiti who had collected the data for the study. Support of Mr. Dipti Sunder Mohanty and Jyoti Prakash of SarvodyayaVikas Samiti is acknowledged during data collection. The study team is grateful to the ASHAs, mothers, and families who helped us immensely during collection of data for the study.
Financial support and sponsorship
Financial support for the study was provided by UNICEF Bihar.
Conflicts of interest
Ghanashyam Sethy and Siddharth Reddy are affiliated to UNICEF Bihar (sponsor of the study and supplement). The views expressed in this paper are those of individuals and not of the organizations they represent.
| References|| |
Saprii L, Richards E, Kokho P, Theobald S. Community health workers in rural India: Analysing the opportunities and challenges Accredited Social Health Activists (ASHAs) face in realising their multiple roles. Hum Resour Health 2015;13:95.
Scott K, Shanker S. Tying their hands? Institutional obstacles to the success of the ASHA community health worker programme in rural North India. AIDS Care 2010;22 Suppl 2:1606-12.
National Health Sysytem Resource Centre. ASHA Which Way Forward: Evaluation of ASHA Program 2010–2011. New Delhi; 2011.
Fathima FN, Raju M, Varadharajan KS, Krishnamurthy A, Ananthkumar SR, Mony PK. Assessment of 'accredited social health activists'-a national community health volunteer scheme in Karnataka State, India. J Health Popul Nutr 2015;33:137-45.
Sarin E, Lunsford SS, Sooden A, Rai S, Livesley N. The mixed nature of incentives for community health workers: Lessons from a qualitative study in two districts in India. Front Public Health 2016;4:38.
Kohli C, Kishore J, Sharma S, Nayak H. Knowledge and practice of Accredited Social Health Activists for maternal healthcare delivery in Delhi. J Family Med Prim Care 2015;4:359-63.
Monthly Program Monitoring Sheets. New Delhi: Division of Child Health and Immunization, Ministry of Health and Family Welfare; 2014.
Common Review Mission. New Delhi: Ministry of Health and Family Welfare, Government of India; 2012.
[Table 1], [Table 2], [Table 3], [Table 4]