Factors influencing performance motivation of Accredited Social Health Activists, the community health volunteers of India - A mixed method study

A BSTRACT Aims and Objectives: This study aims to explore the factors influencing the performance motivation of Accredited Social Health Activists (ASHAs) across four Indian states with different incentive models. Materials and Methods: A mixed-methods study was conducted between March and November 2022, which assessed ASHA motivation across four incentive systems: only performance-based (Meghalaya), fixed top-up (Rajasthan), variable top-up (Chhattisgarh), and fixed incentive (Andhra Pradesh), selected through state consultations. Quantitatively, 1200 ASHAs were surveyed, and descriptive and bivariate analyses were conducted in SPSS 26 and Excel. Qualitatively, in-depth interviews and focus group discussions were conducted with ASHAs and health system personnel, with data analyzed using manual thematic analysis. Data quality was ensured through validated tools and regular triangulation to enhance reliability and consistency. Results: The study found that financial incentives were just one factor affecting ASHA motivation. Nonmonetary factors, both intrinsic (self-motivation, altruism, social responsibility) and extrinsic (career progression, support, work environment), played significant roles. ASHAs in Chhattisgarh showed the highest motivation despite receiving lower financial incentives compared to other states. The qualitative data supported these findings, highlighting the importance of nonmonetary incentives in driving motivation. Conclusion: The results suggest that ASHA motivation can be enhanced by combining both monetary and nonmonetary incentives. A performance-based incentive with a variable top-up model appears effective, but state-level adaptations based on sociocultural contexts are crucial. Given ASHAs’ critical role in delivering government health programs, sustained efforts to boost their motivation are essential to improving primary healthcare delivery.