Abstract
In Bihar, India, coverage of essential health and nutrition interventions is low. These interventions are provided by 2 national programs--the Integrated Child Development Services (ICDS) and Health/National Rural Health Mission (NRHM)--through Anganwadi workers (AWWs) and Accredited Social Health Activists (ASHAs), respectively. Little is known, however, about factors that predict effective service delivery by these frontline workers (FLWs) or receipt of services by households. This study examined the predictors of use of 4 services: (1) immunization information and services, (2) food supplements, (3) pregnancy care information, and (4) general nutrition information. Data are from a 2012 cross-sectional survey of 6,002 households in 400 randomly selected villages in 1 district of Bihar state, as well as an integrated survey of 377 AWWs and 382 ASHAs from the same villages. For each of the 4 service delivery outcomes, logistic regression models were specified using a combination of variables hypothesized to be supply- and demand-side drivers of service utilization. About 35% of households reported receiving any of the 4 services. Monetary immunization incentives for AWWs (OR = 1.55, CI = 1.02-2.36) and above-median household head education (OR = 1.39, CI = 1.05-1.82) were statistically significant predictors of household receipt of immunization services. Higher household socioeconomic status was associated with significantly lower odds of receiving food supplements (OR = 0.87, CI = 0.79-0.96). ASHAs receiving incentives for institutional delivery (OR = 1.52, CI = 0.99-2.33) was marginally associated with higher odds of receiving pregnancy care information, and ASHAs who maintained records of pregnant women was significantly associated with households receiving such information (OR = 2.25, CI = 1.07-4.74). AWWs receiving immunization incentives was associated with significantly higher odds of households receiving general nutrition information (OR = 1.92, CI = 1.08-3.41), suggesting a large spillover effect of incentives from product- to information-oriented services. Product-oriented incentives affect delivery of both product- and information-oriented services, although household factors are also important. In India, existing government programs can mitigate supply- and demand-side constraints to receiving essential interventions by optimizing existing incentives for FLWs in national programs, helping FLWs better organize their work, and raising awareness among groups who are less likely to access services.
Highlights
IntroductionUndernutrition is the underlying cause each year of some 3.1 million deaths in children under 5 years old (45% of all deaths in this group). Delivering 10 evidence-based essential interventions in Frontline Worker Delivery of Health and Nutrition Services in Bihar, India www.ghspjournal.org such areas as adolescent and pregnancy nutrition, infant and young child feeding practices, immunization, and micronutrient supplementation at90% coverage could reduce these total deaths by an estimated 15%.1Community-based Community-based strategies are recognized as strategies are important for delivering such health and nutrition important for delivering health interventions requiring household behavioral changes.interventions— those that require household behavioral changes. frontline workers (FLWs)—paid or volunteer nonprofessional community health care providers3—can improve access to essential interventions and have been effective at preventing and managing neonatal childhood illnesses. Behavioral change interventions such as promotion of breastfeeding and hand washing, as well as instruction on the value of immunization, micronutrients, and insecticidetreated nets, can be delivered in the community by trained health professionals or by lay workers.4FLW roles are quite diverse; some FLWs provide a wide range of preventive and curative services while others provide only selected services. Careful selection and training, continued support including monetary and non-monetary incentives, establishing routine contact with families in the community, and monitoring are critical for a successful FLW program. Supportive supervision is recognized to improve work productivity of FLWs providing preventive or curative services. There is, limited understanding of the differing determinants of effective FLW service delivery for preventive vs. curative services
Accredited Social Health Activists (ASHAs) receiving incentives for institutional delivery (OR = 1.52, confidence interval (CI) = 0.99–2.33) was marginally associated with higher odds of receiving pregnancy care information, and ASHAs who maintained records of pregnant women was significantly associated with households receiving such information (OR = 2.25, CI = 1.07–4.74)
Anganwadi workers (AWWs) receiving immunization incentives was associated with significantly higher odds of households receiving general nutrition information (OR = 1.92, CI = 1.08–3.41), suggesting a large spillover effect of incentives from product- to information-oriented services
Summary
Undernutrition is the underlying cause each year of some 3.1 million deaths in children under 5 years old (45% of all deaths in this group). Delivering 10 evidence-based essential interventions in Frontline Worker Delivery of Health and Nutrition Services in Bihar, India www.ghspjournal.org such areas as adolescent and pregnancy nutrition, infant and young child feeding practices, immunization, and micronutrient supplementation at90% coverage could reduce these total deaths by an estimated 15%.1Community-based Community-based strategies are recognized as strategies are important for delivering such health and nutrition important for delivering health interventions requiring household behavioral changes.interventions— those that require household behavioral changes. frontline workers (FLWs)—paid or volunteer nonprofessional community health care providers3—can improve access to essential interventions and have been effective at preventing and managing neonatal childhood illnesses. Behavioral change interventions such as promotion of breastfeeding and hand washing, as well as instruction on the value of immunization, micronutrients, and insecticidetreated nets, can be delivered in the community by trained health professionals or by lay workers.4FLW roles are quite diverse; some FLWs provide a wide range of preventive and curative services while others provide only selected services. Careful selection and training, continued support including monetary and non-monetary incentives, establishing routine contact with families in the community, and monitoring are critical for a successful FLW program. Supportive supervision is recognized to improve work productivity of FLWs providing preventive or curative services. There is, limited understanding of the differing determinants of effective FLW service delivery for preventive vs. curative services. Frontline workers (FLWs)—paid or volunteer nonprofessional community health care providers3—can improve access to essential interventions and have been effective at preventing and managing neonatal childhood illnesses.. Frontline workers (FLWs)—paid or volunteer nonprofessional community health care providers3—can improve access to essential interventions and have been effective at preventing and managing neonatal childhood illnesses.5,6 Behavioral change interventions such as promotion of breastfeeding and hand washing, as well as instruction on the value of immunization, micronutrients, and insecticidetreated nets, can be delivered in the community by trained health professionals or by lay workers.. In Bihar, India, coverage of essential health and nutrition interventions is low These interventions are provided by 2 national programs—the Integrated Child Development Services (ICDS) and Health/National Rural Health Mission (NRHM)—through Anganwadi workers (AWWs) and Accredited Social Health Activists (ASHAs), respectively. This study examined the predictors of use of 4 services: [1] immunization information and services, [2] food supplements, [3] pregnancy care information, and [4] general nutrition information
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