Community Processes
Key elements of community processes under NHM

The ASHA and her support network at block, district and
state levels.

The Village Health Sanitation and Nutrition Committee
(VHSNC) and Mahila Arogaya Samiti (MAS).

Untied funds to the Sub Centre and the VHSNC

District Health Societies and the Rogi Kalyan Samitis

Community Monitoring

NGOs participation
ASHA’s roles
A.
B.
C.
-
A facilitator or link worker – where there is low use
of health services, the ASHA enables people to access
health services
A volunteer and activist- to enable access to health
entitlements and reaching the marginalized.
A community level care provider- important for her
credibility, to respond to local health needs, particularly
in underserved areas. Closely linked to health outcomes
Each of these roles reinforces the other but Getting the
mix right is the challenge
Working Arrangements






Flexible work schedule
Workload to be limited to 3-5 hours per day on about 4-5 days per week
This would mean in most contexts- ASHA work will not adversely affect
her primary livelihood.
During mobilization events, Eg- pulse polio, or escorting a patient, she may
spend a full day, and would be compensated accordingly.
Such full day work cannot be made mandatory except for training
programmes.
Immediate field level support will be provided by both ASHA Facilitator and
the ANM.
 ANM’s focus will be in her skills for community level care and
identification of illnesses
 Facilitator’s role will be on supporting her in her activist role, in
mobilization and in reaching the marginalized.
Important Milestones and Current Figures
2006: ASHAs for 18 high focus states and in tribal districts in others Target 400,000 ASHAs
2009: Scaled up across the country. Now: 8.57 lakh ASHAs in 31 states /
Uts (except in Goa, Puducherry and Chandigarh). Selection of ASHAs
is underway in Himachal Pradesh
State
High Focus States
North Eastern States
Non High Focus States
Union Territories
Total
Proposed
Number of
ASHAs
520725
54598
357506
870
933699
ASHAs
selected
% Selection
483320
54464
318417
806
857007
92.8%
99.8%
89.1%
92.6%
91.8%
Selection of ASHAs





Experience of selection at field level is mixed
Challenge of selecting ASHAs in areas with poor indicators and small
(dispersed) population still remains in few states Eg- MP, UP, Rajasthan, Bihar
and Gujarat.
Vacancies created by ASHAs progressing to become ASHA Facilitators are
yet to be filled in states like MP and Bihar. In states like UP the newly
selected ASHA facilitators continue to work as ASHAs – which has
increased their work load immensely.
Non resident ASHAs selected in states of Kerala and MP to adhere to the
educational criteria
There is a need to plan for at least 5% annual turnover of ASHAs
Competencies and skills of the ASHA
General: Rapport building, communication, village meetings
Maternal Health: Birth planning, enabling ANC, health and
nutrition education, understanding labour and delivery,
understanding birth outcomes, and high risk identification
and appropriate referral,
Home based Newborn Care: essential newborn care,
breastfeeding, weighing , measuring temperature,
Sick newborn care: knowledge of risks and care of LBW
and pre-term baby, manage breastfeeding problems, skill to
identify and provide first contact care for sepsis.
1.
2.
3.
4.
10
Competencies and skills of the ASHA
5. Child care: nutrition counselling, identifying malnutrition, follow up,
immunization, community based care for diarrhoea, Acute
Respiratory Infections (ARI), and fever,
De-worming and
treatment of anaemia,
6. Women’s health and gender concerns: social determinants of
women’s health – life cycle approach, violence against women.
7. Abortion, FP, STI/RTI: pregnancy test, counselling, identifying
newly married and those with one child, distribution of spacing
methods, appropriate referral for early abortion, counselling on
safe sexual behaviour,
8. Communicable diseases: state specific: knowledge about
prevention, early diagnosis, treatment access and follow-up.
9. Village Health Planning: Village planning, interpretation of basic
data
11
ASHA Training
Induction Training – (Modules 1-5)
On her role and responsibilities, provide the skills of
community rapport building and leadership, and develop an
understanding of the health system and for rights based
approach to health.
Originally consisted of 21 days of training in five module ; but
now modified to an eight day training in one Induction
Module
1.
2. Module 6 & 7- 20 day training to be completed in four
rounds. Consists of key competencies in maternal, new born,
children’s health and nutrition
12
ASHA Training
3. Supplementary or refesher Trainings
 At least 15 days of training annually planned in which new
topics and skills can be added, or to reinforce existing skills in
areas where the ASHAs need further inputs.
 The new skills would be specific to local needs such as gender
based violence, disability screening, mental health counselling,
palliative care, NCD
 PHC review meetings can be used as a forum for such training
13
Training

Module 6 &7 is underway in all states

Adherence to training protocols assure training quality of State and ASHA trainers

Gaps noted in ASHA training in few areas mainly due to logistics and poor
management issues.

On site mentoring of ASHA trainers reported only from MP and Bihar where
systematic monitoring of ASHA training is undertaken.

States of UP, Rajasthan, J & K, Kerala and Haryana lag in training ( Round 1 is
underway)

Refresher training of ASHAs in Rd 1-3 of Module 6 &7 is underway in UK

Monthly meetings used for refresher training of ASHAs in Tripura – :Varsho Divas”

Challenges –

Procurement is the biggest hurdle faced by states in timely rollout of trainings.

Timely release of funds

Shortfall of training venues at block level

Adequate skills and number of trainers

Lack of systematic monitoring of training to ensure quality
ASHAs have completed 1st 3 rounds of Module 6 &
7or more than 60% have been trained in Round 3
More than 70% ASHAs trained in round 1 and more
than 50% ASHAs have also completed round 2
Less than 50 % ASHAs trained in Round 1 and Round
2& 3 training is also underway
States where Round 1 is on going
States which have completed training of trainers
Support Structures for Community
Processes
State
• MD, NRHM
• ASHA Resource Centre
• State ASHA Mentoring group
District
• District ASHA Coordinator/ Mobilizer
• DPMU/District Health Society
Block
• Block Community Mobilizer
• Block Programme Manager
• ASHA Facilitator
Sub block • VHSNCs
16
Formation of
Position of states in 2010
Dedicated Support
Structures
Current Position of states 2013
Support Structures
at all Four Levels
Chhattisgarh , Uttrakhand
Assam
Maharashtra
Bihar ,Chhattisgarh
,Jharkhand, Madhya Pradesh,
Rajasthan, Uttrakhand,
Assam, Tripura
Maharashtra, Haryana
Three Levels
Bihar, Jharkhand, Rajasthan
Arunachal Pradesh, Meghalaya
Orissa, Uttar Pradesh
Arunachal Pradesh, Manipur,
Meghalaya, Mizoram,
Nagaland
Karnataka , Punjab
Two Levels
Madhya Pradesh , Orissa
Tripura
Delhi, Karnataka, Punjab,
Delhi, Sikkim, Gujarat
Only at one level
Uttar Pradesh
Andhra Pradesh, Gujarat, Kerala,
Andhra Pradesh, Jammu &
Kashmir
Kerala, Tamil Nadu, West
Bengal
None; Programme
managed by
Existing NRHM
Staff
Manipur, Mizoram, Nagaland,
Sikkim
Haryana, Jammu and Kashmir,
Tamil Nadu, West Bengal
Four levels
Three levels
Two levels
Only at one level
Support Structures









Substantial progress in establishing support structures across states
Except Odisha and UP, all high focus states have support structures at four
levels.
North Eastern states have 3-4 levels of support structures
Non high focus states like Andhra Pradesh, West Bengal, Tamil Nadu, Kerala,
and Jammu & Kashmir have support structures only at one level.
Capacity building of support structures is underway in most states but quality
of inputs need to be improved
ChallengesLack of mobility support
Poor feedback and handholding
Use of their time for other NRHM activities like data entry and accounts
management
Monitoring the functionality of the ASHAs

1.
Indicators to be monitored:
Newborn visits on first day of birth in case of home deliveries
2.
Set of home visits for new born care as specified in the HBNC guidelines (six visits in
case of Institutional delivery and seven in case of a home delivery)
3.
Attending VHNDs/Promoting immunization
4.
Supporting institutional delivery
5.
Management of childhood illness – specially diarrhoea and pneumonia
6.
Household visits with nutrition counselling
7.
Fever cases seen/malaria slides made in malaria endemic area
8.
ASHAs acting as DOTS provider
9.
Holding or attending village/VHSNC meeting
10.
Successful referral of IUD/female sterilization/male sterilization cases and/or providing
OCPs/Condoms
20
ASHA facilitators will collect information from ASHAs
during monthly meetings. ASHAs are not required to
keep any additional records and use their planning
tools to provide this information.
1
A compiled report is submitted by the facilitators to
the block office on a monthly basis.
Block Coordinators in turn consolidate the report
monthly and submit it to district coordinators on a
quarterly basis.
Districts will report the functionality of blocks in
terms of Grades A (>75% ASHAS functional on all
indicators, Grade B (50-75% ); Grade C (25-50%) and
Grade D (<25%) . No numbers regarding functionality
are to be reported by the district to the state
State and National level will only specify the
percentage of blocks with the grades A, B, C and D
against the total number of blocks
2
3
Performance Monitoring

Introduced in the year 2011-12 to enable identifying gaps and take
corrective actions at each level – district/ block / sub-block

Attempt is to enable a shift away from monitoring as a punitive
process – tool for supportive supervision

Regular reports received from UK, Jharkhand, Delhi, Punjab,
Karnataka and all NE states

Repeated refresher training needed, for effective use of information
and linking with health outcomes. .
Incentives and Payments

A mix of monetary and non monetary incentives:

Performance based incentives for over 30 specific tasks

Findings from surveys and evaluations show that ASHAs earn on an average – Rs.100 –
Rs. 2000 per month.

Over 90% ASHAs have bank accounts and most common mode of payment is by
cheque or e transfers

Single Window payments started in Odisha, Assam, UP and few districts of Bihar and
MP.

Fixed + Performance based incentives provided in Sikkim, Kerala, Rajasthan, West Bengal

Matching amount of the incentive earned annually given in Karnataka, Meghalaya and
Tripura (33% of the amount earned)

Payments through Gram Panchayat have been introduced in Chhattisgarh

Delays have reduced but it still takes up to 15 days – one month for payment of ASHA
incentives
23
Non Monetary Incentives
•
•
•
•
•
•
ID- cards for self esteem and helps to negotiate the health center.
ASHA help desk,ASHA rest houses,ASHA help line
Pension schemes, welfare fund,
Scholarships, Career progression avenues
ASHA Radio /ASHA newsletter,
Common uniform, Bicycle, cell phones, umbrella
Drug Kit

One time drug kit distribution made in all states but
replenishment is an issue

Stock outs of many drugs including ORS and IFA is a regular
feature

Refilling is done in an adoc manner – when ASHAs report
stock out during their facility visits, drugs are provided to them
based on availability.
Grievance Redressal
MoHFW sent guidelines to states to constitute Grievance
Redressal Committees in 2011-12.
 Status  Odhisha, Uttrakhand, Sikkim, Manipur, Nagaland, Mizoram,
Maharashtra, Gujarat, Karnataka and Kerala have set up
district level Grievance Redressal Committees as per the
guidelines
 Rajasthan, UP, Assam, AP, Haryana and Jammu & Kashmir use a
common Grievances Redressal call centre for ASHA
grievances also
 Other states are yet to initiate mechanisms for grievance
redressal.

Village Health and Sanitation Committees



Over 500,000 VHSNCs across the country; GP/Revenue village level
Key platform for social determinants and convergence at village level
Experience demonstrates effective VHSNC functioning where ASHA has a
convening role- mutually supportive

Lack of support / training / hand -holding
districts/ states where NGOs were involved.

Revised Community Process launched in 2013
States are expected to restructure existing VHSNCs accordingly – to enable
active participation of PRI and role of member secretary for ASHAs.
Draft Training manual for trainers and VHSNC members is being devleoped.


for VHSNCs except in few
Mahila Arogaya Samiti (MAS)


One MAS for every 50 to 100 HHs (4 MAS in every ASHA’s
area)
Annual grant of Rs.5000 from NUHM to each MAS every year.
Strong focus on using or aligning with existing community
groups  Community structures like Neighborhood Groups (NHGs) and
Neighborhood Committee (NHC) created under the Swarna
Jayanti Shahari Rojgar Yojana (SJSRY)
 Women and Children in Urban Areas groups of at least 10
urban poor women and Thrift Credit Groups (TCG)

Involving NGOs and Civil Society Organizations



As Additional Technical Capacity and as Innovators
Active Participation in ASHA Mentoring Groups
Being National Training Sites





. Bihar : training is NGO led, consortia based – at state and district levels
West Bengal and Uttarakhand: building on the mother NGO scheme
Training programmes for VHSNCs in almost all states
wherever it has happened.
Enabled community monitoring
But still there is much more scope……streamlining
mechanisms for selection and funding needed
ASHA Programme in Gujarat









Selection – 31839 ASHAs – 90% of the target (35237)
Training Quality of training varies across districts - Training methodology altered –
20 days training completed in 5-10days in some districts.
Full time availability of trainers is an issue – mostly from government health
departments who find it difficult to devote time for training.
Need to expand the pool of trainers to enable monitoring and ensure quality
Refresher training in skills of Module 6 & 7 for all high focus districts/
blocks
Rapid assessment of Module 6 & 7training in all non high focus districts is
an immediate priority – to be followed by need based refresher training of
ASHAs
Kits – Drugs and HBNC – available but replenishment is an issue
Payments – Process streamlined yet delays reported – varies across
districts.
ASHA Programme in Gujarat

Support –

Using existing structures at district and block level – but that seems to be working well

Since all ASHA facilitators are not trained in training modules of ASHAs, quality of
mentoring support was found to be poor.

Training of all ASHA Facilitators should be done in induction module and Module 6 &
7 + Handbook for ASHA Facilitators

Regular monthly meetings of ASHAs conducted by PHC MOs – Can be used for
refresher training sessions.

Performance Monitoring – yet to be introduced

Need to expand the role of Civil Society –

Taking trainers or sites from NGOs (for ASHA/VHSNC)

Regular AMG meetings and allocation of districts to members

Community monitoring
ASHA certification programme
Worked out in coordination with National Institute of Open Schools.
 Certification of Training sites, trainers, Training curriculum, ASHA
Facilitators and ASHAs
Levels  Level-1 Entry Certification: Those already on the job – more like an
identity and entry for phase 2.
 Corresponds to modules 1 to 5 or 8 day induction module.
 Level 2: Intermediate Certification: corresponds to skills in Modules
6&7
 30% on internal- post training evaluation and assignments
 40% on practicals- internal with some degree of externality- and
 30% written examination: purely external.
 Level 3 Certification: special skills- general community health nurse;
mental health, disability, advanced RCH etc.

33
Matching aspirations, work loads and skills.

Increase Career Opportunities : the CP facilitator, AWW, ANM,
paramedics, Elected panchayat members & Community Health Nurses

As we approach 30 hours of work ( 6 hours per day * 5 days per week)
we need to consider Level- 3 certificate and a regular income.

As work exceed 40 hours of work a week ( 8 hours per day * 5 days
per week) we need to consider a second ASHA

Need to plan for a transition over two plan periods from a CHV or
a CHW programme to a Community Health Nurse Programme

New roles for ASHAs - Non-communicable diseases, disability screening,
palliative care and addressing violence against women at the community level etc.
34
Thank You