Sampling and sample size

Maximum variation sampling using a combination of purposive and random selection at different levels was applied to capture heterogeneity in service delivery contexts [24]. Three districts were purposively selected from among the 30 total districts in the state, to attain variations between districts. Existing district-level survey data [25, 26] were used to construct a set of criteria pertaining to service coverage and household factors (e.g., coverage of immunization and vitamin A supplementation, three or more antenatal care visits, and institutional delivery; access to toilet and electricity; and type of cooking fuel), and changes in these indicators between two survey rounds were examined. All districts were grouped into three categories: better performing districts (i.e., those with positive change over time), average performing districts (i.e., no change), and poorly performing districts (i.e., those with negative change). Then, in a meeting organized by the researchers to explain the study and conduct a joint process of district selection, state-level officials from the Department of Health and Family Welfare (DHFW) and the Department of Women and Child Development (DWCD) randomly drew the name of one district from each category: District 1 as better performing, District 2 as average performing, and District 3 as a poorly performing district.

In each district, we randomly selected four blocks (subdivision or town) (n = 12) and two villages from two of the blocks (n = 12) to study service delivery by three different cadres of FLWs within each village. In a village, there is usually one Anganwadi Center (AWC) with an Anganwadi Worker (AWW). The AWW is responsible for the AWC and delivers health and nutrition services and preschool education under the ICDS program; she is an honorary female worker selected from the local community. The AWW in each village, along with the Accredited Social Health Activist (ASHA) and the Auxiliary Nurse Midwife (ANM) working in the same area were interviewed in this study. The ASHA is a female health worker, selected from the community and serves the role of community mobilizer to access services and community-level care provider. The ANM is a multipurpose female health worker who provides a package of preventive and curative services largely for women and children, at a sub-center that covers a population of 3,000–5,000 for rural areas, which is approximately 6–8 villages, and through outreach services. We conducted a total of 145 semi-structured interviews with the three types of FLWs, as well as with block, district, and state-level staff of the ICDS and health departments and from other sectors (Table 1). Interview guides are shown in Additional files 1, 2, 3, and 4.

Study sample size by administrative level and sector

^aDistrict collector is the chief administrative and revenue officer, appointed by the state government

^b Gaon Kalyan Samiti/Village Health and Sanitation Committee (GKS/VHSC) is the local management body instituted by the National Rural Health Mission, comprised of village representatives and headed by a village ward member. GKS is responsible for community-based planning and implementation of health and related activities, and creating awareness and promoting public health and sanitation activities. It receives an untied grant of Rs. 10,000 annually (approximately USD 160) to ensure that such activities are carried out

^cBlock development officer is responsible for monitoring the implementation of all programs related to block planning and development

^dPanchayai Raj Institution (PRI) is the oldest system of local government, the most basic administrative unit or assembly of community representatives, that is responsible for all matters of community development

Written informed consent was obtained from the study participants prior to interview. This study was approved by the IFPRI Institutional Review Board and Odisha’s Department of Women and Child Development and Department of Health and Family Welfare in India.