1.2 Brief Overview of the ASHA Program
The government of India launched the National Rural Health Mission (NRHM) in 2005 to improve health in general and to make progress toward Millennium Development Goals (MDGs). MDGs were established in the year 2000 and consisted of eight specific goals for international development, two of which were focused on reducing child mortality and improving maternal health. The NRHM consists of several planned actions intended to help facilitate an overarching goal:
The Goal of the Mission is to improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children3.
This Mission, and the funding that supports it, had many specific plans of action and accompanying policy initiatives that have resulted in major changes to the landscape of health services in India. Project RISE is specifically concerned with Component A of the NRHM’s Plan of Action, The Accredited Social Health Activist, or ASHA, who are a specific type of CHW and the overall focus of Project RISE.
Every village/large habitat will have a female Accredited Social Health Activist (ASHA) - chosen by and accountable to the panchayat [village-level government]- to act as the interface between the community and the public health system.
While the NRHM gives a lot more detail about the ASHA role and how it will be implemented, at this stage we emphasize that central to the nature and definition of the ASHA is that she will be a connector, an interface, between the ‘community and the public health system.’ Her role is part of a broader mission to improve health in rural settings by recruiting and training members of the very communities that the ASHA will serve.
The NRHM was vast and ambitious. To meet the requirements of one ASHA per village-level unit, or about one per 1000 people in rural settings, approximately 300,000 women had been recruited and trained as ASHAs in high-focus states within the first two years of the program (Agarwal et al. 2019). The ASHA program expanded and matured with time such that today there are around one million ASHAs across the states of India (Smittenaar et al. 2020). About 10% of these ASHAs are working in Bihar, the focal area of Project RISE.
ASHAs are one type of Community Health Worker. CHW programs are common worldwide and have been important for improving health behaviors in rural and economically under-resourced areas across the globe. They are often key parts of national health programs, broadly similar to the NRHM, which have recognized the potential of locally-trained personnel in this intermediary role connecting community to health system (Kok et al. 2017; Exemplars 2020). However, many reviews of CHW programs have concluded that efficacy could be improved, but the best way to achieve these desired increases in efficacy are still unclear (World Health Organization 2018).
Project RISE is such an effort, but one that takes a very different approach to understanding the factors that can limit and/or enhance CHW performance. While evaluations of extrinsic motivators like financial incentives (Koehn et al. 2020; Ormel et al. 2019) or accountability systems (Schaaf et al. 2020) can be informative, they have not thus far been effective at identifying how to sustainably improve CHW performance or motivation.
Project RISE takes a novel approach to understanding CHW experience, motivation, and efficacy. One that considers the lived experiences of the ASHA and her beneficiaries, especially the role of community and individual rituals as a social and psychological pathway to enhance social cohesion, trust, prestige, and other intrinsic factors that have been linked to motivation in fields like cognitive science and social and behavior change communication (SBCC). Project RISE uses both qualitative and quantitative methods to understand this complex topic and to create a data-driven human-centered-design intervention that will be prototyped and developed with local community input. By using the principles of human-centered design, Project RISE strives to develop an intervention that is not constructed from an outsider’s perspective but with direct input and feedback from the ASHAs who are the focal ‘end-users’ of the intervention effort.