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Means, Motives and Opportunity: determinants of community health worker performance
  1. Aparna John1,
  2. Thomas Newton-Lewis2,
  3. Shuchi Srinivasan2
  1. 1Institute of Development Studies, University of Sussex, Brighton, UK
  2. 2Oxford Policy Management, New Delhi, India
  1. Correspondence to Thomas Newton-Lewis; tom.newtonlewis{at}


The performance of community health workers (CHWs) typically depends on the interaction between their motivation (their intent to achieve personal and organisational goals) and the constraints that they face in doing so. These constraints can be both at the individual level, for example, whether the worker has the skills and knowledge required to deliver on their job role, and the organisational level, for example, whether the worker is provided with the resources required to perform. Designing interventions to improve the performance of CHWs requires identifying the constraints to performance in a particular context. Existing frameworks on CHW performance tend to be derived empirically, identifying a broad range of intervention design and contextual factors that have been shown to influence CHW performance. These may not always be able to guide policy makers to identify the precise cause of a specific performance problem in a particular context and develop an appropriate policy response. This article presents a framework to help practitioners and researchers diagnose the constraints to performance of CHWs and guide programmatic and policy responses. The Means, Motives and Opportunity (MMO) framework has been adapted from the SaniFOAM framework used to identify the determinants of sanitation behaviours. It is based on three interdependent and interacting domains: means (whether an individual is capable of performing), motives (whether an individual wants to perform) and opportunity (whether the individual has the chance to perform). A wide range of data sources are expected to be used when applying the MMO framework, especially qualitative research that captures the perspectives and lived realities of CHWs and their communities. In this article, we demonstrate how the MMO framework can be applied to identify the constraints to CHW performance using the case study of Anganwadi Workers (village nutrition workers) in Bihar, India.

  • health policy
  • health systems
  • health systems evaluation
  • public health

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Handling editor Kerry Scott

  • Presented at The work was presented at the Women Deliver Conference in Vancouver, June 2019.

  • Contributors Each author contributed to the conceptual development of the framework presented and were jointly responsible for manuscript preparation. AJ led on the qualitative study of the determinants of AWW performance that was the original genesis.

  • Funding This work was funded under the Frontline Worker Knowledge Synthesis grant received by Oxford Policy Management from the Bill and Melinda Gates Foundation (BMGF) (OPP1194341).

  • Competing interests None declared.

  • Patient consent for publication Not required.

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

  • Data availability statement There are no data in this work.

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