6.6 Chapter take-aways

In the first of the quantitative chapters, we present a statistical overview of samples of Mothers and ASHAs who completed our quantitative survey. The survey questions and option sets were informed by qualitative research described in previous chapters.

Lived experience:

We documented the extent to which the demographic backgrounds of ASHAs are similar to beneficiaries. We find that ASHAs are more likely to be Hindu than Mothers and more likely to be from OBC Or General Castes. ASHAs are also on average older, more wealthy, and more educated.

ASHAs have multiple motivations to perform their jobs. These include a sense of responsibility to serve their communities, provide for their families, and earn income. ASHAs use their incomes to support their families, and particularly to support their children’s education, demonstrating the critical impact of ASHAs not only in supporting community health, but in supporting their own families.

Connectedness:

ASHAs are providing many services to multiple beneficiaries on any given month (commonly 5-10). These services range from accompanying beneficiaries to ANC visits and institutional deliveries to postnatal home visits. ASHAs are also heavily involved in vaccination campaigns, household surveys, and village health and nutrition days (VHND).

Our survey data provide convergent support for our qualitative data that the incentive structure imposed by the health systems strongly impacts the behaviors ASHAs prioritize. For example, ASHA’s are spending more time engaging in discrete incentivized behaviors (institutional delivery, family/planning sterilization, vaccination drives), rather than organizing their schedules around critical points of potential influence in the perinatal journey (home visits during pregnancy). Visiting early on in the pregnancy (or well before pregnancy) could potentially provide the ASHA an opportunity to build a trusting relationship with her beneficiaries and to educate and influence multiple target behaviors during the same visit, rather than only the behavior being incentivized.

Betweenness:

Our data demonstrate that beneficiaries value ASHAs and the services they provide, providing convergent support for the results of the qualitative research. They seek out ASHA’s advice and invite them to family celebrations and rites of passage (including marriage, pregnancy, and birth rituals). Beneficiaries also report valuing ASHA’s advice more highly than many other influencers. ASHA’s husbands and families also take pride in the work ASHAs do.

ASHAs are balancing personal and professional demands. These include the need to meet their family’s financial, educational and domestic needs, as well as the needs of beneficiaries. The range of services ASHAs provide is large, and entails interacting with many other local influencers, ranging from Dais to healthcare practitioners to other frontline workers. For example, ASHAs provide substantial support to other frontline workers (supporting VHNDs and vaccination drives). They accompany beneficiaries to clinics and administrative offices for services ranging from institutional delivery to birth certificates. They also visit beneficiary’s homes directly, often during difficult circumstances (the week immediately following birth). Each of these points of contact are associated with their own sets of challenges. Opportunity areas include providing ASHAs with targeted support and training to successfully provide a broad range of services.