One of the key strategies under the National Rural Health Mission (NHM) is having a Community Health Volunteer i.e. ASHA (Accredited Social Health Activist) for every village with a population of 1000. Detailed guidelines have been issued by the Government of India in matter of selection and training of ASHA. The States have been given the flexibility to relax the population norms as well as the educational qualifications on a case to case basis, depending on the local conditions as far as her recruitment is concerned.
The above said guidelines also clearly bring out the role of ASHA vis-&-vis that of Anganwadi Worker (AWW) and the Auxiliary Nurse Midwives (ANM). The non-ASHA States (including the NE) have been advised that they could provide for similar link workers at the village level in the revised Project Implementation Plan for RCH-II in the current year. States like Andhra Pradesh and Haryana are already having the link workers. The ASHA scheme is presently in place in 33 states (except Goa, Chandigarh & Puducherry). The states can select ASHAs in urban areas also as link workers subject to similar provisions being made in the State PIP for RCH-II in the current financial year.
The reports received from the States indicate that over 8.9 Lakh ASHAs have been selected uptill 31st March 2014 and that they are being provided with orientation training as envisaged in the guidelines issued on ASHA. Now, a careful strategy needs to be devised for providing the necessary management support to ASHA so that she is not left alone in the village without having any linkage with the health system.
The following set of guidelines are issued to enable the States to develop and put in place a proper support mechanism for ASHA.
ASHA Mentoring Group: The Government of India has set up an ASHA Mentoring Group comprising of leading NGOs and well known experts on community health. Similar mentoring groups at the State/District/Block levels could be set up by the States to provide guidance and advise on matter relating to selection, training and support for ASHA. At the District level, MNGOs and at Block level, FNGOs could be involved in the mentoring of ASHA. The State Govt. may utilize the services of Regional Resource Centre (RRC) and include them in the Mentoring Group at the State level.
Selection of ASHA As ASHA will be in the village on a permanent basis, she should be selected carefully through the process laid down in the first set of ASHA guidelines. It is possible that the selected ASHA drops out of the programme. It is, therefore, necessary to keep a record of such cases at SUb-Centre/ PHC level. In the above circumstance, a new ASHA could be selected from the panel of three names previously prepared on the recommendation of the Gram Sabha.
Training of ASHA The guidelines already issued on ASHA envisage a total period of 23 days training in five episodes. However, it is clarified that ASHA training is a continuous one and that she will develop the necessary skills & expertise through continuous on the job training. After a period of 6 months of her functioning in the village it is proposed that she be sensitized on HIV / AIDS issues including STI, RTI, prevention and referrals and also trained on new born care.
Familiarizing ASHA with the village: Now, that ASHAs have been selected, the next step would be to familiarize her with the health status of the villagers and facilitate her adoption to the village conditions. Although, ASHA hails from the same village, she may not be having knowledge and information on the health status of the village population. For this purpose, she should be advised to visit every household and make a sample survey of the residents of village to understand their health status. This way she will come to know the villagers, the common diseases which are prevalent amongst the villagers, the number of pregnant women, the number of newborn, educational and socio economic status of different categories of people, the health status of weaker sections especially scheduled castes/scheduled tribes etc. She can be provided a simple format for conducting the surveys. In this she should be supported by the AWW and the Village Health & Sanitation Committee.
The Gram Panchayat will be involved in supporting ASHAs in her work. All ASHAs will be involved in this Village Health and Sanitation Committee of the Panchayat either as members or as special invitees (depending on the practice adopted by the State). ASHAs may coordinate with Gram Panchayats in developing the village health plan. The untied funds placed with the Sub-Centre or the Panchayat may be used for this purpose. At the village level, it is recognized that ASHA cannot function without support. The SHGs, Woman's Health Committees, Village Health and Sanitation Committees of the Gram Panchayat will be major sources of support to ASHA. The Panchayat members will ensure secure and congenial environment for enabling ASHAs to function effectively to achieve the desired goal.
Maintenance of Village Health Register: A village health register is maintained by the AWW which is not always complete. ASHA can help AWW to complete and update this register by maintaining a daily diary. The diaries, registers, health cards, immunization cards may be provided to her from the untied funds made available to the Sub-Centres.
Organization of the Village Health and Nutrition Day: All State Governments are presently organizing monthly Health and Nutrition day in every village (Anganwadi centers) with the help of AWW/ANM. ASHA along with AWW should mobilize women, children and vulnerable population for the monthly health day activities like immunization, careful assessment of nutritional status of pregnant/lactating women, newborn & children, ANC/PNC and other health check-ups of women and children, taking weight of babies and pregnant women etc. and all range of other health activities. The ANM and the AWW will guide the ASHA during the monthly health days. The organization of the monthly Health and Nutrition Days ought to be jointly monitored by the CDPO, LHVs, and the Block Supervisor of the ICDS periodically.
Co-ordination with SHG Groups: ASHA would be required to interact with SHG Groups, if available in the villages, along with AWW, so that a work force of women will be available in all the villages. They could jointly organize check up of pregnant women, their transportation for safe institutional delivery to a pre-identified functional health facility. They could also think of organizing health insurance at the local level for which the Medical Officer and others could provide necessary technical assistance.
Meeting with ANM: ANM should have a monthly meeting with the ASHAs stationed (5-6 ASHAs) in the villages of her work area at the Anganwadi Centre during the monthly Health and Nutrition Day to assess the quality of their work and provide them guidance.
Monthly meetings at PHC level: The Medical Officer In-charge of the PHC will hold a monthly meeting which would be attended by ANM and ASHAs, LHVs and Block Facilitator. During this period, the health status of the villages will be carefully reviewed. Payment of incentive to ASHAs under various schemes could be organized on that day so that ASHA need not visit the PHC many times to receive her incentives. States may ensure that payment to ASHA are made promptly through a simplified procedure. During these meetings, the support received from the Village Health and Sanitation Committee and their involvement in all activities also should be carefully assessed. The ASHA kits also could be replenished at that time. Replenishment of kit should be prompt, automatic and through a simplified procedure.
Monthly meetings of ASHAs: A meeting of ASHA could be organized on the day monthly meetings are organized at the PHC level to avoid unnecessary travel expenditure and wastage of time. The idea is that apart from the meeting with officials they should be given opportunity to share sometime of their own experience, problems, etc. They will also get an opportunity to independently assess the health system and can bring about much needed changes.
In addition to monthly meetings at PHC, periodic retraining of ASHAs may be held for two days once in every alternate month where interactive sessions will be held to help then to refresh and upgrade their knowledge and skills, as provided for in the original guidelines for ASHA.
Block level management: At the block level, the BMO will be in overall charge of ASHA related activities. However, an officer will be designated as Block level organizer for the ASHA to be assisted by Block Facilitators (one for every 10 ASHAs). Block Facilitators could be appointed as provided for under the first set of guidelines on ASHA already issued to the States. The Block Facilitator may be necessarily women. However, male members if any, who may have already been appointed earlier as Block Facilitator may continue. The Block Facilitators would provide feedback on the functioning of ASHAs to the BMO & Block level organizers. They shall also visit the ASHAS in villages.
Management Support FOR ASHA: Officials in the ICDS should be fully involved in ASHAs activities and their support should be provided for at every level i.e. PHCs, CHCs, District Society etc. The management support which would be provided under RCH/NHM at the Block, District & State level should be fully utilized in creating a network for support to ASHA including timely disbursement of incentives, at various levels. This support system should have full information on the number of ASHAs, quality of their out put, outcomes of the Village Health and Nutrition Day, periodic health surveys of the villages to assess her impact on community etc.
Community monitoring: Periodic surveys are envisaged under NHM in every village to assess the improvement brought about by ASHA and other interventions. The funding for the survey will be provided out of the untied funds provided to the Sub-Centre. The first survey would provide the base line for monitoring the impact of health activities in the village.
Role of District Health Missions: The District Health Mission in its meetings will specially assess the progress of selection of ASHAs, their training and orientation, usefulness to the villages etc. They should also have a Cell in the DPU to collect all information related to ASHA and the community which should be available on the computer network. This information should be accessible by the State Health Missions as well as the Mission at the national level.
Linkage with Health Facility The success of NHM to great extent depends on performance of ASHA and her linkage with functional health system. The health system has to give due recognition to ASHA and take prompt action on the referrals made by her; otherwise the system cannot be sustained. Every ASHA must be familiar with the identified functional health facility in the respective area where she can refer or escort the patients for specific services. The persons manning these health facilities should be sensitized to effectively respond to the instant needs of the local people. Funds available under IEC-programme may be used for education and publicity in respect of above services. The role of the State & District level Missions would be to provide support to ASHA from village to the district level without any blockage on the way. The States may take appropriate steps to locally adopt these guidelines and make the ASHA scheme a complete success.
One of the key strategies under the National Rural Health Mission (NHM) is a community health worker i.e., Accredited Social Health Activist (ASHA) for every village at a norm of one per thousand population. Right after the launch of the Mission, detailed guidelines were issued by the Government of India for selection and training of ASHAs. The above guidelines clearly brought out the role of ASHA vis-&-vis that of Anganwadi Worker (AWW) and Auxiliary Nurse Mid-wife (ANM). The guidelines also gave break up of the expenditure on selection, training and provision of drug kits to ASHAs. The scheme for providing performance linked compensation and the methodology of payment of compensation was also delineated in those guidelines.
In view of the selection of large number of ASHAs, a need for providing a support mechanism for ASHAs has been acutely felt. A set of guidelines was therefore issued to the States to facilitate putting in place a mechanism for this purpose. These guidelines provided for inter-alia ASHA mentoring group at State level, Block Level Facilitators at the rate of one per ten ASHAs, a system of monitoring meetings of ASHAs at the PHC level, coordination with Self-Help Groups etc.
The implementation framework for the NHM has recently been approved. The scheme of ASHA has now been extended to all the 18 high focus States. Besides, the scheme would also be implemented in the tribal districts of the other States. In the new implementation framework, a provision has been made for an expenditure of Rs. 10,000 per ASHA during a financial year. This ceiling does not include the performance-based compensation, which the different programme divisions would disburse from their own funds. The earlier ASHA guidelines had visualized an expenditure of Rs. 7,415/- per ASHA. The increased outlay gives a valuable opportunity to further strengthen the support mechanism.
Over the last one year, the States have selected more than 200,000 ASHAs. The number of ASHAs is likely to be increase very rapidly over the next two years. As a matter of fact, a district alone is expected to have more than 1,000 ASHAs. Obviously, a very strong support mechanism is required at block, district and State level to ensure that the scheme of community health worker meets the objectives, which the Mission has envisaged for it. The support functions which would have to be carried out at these levels include inter-alia, preparation of training calendar for the trainers as well as for ASHAs, monitoring the implementation of the training programmes, adapting the training modules (provided to the States by the GoI) to suit the local conditions, translation in local language, printing and distribution of these manuals, developing ASHA monitoring forms and monitoring her performance, developing IEC materials, addressing grievances of ASHAs if any etc.
In order to provide adequate support to the ASHAs, the following has been provided:
At State Level: In the implementation framework of the NHM a provision has been made for a State Health System Resource Centre (SHSRC) in every State. It is envisaged that once this centre is set up they would provide the leadership and support to the ASHA scheme at the State level. However, setting up of SHSRC may take a year. Since the support mechanism for ASHAs at the State level cannot wait for that long, a provision is being made for ASHA resource centre on the lines of the set up in Rajasthan. In the State having more than 20,000 ASHAs, a resource Centre would comprise a Project Manger (MBA), a Deputy Project Manager (MSW), one Statistical Assistant (Graduate in Statistics), a Data Assistant and Office Attendant.
In the smaller States (other than North Eastern States) having less than 20,000 ASHAs, three persons are being provided at the State level i.e. one Project Manager, a Statistical Assistant, and one Office Attendant.
These functionaries together would comprise an ASHA Resource Centre which would ultimately get subsumed in the State Health Resource Centre (SHRC) as and when the SHRC gets off the ground.
In the detailed cost estimates as given in the Guidelines for Community Processes, adequate provisioning has been done for office expenses and other contingent expenditure. This amount will be provided as a lump sum so that the States have the flexibility to use the amount as per their needs.
At District level: In the existing ASHA guidelines, at the district level a District Nodal Officer has been provided. The District Nodal Officer is to be an officer nominated by the Civil Surgeon. Since the guidelines do not provide for additional human resources, it is expected that he/she would be doing the work with the existing human and financial resources. However, as has been mentioned above, managing the various aspects of the functioning of more than 1,000 ASHAs will not be a simple task without adequate human and financial resources. It is, therefore, now proposed that each District Nodal Officer would be supported by a Community Mobiliser who would have the qualification of MSW. A Data Assistant may also be provided to satisfactorily discharge the work.
At Block Level: At the block level, as per the existing ASHA guidelines, the Block Nodal Officer is to be nominated by the Block Medical Officer. The Block Nodal Officer will have the services of a number of Block Facilitators @ 1 per 10 ASHAs. Even though a need has been actually felt for the services of a Block Coordinator, looking to the large number of blocks in the States, the outgo in providing for an additional Block Coordinator at the block level would be considerable. It may not, therefore, be possible to provide for the services of a Block Coordinator without overshooting the norm of Rs. 10,000 per ASHA. However, in the earlier guidelines, a provision of one Facilitator for ten ASHAs has already been made. It is expected that this arrangement would suffice. However, a flexibility would be available to the Block Nodal Officer to utilize the services of the Facilitator posted at the block or any other Facilitator for other administrative work in his office relating to ASHAs. For this purpose a small honorarium could be permissible to the Facilitators.
At PHC level: There would be considerable workload at PHC level as many of the bills for payment to ASHA would be processed in that office. Since no additional manpower is provided at this level, a suitable honorarium for LHV and the Block Supervisor for ICDS is being provided in the guidelines.
The details of the cost estimates, post and qualification are given in the support structure guidelines detailed in the Guidelines for Community Processes. The appointment to the above positions can only be on a contractual basis.