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What do community health workers want? Findings of a discrete choice experiment among Accredited Social Health Activists (ASHAs) in India
  1. Marwa Abdel-All1,2,
  2. Blake Angell2,
  3. Stephen Jan1,3,4,
  4. Martin Howell5,
  5. Kirsten Howard5,
  6. Seye Abimbola1,2,
  7. Rohina Joshi1,2,6
  1. 1Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
  2. 2The George Institute for Global Health, Newtown, New South Wales, Australia
  3. 3Health Economics and Process Evaluation Program, The George Institute for Global Health, Sydney, New South Wales, Australia
  4. 4Facultyof Medicine, University of New South Wales, Sydney, New South Wales, Australia
  5. 5School of Public Health, University of Sydney, Sydney, New South Wales, Australia
  6. 6School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
  1. Correspondence to Dr Marwa Abdel-All; mabdel-all{at}


Introduction A number of factors contribute to the performance and motivation of India’s Accredited Social Health Activists (ASHAs). This study aims to identify the key motivational factors (and their relative importance) that may help retain ASHAs in service.

Methods A discrete choice experiment (DCE) survey presented ASHAs with eight unlabelled choice sets, each describing two hypothetical jobs that varied based on five attributes, specifically salary, workload, travel allowance, supervision and other job benefits. Multinomial logit and latent class (LC) models were used to estimate stated preferences for the attributes.

Result We invited 318 ASHAs from 53 primary health centres of Guntur, a district in south India. The DCE was completed by 299 ASHAs using Android tablets. ASHAs were found to exhibit a strong preference for jobs that incorporated training leading to promotion, a fixed salary and free family healthcare. ASHAs were willing to sacrifice 2530 Indian rupee (INR) from their monthly salary, for a job offering training leading to promotion opportunity and 879 INR for a free family health-check. However, there was significant heterogeneity in preferences across the respondents. The LC model identified three distinct groups (comprising 51%, 35% and 13% of our cohort, respectively). Group 1 and 2 preferences were dominated by the training and salary attributes with group 2 having higher preference for free family health-check while group 3 preferences were dominated by workload. Relative to group 3, ASHAs in groups 1 and 2 were more likely to have a higher level of education and less likely to be the main income earners for their families.

Conclusion ASHAs are motivated by both non-financial and financial factors and there is significant heterogeneity between workers. Policy decisions aimed at overcoming workforce attrition should target those areas that are most valued by ASHAs to maximise the value of investments into these workers.

Trial registration number CTRI/2018/03/012425.

  • motivation
  • preferences
  • willingness to sacrifice salary
  • latent class analysis
  • discrete choice experiment (DCE)
  • the accredited social health activists (ASHAs)

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  • Handling editor Sanni Yaya

  • Contributors The study design was developed by RJ and MA-A. BA and MA-A performed the analysis under the supervision of MH and KH. MA-A and RJ drafted this article and all authors revised the manuscript.

  • Funding RJ is funded by the Australian National Heart Foundation Future Leader Fellowship. SJ is funded by an NHMRC Principal Research Fellowship.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Approval for the overall study was obtained from The George Institute Ethics Committee of The George Institute for Global Health, India (project number 009/2017).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data relevant to the study are included in the article or uploaded as supplementary information.

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