The impact of India’s accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study

In 2015, India accounted for approximately 45 000 (range 36 000 to 56 000) pregnancy-related maternal deaths, making it one of two countries that account for one third of all maternal deaths globally [1]. Between 1990 and 2016, the maternal mortality ratio (measured as a pregnancy-related deaths per 100 000 live births) declined by 77% [1]. While some progress was made to achieve the Millennium Development Goal of a two-third reduction in maternal mortality, the target was not met and progress varied substantially across states [2]. Between 2005–2006 and 2015–2016, the coverage of four or more antenatal care visits (ANC) increased from 37 to 51%, institutional deliveries increased from 39 to 79%, and percentage of births with a skilled attendant increased from 47 to 81% [3].

A number of studies have demonstrated the positive impact of community health worker (CHW) programs on the promotion of reproductive health services and family planning, appropriate care seeking, antenatal care during pregnancy, and skilled care for childbirth [4‐8]. However, there have also been several concerns about the performance and accountability of CHW programs, especially in programs scaled beyond the efficacy settings [9]. To date, most of the studies on the effectiveness of CHW programs have been small-scale randomized trials with interventions delivered under controlled settings; limited evidence exists on the effectiveness of national-level CHW programs. The WHO guidelines on health policy and system support to optimize CHW programs highlights the need for using longitudinal methods to assess the long-term impact of CHW programs [10]. India’s accredited social health activist (ASHA) program is the largest government-led CHW program globally with nearly one million trained CHWs.

In response to the relatively slow progress to strengthen maternal and child health, the Government of India (GoI) launched the National Rural Health Mission (NRHM) in April 2005. The NRHM is an ambitious effort to strengthen the national health systems and health care delivery, with a special focus on improving health care outcomes among the poorest populations [11]. The ASHA program, considered vital to the success of the NRHM, aims to increase community engagement with the health system and support access to public health services [12, 13]. The ASHA program was first launched in 2006 in 18 high-focus states—including 10 high-focus states (Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Himachal Pradesh, Jammu and Kashmir, Uttar Pradesh, Uttaranchal, Orissa, and Rajasthan) and 8 northeastern high-focus states (Arunachal Pradesh, Manipur, Assam, Nagaland, Meghlaya, Tripura, Mizoram, and Sikkim). Within 2 years, over 300 000 ASHAs were trained and deployed at a ratio of one ASHA to 1000 population in rural areas. In 2009, the program was expanded to the rest of the country [14]. As of December 2015, there were 937 595 ASHAs operating nationally. Of these, 544 074 ASHAs are in high-focus states, 56 104 in the northeastern states, and 337 417 in other non-high-focus states [15, 16]. The ASHAs are an all-female cadre of CHWs, selected based on national guidelines by local village committees. Though they are considered volunteers, they receive some performance-based incentives. Although variations exist across states in the recruitment, training, responsibilities, incentives, and supervision systems for the ASHAs, there are some common guiding tenets. Table 1 summarizes their training [17], responsibilities specific to promoting the health of mothers and children [14, 18], and compensation structure [19, 20].

Given the size and scope of the ASHA program, an assessment of the program has relevance not only for the GoI, but also for other countries investing in similar CHW programs. Over the last decade, the ASHA program has been scaled nationally, with a budget allocation ranging from 80 million rupees (~ $1.2 million) to 1.05 billion rupees (~ $15.5 million) per state, between 2005 and 2010 alone [14, 21]. Furthermore, governments in other South Asian and African countries such as Ethiopia, Bangladesh, Kenya, Uganda, Ghana, and South Africa are in various stages of training and deploying cadres of CHWs to fill critical gaps in delivering health services to women and children [22]. Despite the importance of such programs, the evidence on their effectiveness, especially at scale, is limited.

Previous assessments of the effect of the ASHA program on maternity care have been descriptive [23], limited to certain states [14], or limited to assessing the performance of the ASHAs [11, 24] and not the impact of the ASHA program on health care outcomes. In this study, we investigate whether the ASHA program is reaching its target populations and assess whether the receipt of ASHA services is associated with an increase in the utilization of maternity care services.

We used data from two rounds of the nationally representative, longitudinal Indian Human Development Surveys (IHDS). The surveys were funded by the National Institutes of Child Health and Human Development (NICHD) and were produced jointly by the National Council of Applied Economic Research (NCAER), New Delhi, and the University of Maryland. IHDS-I (2004–2005) was administered to 41 554 households—27 010 rural and 13 126 urban households. The rural sample was drawn using stratified random sampling of defined units. In urban areas, a stratified sample of towns and cities within states was selected by probability proportional to population size [25, 26]. Eighty-three percent of the households interviewed in 2004–2005, were re-interviewed in IHDS-II (2011–2012), and an additional replacement sample of 2134 households was added. Appendix 3 presents an analysis of households that were not interviewed in IHDS-II and were lost to follow-up. The IHDS-II survey was administered to 42,152 households in 33 states and union territories, 384 districts (of 612 districts), 1503 villages, and 971 urban areas.

Both rounds of the IHDS survey include a household interview with information about household asset ownership, and an interview with ever-married women of reproductive ages (15–49 years) with information about birth history, reproductive health, and antenatal and delivery care for the most recent birth. IHDS-I recorded 11 670 births, and IHDS-II recorded 13 881 births (demographic characteristics presented in Appendix 1). The implementation of the ASHA program started in April 2005. IHDS-I covers births from 2000 to 2005, and IHDS-II covers a 6-year period (2005–2011) after the implementation of the ASHA program.

Nationally, 25% of women who had a live birth since 2005 reported receiving one or more ASHA services during their last pregnancy (measured as proportion of women who reported receiving ASHA services during their last pregnancy, among all women who had a live birth since 2005). Fifty-nine percent of women interviewed in IHDS-II live in clusters where an ASHA has been reported. Substantial variations in the receipt of ASHA services were reported at the state level (Fig. 1). Sixty-six percent of women in northeastern states, 30% of women from high-focus states, and 16% of women in other states reported receipt of ASHA services (Fig. 2). Over 30% of all rural women reported ASHA services, compared to less than 10% of urban women.

To understand whether ASHAs were differentially targeting any demographic groups within clusters where they are active, we restricted the analysis to only those 59% (n = 7985) of the clusters that reported an ASHA (Table 2). Compared to the youngest women ages 15–19 years, women in age groups 30–34, 35–39, and > 40 were significantly less likely to report ASHA services in the restricted sample. Within clusters with an active ASHA, compared to women with no education, women with 6–11 years and > 12 years of education were more likely to report receipt of ASHA services. This pattern was observed nationally, as well as when the sample is restricted to rural areas and to high-focus states. Compared to forward castes, women belonging to disadvantaged groups of OBC and scheduled castes are more likely to report ASHA services. However, no significant difference in receipt of ASHA services was observed among women belonging to scheduled tribes. Within clusters with an active ASHA, odds of reporting ASHA services declined steadily with increasing wealth status—nationally, in rural areas, and in high-focus states. No significant differences in the receipt of ASHA services were reported by religion across all groups.

Between 2005 and 2012, the use of at least one antenatal care increased from 74 to 84%, the use of a skilled attendant at birth increased from 53 to 75%, and the use of health facilities for giving birth increased from 43 to 66%. Table 3 presents three models to assess the relationship between exposure to ASHAs (exposure S1) and utilization of maternity services using a difference-in -differences model—a crude model (M1) without any confounders, a model (M2) with confounding covariates, and a model (M3) with confounding covariates and cluster-level fixed effects. Across all four outcomes, the crude model suggests that exposure to ASHAs is associated with a decrease in the use of the maternity services. However, this relationship is reversed, and a positive association is seen when the confounding variables are accounted for in M2; the positive relationship is further strengthened when cluster-level fixed effects are accounted for in M3. The reversal of the association may be explained by the results in Table 2 that show that receipt of ASHA services is more likely to be reported by the most marginalized women—women who are also least likely to have care-seeking behaviors.

Exposure to ASHAs is associated with a 17% increase in the utilization of at least one antenatal care visit, a 5% increase in the utilization of 4 or more antenatal care visits, a 26% increase in SBA, and a 28% increase in giving birth in a health facility (Table 3). This implies that for every 10 women receiving ASHA services, one or two additional women would receive at least one ANC visit, and additional two or three women would give birth in a health facility or with a skilled birth attendant outside a facility. High maternal education and household wealth, upper castes, and lower parity were associated with increased probability of having ANC, SBA, and giving birth in a health facility (results presented in Appendix 2). The association between exposure to ASHAs and maternity outcomes was robust to variations in cluster size and exposure specifications. While the magnitude of the association varies for the different exposure specifications, the results still suggest a significant association between receipt of ASHA services and the outcomes (Fig. 3)

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We attempted to understand the role of conditional cash transfers in motivating women to go to health facilities for birth and have a skilled attendant at the time of birth. Exposure to ASHAs is significantly associated with a reduction in home births, and births without a skilled attendant (Fig. 4). Exposure to ASHAs with financial incentives was significantly associated with a 12% and 15% increase in heath facility births and skilled birth attendance, respectively.

Exposure to ASHAs was strongly correlated with the utilization of maternity services. Even the most conservative assumptions for specifying exposure to ASHAs suggest that the ASHA program is associated with improved utilization of at least one antenatal care visit, skilled birth attendance, and giving birth in a health facility. The results also highlight the role of conditional cash transfers to incentivize facility-based births, and suggest that the presence of the ASHAs further augments this effect. The intent of the ASHA program was to reach marginalized communities—to connect communities that do not typically avail of services in health facilities to health care services at the community level. Our results suggest that the ASHA program is meeting these objectives as few programs have successfully done in the past.

While the ASHA program had the highest reach in the poorest populations, it does not address the disparities in the utilization of services across women from different socioeconomic and caste groups, especially the scheduled tribes. Historically, women belonging to scheduled tribes have minimal utilization of health services. For example, the National Family Health Survey (NFHS) reports facility-based delivery at 18% among scheduled tribes, compared to 33% among scheduled castes, and 51% among forward castes [32]. Our study indicates that utilization of maternity services continues to be the lowest among scheduled tribes, even after accounting for receipt of ASHA services. The tribal nature of these communities makes linkages to the health care system challenging and warrants further programming that is responsive to tribal customs around childbirth.

Prior process evaluations of the ASHA program highlighted several operational challenges. In several areas, the ASHAs do not receive timely payments for their services, which affects their performance [19]. Performance-based payments alone do not provide the financial security that is expected [33]. Studies conducted at the district or state level have reported that ASHAs may not be motivated in their role due to poor financial compensation [24, 34, 35]. Others have reported that ASHA activities in some states are hindered due to poor supportive supervision and mentoring structures [36]. Given our findings about the potential impact of the ASHA program on the utilization of services, especially for the marginalized, it is even more vital that these operational challenges are better understood and addressed. First, for the ASHA program to be sustainable, recruiting and training new ASHAs is as important as continued investments to ensure that the existing ASHAs have the institutional support and ongoing education needed to deliver the ever-expanding set of services expected of them. The effectiveness of large-scale mobile programs such as Mobile Academy for training of ASHAs should be robustly evaluated and, if effective, should serve as an adjunct instead of replacement for face-to-face instruction. Second, further research is needed to understand how the different implementation approaches, incentive systems, and support structures adopted by individual states have influenced the uptake and functioning of the ASHA program. Third, the role of the ASHAs in facilitating respectful maternity care needs to be further explored.

Contrary to the results of this study, a recent ecological analysis that explored the relationship between the change in proportion of villages within a district with an ASHA and a number of maternal health utilization outcomes, showed no impact of ASHA exposure on institutional delivery [37]. This study has several analytic improvements over the previous study in accounting for demographic characteristics which are established confounders of this relationship in the models, individual-level (instead of district-level) measurement of ASHA exposure and outcomes, and a longitudinal study design that accounts for targeting of the program by employing fixed effects methods at the cluster level. We assumed that accounting for cluster-level effects addresses variations in available health infrastructure thought of as critical to the success of the ASHAs. We used whether a woman received ASHA services as a proxy for whether the ASHA program was active in the area. By measuring ASHA exposure based on women’s self-reports, we capture functional exposure to the ASHA program. While this leaves room for measurement error in estimating the level of exposure, we account for this by presenting results from sensitivity analyses assuming a range of exposure definitions. Our study has some limitations. Seventeen percent of the households that were lost to follow-up in the IHDS-II survey were mostly urban, overall better-off households with higher levels of service utilization compared to the households that were part of both IHDS surveys. This limits the external validity of our findings. As with any non-experimental evaluation, our analysis is limited by unobserved factors associated with selective uptake of the ASHA program. Lastly, we are unable to disentangle the impact of the ASHAs from the impact of conditional cash transfers in driving the increase in SBA and facility births. Given that in most places the ASHAs bear the responsibility of informing women about the government’s conditional cash transfer scheme, we expect the impact of the two programs to be synergistic.

Our analysis presents an encouraging picture of the ASHA program 6–7 years into its implementation at scale. The ASHA program has increased in the utilization of antenatal care services, skilled birth attendance, and facility deliveries across caste, religion, and demographic groups. Most importantly, our analysis suggests that the ASHAs are more likely to reach groups that are typically left out of the formal health care system—poorer populations living in rural areas and women belonging to backward castes. The results of our study are promising given the sustained investments into the ASHA program by the national and state governments. However, the government needs to invest into supporting and increasing the reach of the ASHAs in marginalized regions with scheduled tribes. We emphasize the need to conduct ongoing monitoring and evaluation of the program to understand approaches to effectively scale the program and strengthen strategies to recruit, train, incentivize, and retain ASHAs.

In 2013, an expert consultation on the theme of CHWs in health care, organized by the United Nations Health Agencies (H4+) (UNAIDS, UNFPA, UNICEF, UN Women, the WHO, and the World Bank), highlighted the importance of CHW programs in strengthening national health systems and the critical need for identifying evidence-based interventions that CHWs can undertake in the reproductive health space. Identifying what interventions can be effectively delivered by CHWs would further strengthen the WHO and partner recommendations on task-sharing/task-shifting. This study addresses this gap by assessing the potential role of CHWs in effectively delivering maternity interventions and identifying the kind of interventions that are most likely to be affected through the engagement of CHWs. Historically, CHW programs at scale have not demonstrated the same impact as they have in controlled trials. Given the demonstrable impact of the ASHA program on the utilization of maternity services in our research, other countries and donor agencies can draw from the unique implementation features of the ASHA program in India.