The Impact of India's Accredited Social Health Activist (ASHA) Programme on the Utilization of Maternity Services: A Modelling Study

Abstract

Background: In 2006, the Government of India launched a community health worker programme called the Accredited Social Health Activist (ASHA) programme, with the goal to connect marginalized communities to the healthcare system and improve maternity health outcomes. We assessed the effect of the ASHA programme on the utilization of maternity services. Methods: We used data from Indian Human Development Surveys done in 2004-2005, and in 2011-2012 to assess demographic and socio-economic factors associated with the receipt of ASHA services; and used difference-in-difference analysis with cluster-level fixed effects to assess the effect of the ASHA programme on the utilization of at least one antenatal care (ANC) visit, four or more ANC visits, skilled attendance at birth (SBA) and delivery at a health facility. Findings: Substantial variations in the receipt of ASHA services were reported with 66% of women in northeastern states, 30% in high-focus states, and 16% of women in other states. In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backwards castes, had the highest odds of receiving ASHA services. Exposure to ASHA services was associated with a 17% (95% CI 11.8-22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI -1.6 - 11.1), 26% increase in SBA (95% CI 20-31.1), and 28% increase (95% CI 22.4-32.8) in facility births. Interpretation: Our results suggest that the ASHA programme is successfully connecting marginalized communities to maternity health services. The study highlights the need improve the coverage of four or more ANC visits, and target programmatic activities to women belonging to scheduled tribes. Given the potential of the ASHA in impacting service utilization, we emphasize the need to strengthen strategies to recruit, train, incentivize and retain ASHAs. Funding: None Declaration of Interest: The authors declare no conflicts of interest that would influence the results and recommendations of this work. Ethical Approval: Ethical approval was received from the University of North Carolina, Chapel Hill Institutional Review Board.