Does Universal Health Coverage Include the Caregivers? A Mixed Method Study on Accessibility and Out-of-pocket Expenditure for Healthcare Services by Accredited Social Health Activists of North India

Abstract Background: Despite the load of voluntary work done by Accredited Social Health Activists (ASHAs), they are not recognized and are not provided any health security measures. The current study aims to estimate the proportion of income spent on healthcare services by ASHA and her family in the past 6 months and to explore their access to healthcare services. Methods: A mixed-method study was done among ASHAs under one community health center in North India in 2022. A self-administered questionnaire was used to collect data on the healthcare preferences and expenses of the ASHAs and their family. In the second phase, focused group discussions were conducted among the ASHAs in groups of 6–8 to collect data on their experiences with healthcare services. One of the co-investigators was the moderator, another was conducting audio recordings and taking notes. Results: Eighteen ASHAs were included in the study, and 38.8% of them had health insurance. For preventive services, they preferred community health centers (CHCs) (83.3%). Health expenses in the past 6 months were about 12.18% of their family income. The focused group discussion was based on themes including ASHAs’ expectations from the system they are working with, their healthcare-seeking behavior, and both of its effects on their performance in the implementation of the target-oriented program at the ground level. Conclusion: Being part of the health system, the community health worker is aware of the quality of services provided. Not preferring the public health system was reported due to disrespect in the system and unavailability of some curative services.