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Assessment of ASHA and
Janani Suraksha Yojana
■
in Rajasthan
.•
C()RT
M esearch th<st makes z diffeience
402, Woodland Apartment
Race Course Circle
Vadodara - 390 007.
April, 2007.
Bella Patel Uttekar
Sandhya Barge
Wajahat Khan
Yashwant Deshpande
Vasant Uttekar
Jashoda Sharma
Balaji Chakrawar
Shweta Shahane
Preface
JSY, Janani Suraksha Yojana, is an integral component of the National Rural Health
Mission, launched in April 2005. JSY aims to reduce maternal and neo-natal mortality by
promoting institutional deliveries, focusing on women living below the poverty line (BPL).
Another core strategy of the NRHM is to have a female Accredited Social Health Activist
(ASHA) for every village with a 1,000 population to act as an interface between the
community and the public health system. As a volunteer she receives performance-based
compensation for promoting a variety of primary health care services such as referral and
escort services for institutional deliveries, universal immunization, DOTS treatment for
tuberculosis or construction of sanitary toilets.
In response to a request by the Ministry of Health and Family Welfare (MoHFW) to assess
JSY in Rajasthan, the United Nations Population Fund (UNFPA) commissioned the Centre
for Operations Research and Training (CORT) to conduct the study. The aim was to assess
the current status of the ASHA intervention and JSY in three districts of Rajasthan, namely
Bhilwara, Jailsalmer, and Udaipur. The present report documents the process of
implementation of the ASHA intervention and JSY, involvement of ASHA’s, and services
and payments received by the JSY beneficiaries, and highlights program implications that
need to be addressed in order to further improve JSY. This document aims to provide
useful information for policy makers and programme managers at the national and state
levels for further strengthening the scheme as well as to develop training and IEC
strategies and campaigns. It may also be pointed out here that the study was conducted
in the initial stages of the programme being implemented in the state which has been
undergoing modifications and the situation remains dynamic. As far as possible we have
tried to incorporate all the themes, but in case of any lapses we are responsible for the
same.
We are also very grateful to Mr. K. D. Maiti, Director, Ministry of Health and Family Welfare
for his valuable inputs in framing the questionnaire and analyzing data. We would also
like to acknowledge Dr. Dinesh Baswal, ASHA Training Coordinator at national level and
Dr. Subhra Singh, Director NRHM, Rajasthan, DHO of the selected districts and Managers
of DPMU for all the support extended by them.
At the outset, we take this opportunity to thank the UNFPA for having entrusted the work
of conducting the assessment to CORT. Our sincere thanks are due to Mr. Venkatesh
Srinivasan, Assistant Representative, Dr. Dinesh Agarwal, Team Manager, Technical
Support Unit and Dr. K. M. Sathyanarayana, Technical Advisor (Management), for the
cooperation extended to us during the various stages of the study. We appreciate their
inputs in helping us develop the research tools, in administering the study in the field and
commenting on the draft report. We are especially thankful to them for their meticulous
work, quick replies and patience. We also appreciate and thank Mr. Hemant Dwivedi, and
Mr. Sunil Thomas from the UNFPA office in Jaipur for all the support extended.
We thank our respondents - officers at the state, district and block levels, PRI members,
ASHAs, ANMs, community members and of course the JSY beneficiaries without whose
cooperation it would not have been possible to complete the study successfully.
I wish to put on record my deep appreciation for Dr. Bella Patel Uttekar, the Principal
Investigator of this project, and all the team members for contributing their might in the
success of this project and thereby ensuring quality.
Prat. M. M. Gandotra, Director
e for Operations Research and
i n g i CO R f i. v dod a r a
Contents
Executive Summary
i-vi
Chapter 1: introduction
The background..............................................
1
Objectives of the study..................................
2
Study design.....................................................
The Sample.......................................................
3
3
3
Interviews of ASHAs..........................
3
Interviews of beneficiaries with JSY
Study tools.......................................................
4
4
4
Field operations..............................................
5
Ethical considerations...................................
5
Data management and analysis.................
5
Presentation of the report...........................
5
Study area.........................................................
Other stakeholders.............................
Chapter 2: Operationalization of ASHA Intervention and JSY
Adoption of ASHA Intervention
. 7
Adaptation of JSY guidelines ...
1 1
Swasthya Chetna Yatra.............
1 5
Chapter 3: Engagement of ASHA in the National Programmes
Background characteristics of ASHA..............................
About ASHA: Their selection and motivation to work
Training of ASHA...............................................................
Quality of training .............................................................
Payments during training...................................
Use of reading materials....................................
17
19
20
21
21
22
Knowledge of ASHA
Antenatal and child care services.................................
Pregnancy, delivery complications and action/s.......
Knowledge about newborn care....................................
Knowledge about tasks to performed by ASHAs.......
Organization of work by ASHAs....................................
Availability and utilization of drug kits........................
22
22
23
24
25
25
ASHA’s clientele........................................................................
Cash remuneration received as ASHAs...............................
Interface and monitoring of system....................................
Support mechanism and networking of ASHA .................
Strengthening of ASHA intervention as perceived by JSY
26
27
28
29
32
Chapter 4: Beneficiaries of JSY in Rajasthan
Background information of JSY beneficiaries....................................
Awareness about JSY ..............................................................................
Process of registration under JSY .......................................................
Utilization of ANC services by JSY beneficiaries...............................
Role of ASHA in micro-birth planning................................................
Intention and actual place of delivery.................................................
Motivation and decision making for institutional delivery............
Process of arranging transport to reach health institution............
Difficulties faced in reaching place of delivery................................
Persons accompanying JSY beneficiaries to the health institution
Quality of services available at the place of delivery ......................
Payments incurred for services at the health center.......................
Satisfaction with the services at the place of delivery.......................
Persons who assisted delivery and views about TBA.......................
Dynamics of delivery at home..............................................................
Mode of payments and difficulties faced...........................................
Use of cash assistance received for delivery.....................................
Appreciation of JSY by the beneficiaries............................................
Impact of JSY on institutional delivery................................................
Role of ASHA in JSY.................................................................................
35
36
37
37
38
39
39
40
41
42
42
43
.43
44
44
46
47
48
48
49
Chapter 5: Recommendations
Summary of findings.......
Recommendations...........
Policy...................................
Programme management
Demand generation........
51
52
52
53
55
Annexure 1: Tables based on background characteristics of the
JSY beneficiaries.....................................
Annexure 2: Government of Rajasthan - Office Order..................
57-67
69-79
List of Tables
4
Table 1.1:
Sample covered for qualitative component in Rajasthan, 2007
Table 2.1:
Number of ASHAs selected and trained in Rajasthan
10
Table 2.2:
upto October, 2006...................................................................
Cash assistance package for JSY beneficiaries in Rajasthan
Table 3.1:
Profile of ASHA functionaries in Rajasthan, 2007 .....................................
18
Table 3.2:
Duration of work and earning of ASHAs in Rajasthan, 2007 ..................
19
Table 3.3:
Motivation for being an ASHA in Rajasthan, 2007 ....................................
Table 3.4:
Topics covered in the training of ASHA in Rajasthan, 2007....................
19
20
Table 3.5:
Teaching aids used for training of ASHAs in Rajasthan, 2007...............
21
Table 3.6.
Payments received during training by ASHA in Rajasthan, 2007 ..........
21
Table 3.7:
Knowledge of ASHAs about pregnancy and their management
23
Table 3.8:
in Rajasthan, 2007 .......................................................................................
ASHA’s Knowledge about common complications during delivery
that could result into maternal mortality, Rajasthan, 2007....................
23
Table 3.9:
12
Knowledge about likelihood of neonates dying after birth in
Rajasthan, 2007 ............................................................................................
24
Table 3.10: Feeling of working as ASHA in Rajasthan, 2007 ......................................
25
Table 3.11: Brief details of ASHAs interaction with her last client, Rajasthan, 2007
27
Table 3.1 2: Cash remuneration received by ASHA in Rajasthan, 2007......................
27
Table 3.13: Networking of ASHA with other stakeholders in Rajasthan, 2007
Table 3.14: Suggestions for further strengthening their work as ASHAs and
29
challenges faced by ASHA in Rajasthan, 2007.................................
33
Table 4.1:
Background information of JSY beneficiaries, Rajasthan, 2007....................35
Table 4.2:
Sources of information about JSY in Rajasthan, 2007.................................... 36
Table 4.3:
Process of registration under JSY of the beneficiary in Rajasthan, 2007.... 37
Table 4.4:
Number of ante-natal check-ups during index pregnancy,
38
Table 4.5:
Rajasthan, 2007 ...........................................................................................
Role of ASHA in micro birth planning for JSY beneficiary,
Rajasthan, 2007 ...........................................................................................
38
Intend vs actual place of delivery, Rajasthan, 2007 ...............................
Motivation for institutional delivery among JSY beneficiaries who had
39
institutional delivery, Rajasthan, 2007.....................................................
39
Table 4.6:
Table 4.7:
Table 4.8:
Process of arranging transport to reach health institution,
40
Table 4.9:
Rajasthan, 2007 ...........................................................................................
Duration of time to arrange transport and travel to place of delivery,
Rajasthan, 2007...........................................................................................
41
Table 4.1 0: Persons accompanying JSY beneficiaries to the health institution,
Rajasthan, 2007 ..........
Table 4.11: Average hours after delivery women was discharged, Rajasthan, 2007
Table 4.12: Payments incurred for services at the health centre, Rajasthan, 2007..
42
42
43
43
Table 4.13: Satisfaction with the services at the place of delivery, Rajasthan, 2007
Table 4.14: Persons who assisted home delivery and views about TBA,
Rajasthan, 2007................................................................................................... 44
Table 4.1 5: Background information of JSY beneficiary, Rajasthan, 2007....................... 44
Table 4.1 6: Perceived reasons for women to deliver at home despite cash assistance
being paid under JSY for institutional delivery, Rajasthan, 2007................. 45
Table 4.17: Payments made for JSY beneficiaries, Rajasthan, 2007................................. 46
Table 4.1 8; Shift the place of delivery before and after JSY in Rajasthan, 2007............. 48
Table 4.1 9: Performance of institutional deliveries in public sector,
Rajasthan 2004-7
49
List of Figures
Figure 3.1 :
Scoring knowledge of ASHAs in Rajasthan ...
22
Figure 3.2 .
ASHAs awareness about her responsibilities
24
Figure 3.3 :
Network of ASHA with stakeholders
(Percent meeting with the stakeholders)....
29
Figure 4.1 :
Figure 4.2 :
Time when the beneficiary heard about the JSY................
Sufficiency ofcash incentives received by JSY beneficiary
36
47
Executive Summary
Towards achieving the objectives of the National Rural Health Mission (NRHM), Janani
Suraksha Yojana was launched in April 2005 to promote institutional deliveries
among the poor population, through provision of referral, transport, and escort
services. JSY integrates cash assistance with delivery and post delivery care for women
to have healthy outcomes of pregnancy and childbirth. The NRHM aims to have a
village-based female Accredited Social Health Activist (ASHA) to act as the interface
between the community and the public health system and negotiate health care for
poor women and children. The Ministry of Health and Family Welfare (MoHFW)
decided to undertake an assessment of JSY. The Centre for Operations Research and
Training, CORT, based at Vadodara conducted this assessment of JSY for UNFPA and
the MoHFW to understand the process of implementation of the programme,
involvement of ASHAs and experiences of JSY beneficiaries. This report is based on
the qualitative and quantitative assessment of JSY in Rajasthan covering three districts
of Bhilwara, Jaisalmer and Udaipur.
Using semi-structured study tools, 173 ASHAs and 248 JSY beneficiaries were
interviewed through a quantitative survey. In-depth interview were conducted with
key stakeholders at state, district and block level related to JSY.
Impie mentation of J SY
A major modification in the national guidelines was the state’s decision to bring in
intersectoral convergence with the Department of Women and Child Development to
involve 32,000 Sahyogini, an additional human resource working in the Anganwadi
center to help the AWW, as ASHA Sahyogini and to recruit the balanced around
1 1,000 ASHAs to ensure complete coverage of the state by March 2007. Two state
officials - ASHA nodal officer and JSY nodal officer implement the programme at the
state level. ASHA Mentoring Croup and a State Resource Unit play a major role along
with District Project Management Unit (DPMU) to implement and monitor the progress
on regular basis. JSY helpline was established in selected blocks to promote prompt
emergency referral and ensure safe delivery of women with obstetric emergencies at
the health facilities.
As per the national guidelines, all the pregnant women delivering in government
institution or accredited private institutions are eligible for getting JSY benefits. For
BPL pregnant women, cash assistance of Rs. 500 is given for delivery at home.
PRIs were involved in implementing the scheme and managing the untied fund of Rs.
10,000 at the Village Panchayat level along with the ANMs. The Cram Sabha and
sarpanch selected and introduced ASHA to the village, supported their work, and
helped in developing village health plan and organizing village health day. At the
village level, ASHAs worked under the guidance of sarpanch, ANM, AWW, and SHG and
in collaborations provided ANC and PNC services.
ASHAs are supposed to be daughter-in-law from the village, who is at least eighth
standard pass and aged between 25 and 45 years. Rajasthan faced problems in
identifying eligible ASHAs with eighth standard pass, particularly in remote and tribal
areas.
The State Institute of Health and Family Welfare (SIHFW) organized training of state
trainers for four days. First round of training of around 30,000 ASHAs of 7 days
residential training, mostly organized at the district and block level, was completed in
the state by December 2006. State, district, and block level officers of Medical and
Health Department and DWCD monitored the implementation of training of ASHAs.
ASHAs were given reading materials presenting their roles and responsibilities during
training.
In Rajasthan, Swasthya Chetna Yatra (health awareness rally) was organized in
December 2006 to propagate and publicize the JSY. The rally covered all the villages
of Rajasthan. Largely because of this rally, the community was now aware of JSY and
involvement of ASHA.
Private institutions have yet to be accredited, but each of the ASHAs were briefed
during training about the nearest functional health facility for referral services.
Monitoring and supervision was happening at all the levels, yet there is a need to
develop a simple and sustainable monitoring system. One of the suggestions is that
ASHAs need to attend all the monthly meetings at PHC.
Involvement of ASHA in the National Programme & JSY
Most of the ASHAs are young, educated and married staying in the same village where
they were functioning. Of the 1 73 ASHAs interviewed, 1 6 percent did not fulfill one or
the other eligibility criteria. Before JSY, two-thirds of the ASHAs themselves delivered
their child at home.
On average, the respondents worked as ASHA for 7.1 months. Earlier, several of them
were working as ASHA Sahyogini. It was revealing that 55 percent of ASHAs had not
received any payment until the date of survey, though most of them worked as ASHA
since four months or more. On average, ASHA who were paid, received rupees 339.1
monthly from working as ASHA.
Over half of the respondents first came to know about the ASHA from ANM and nearly
a quarter from the anganwadi supervisor/worker. Government doctor, health
personnel, gram panchayat or hoardings kept at public health centre also informed
them about ASHA.
Netaji, politician, sarpanchh or Gram Sabha selected fifty-three percent ASHAs. ANMs,
doctor, village elders, husbands, father-in-law, CDPO and block facilitators played a
role in selection of ASHAs. In most cases (97 percent) Gram Sabha approved their
name. The main motivation to be ASHA was to serve/help the community
(73 percent), earn money (30 percent) and learn new things (1 0 percent).
In Rajasthan, training of ASHAs was done, on average, 6.4 months ago for six days.
Except for some logistic arrangements at the place of training, ASHAs appreciated the
training including trainers and training methods as good and useful. The study brings
out need to reorient ASHAs on topics such as disposal of wastewater, nutrition,
NRHM, reproductive and sexual health, and management of diarrhea and pneumonia.
Of the 165 ASHAs who attended training, 83 percent received their allowance during
training. Only 9 percent of the ASHAs received the total amount, which was due to
them. On average, they received rupees 605. Informal discussions with the trainers
~ . U
100' .per day
and finance personnel revealed that the ASHAs were given Rs.
' . rfor
the
distance
she
travelled
(instead
of
attending training and transport depending on
Rs. 1 00 irrespective of the distance travelled as per the guidelines.
Nearly 86 percent of the ASHAs had
reading materials for the implementation
and promotion of JSY and two-thirds of
them were largely able to follow the
reading materials. Majority of the ASHAs
scored Grade A or O for answering 8 to
1 0 out of 1 0 questions correctly.
Scoring knowledge of ASHAs in
Rajasthan
Grade B
29%
Grade A
59%
Grade C
6%
Grade
ASHAs knew about the complications
'O'
during pregnancy, but less than 7
6%
percent talked about abdomen or body
pain, weak movement or abnormal position of foetus. In such situation, ASHAs said
that they would immediately refer the pregnant woman to the nearest functional FRU,
while surprisingly 45 percent said that they would ask the pregnant woman to consult
the ANM the next day. Only 8 percent ASHAs would ideally accompany women with
complication to the hospital and only one ASHA said she would provide money for
transportation to the women. ASHAs need to put into practice their knowledge about
ANC care while providing services and/or advise.
The main responsibilities of ASHAs are to accompany delivery cases (83 percent),
create awareness on health/HIV, counsel, village health planning, and mobilize
community to utilize health services. Only a few ASHAs mentioned about family
planning, registration of birth and death, and timely referrals. ASHAs visit house to
house, besides attending immunization session and accompanying ANM and women
for delivery.
Only one-fourth of the ASHAs received the drug kit, and majority had used the
medicines available in the kit within the last fortnight
ASHAs do provide constellation of services and play a potential role in providing
primary medical care as their last client came seeking services related to
immunization, advice about place of delivery, receiving IFA tablets, medicines for
primary care. They also came for registration of vital events, collect information about
family planning, and to collect cash assistance as JSY beneficiaries.
iii
Eighty-six percent of the ASHAs had accompanied an average of 1.2 JSY cases for
institutional delivery, mainly to CHC or PHC. Forty percent of the total ASHAs stayed
with JSY beneficiaries at the place of delivery.
According to ASHAs, when women go to their natal place for delivery, they would get
benefits at their natal place, and ASHAs at women’s natal place would take care. Only
5 percent ASHAs mentioned that they would give JSY card from the village and referral
slips so that women could receive the cash assistance at the place of delivery.
ASHAs network with the various stakeholders in the village to implement JSY. Ninety
percent of the ASHAs met AWW almost daily, with ANM the meeting was once a week
(42 percent), fortnightly (1 8 percent), or once a month (36 percent).
Only 42 percent of the ASHAs did receive some cash incentive money as ASHAs for
immunization of children and half of them for attending JSY beneficiaries. The mean
monthly amount received for attending JSY beneficiary in three months varied between
Rs. 294-421 (ranging between 1 00-800) and for immunization of children between Rs.
150-187 (ranging between 100-550). Some of the ASHAs expressed that they were
unsatisfied or indifferent with the cash assistance as it was ‘too much of work and too
little money’ll percent), or money was not available timely (1 5 percent).
ASHAs also spent 4 hours every week in preparing various registers and ASHA s work
was mostly monitored by the ANMs and AWWs. Supervisory support from other
officials was lacking.
Beneficiaries of JSY in Rajasthan
The JSY beneficiaries interviewed were young and mostly those who had no formal
education (68 percent) or had schooling up to middle level (22 percent). One-third of
the JSY beneficiaries belonged to SC/ST and one-half to the other backward classes. It
can be said that JSY was reaching to the socio-economically lower strata of women
covering poor segment of the society.
The beneficiaries learnt about JSY during various stages of pregnancy, or even after
the delivery, from ANM, ASHA, doctor or AWW and got themselves registered under
JSY. One-third of the JSY beneficiaries got registered in the first trimester, and on
average, women had 4 antenatal check-ups during their index QSY) pregnancy. Since
ANC card showing that the women had taken full ANC was required for claiming
payment of cash assistance, women ensured that they go for 3 or more ANC check
ups at CHC or PHC. Husbands, mother/sister-in-law, and ASHAs accompanied the
beneficiary for ANC visit(s). One-tenth of the women received antenatal care at home.
• beneficiaries
■
- ■ ■ ; were informed about 4 or more aspects (out of 5)
Only 40 percent of- the
of micro-birth planning. Nine percent JSY had no discussions on any aspect of the
micro-birth planning.
IV
Talking about the actual
place of delivery, 30 percent
Place where last delivery of JSY
beneficiary took place
had delivery at home as
Total
At home
Institutional
against 41
percent who
Intended place for last delivery
intended to deliver at home. Institutional
59.3(147)
4.5
54.8
40.7 (101)
25.8
14.9
A statistically
significant At home______________ _____
30.3 (75) 100.0 (248)
69.7 (173)
shift can be noticed among Total______________________
1 5 percent of the beneficiaries who intended to deliver at home but shifted to
institution. It is challenging to change the mindset of the women (and their families)
who intended to deliver at home and did so. Majority of the deliveries took place in
CHC/PHC.
Cash assistance, better access to institutional delivery, support provided by ASHA and
other health personnel and safety of both mother and child were the main
motivations for opting for institutional delivery. These were the main reasons for 62
women who had their previous birth at home to shift to institution for the index
delivery.
In Rajasthan, JSY beneficiaries had to travel, on average, 11.6 kms to reach the
ultimate place of delivery. Women spent approximately one hour to arrange transport
and reach the ultimate place of delivery and another 25 minutes after reaching the
institution on registration and administrative process and as waiting time until
someone attend them.
ASHAs accompanied 1 8 percent of the women to the health institution for delivery
despite it being one of their main responsibilities under JSY, while another 20 percent
women were accompanied by dai, ANM and anganwadi worker. Out of the 31 JSY
beneficiaries accompanied by ASHA, most (90 percent) said that the presence of ASHA
facilitated in obtaining services at the place of delivery. They helped in expediting
registration and other administrative activities, spoke to the medical personnel, and
helped in getting JSY cash incentive, besides psychological and moral support.
On average, women were discharged in around 1 5.2 hours after normal delivery, for
assisted delivery in around 2 days and for caesarean after 6 days.
Nearly 85 percent of the beneficiaries received payment and they all received it in one
go (but much later) from the ANM or PHC/CHC doctor. The JSY beneficiaries spent an
average of Rs. 1409 during ANC period, Rs. 280.2 for transportation to the place of
delivery and Rs. 1277.6 for delivery, against which they received an average of Rs.
780.3 from the government as cash assistance.
The process of paying cash assistance to the JSY beneficiary was not so simple. The
accountant at the place of delivery checked for ANM’s and ASHA’s signature,
discharge slip signed by the MO-IC, ANC card to ensure that the women received full
ANC care and ration card. Requirement of the ANC card showing full ANC services
could be one of the reasons for high levels of ANC check-ups.
v
Most of the women were satisfied with JSY and would recommend relatives or
friends/neighbours to be a beneficiary under the JSY, mainly because they did receive
cash on filling up form to meet expenses iincurred
--------------at hospital. Besides, they had safe
delivery in the hospital.
All the JSY beneficiaries interviewed were asked about reasons why women prefer to
deliver at home despite cash assistance paid under the JSY. Major reasons for not
preferring institutional delivery were fears - fear of hospital, injection, needles,
equipments, doctor, nurse, dai, stitches, caesarean or bad omen; lack of cleanliness
maintained at hospital, no importance of institutional delivery, and opposition from
family members.
I
Shift in the place of delivery before and after JSY (Percentage^
Particulars
Place of delivery for last but
one child
Institutional
Home
Total
Place of delivery for last (JSY) child
Total
Home
Institutional
27.7 (46)
37.4 (62)
65.1
(108)
4.8 (8) 32.5 (54)
30.1 (50) 67.5 (1 1 2)
100.0
34.9
(166)
(58)
Out
of
the
166
JSY
beneficiaries who had two or
more children, 67 percent of
the
previous
delivery was
reported delivery at home. Of
the total 166 women, 28
with
percent
continued
institutional delivery and 30
percent with delivery at home. Interestingly and encouragingly, a major shift from
home to institutional delivery was noticed between two pregnancies among 37
percent of the total JSY beneficiaries.
The study also shows that the women with no formal education or those who had
studied up to primary level and those belonging to SC/ST go for home deliveries.
Even among literate and high caste Hindus, one in every 5-6 women deliver at home.
Study revealed that grassroots level health functionaries were reaching this group to
motivate them for ANC and institutional delivery, but it is a challenge to motivate
them for institutional delivery.
vi
Chapter 1
Introduction
The Background
The Government of India launched the National Rural Health Mission (NRHM) in 2005.
The aim was to provide accessible, accountable, affordable, effective and reliable
primary health care, especially to the poor and vulnerable sections of the population.
The Mission envisages equitable, and quality health care services to rural women and
children in the country with greater emphasis on 1 8 highly focused states. It adopts a
synergistic approach by encompassing non-health determinants that have a bearing
on health such as nutrition, sanitation, and safe drinking water. The mission aims to
achieve greater convergence amongst related social development sectors.
One of the core strategies proposed, to accomplish the goals, was to have a female
Accredited Social Health Activist (ASHA) for every village with a 1,000 population. It
was suggested that ASHA would be chosen by and would be accountable to the
Panchayat. She would act as an interface between the community and the public
health system. As an honorary volunteer, ASHA would receive performance-based
compensation for promoting variety of primary health care services in general and
reproductive and child health services in particular such as universal immunization,
referral and escort services for institutional deliveries, construction of household
toilets, and other healthcare interventions.
In order to enable the states for proper implementation, ASHA guidelines were
formulated by the Ministry of Health and Family Welfare (MOHFW), Government of
India (GOI) wherein institutional arrangements, roles and responsibilities, integration
with ANM and Anganwadi, working arrangements, training, compensation, fund-flow
etc were discussed. The training modules and facilitators guide were prepared and
shared with the states for rolling out the trainings. The guidelines accorded flexibility
to the states in designing the operationalization of the intervention. Many states
modified the guidelines depending on the local context to suit their requirements, in
the true spirit of the NRHM guidelines of decentralized programme management.
On the other hand, as an integral component of NRHM, the Honorable Prime Minister
of the Country launched safe motherhood intervention in the form of Janani Suraksha
Yojana (JSY) for reducing maternal and neo-natal mortality on April 12, 2005. The
scheme aims to promote institutional deliveries among poor pregnant women in all
the states and Union Territories (UTs) of the country with special focus on low
performing states (LPS). It is a central government sponsored scheme and links cash
assistance with delivery and post-delivery care. In availing institutional delivery
services, the client needs to be escort, need transport to reach the institution and in
case of complications, referral services are required. The scheme considered all these
elements and made provision for transport including referral and escort (by ASHAs)
and at the same time invested in improving public health institutions and services
through the Reproductive and Child Health (RCH) Programme interventions. Moreover,
states have flexibility to evolve public-private partnership (PPP) mechanism and
accredit private health institutions for providing institutional delivery services. As
stated earlier, special dispensation was made for IPS in both rural and urban areas
and was linked to the ASHA intervention.
The LPS are states that have low institutional delivery rates and include Assam, Bihar,
Chhattisgarh, Jammu and Kashmir, Jharkhand, Madhya Pradesh, Orissa, Rajasthan,
Uttaranchal and Uttar Pradesh. In the remaining states and UTs categorized as High
Performing States (HPS) similar provisions were made wherein Anganwadi worker,
traditional birth attendant or ASHA like activist could be engaged and be associated
with JSY. To facilitate the states in implementing JSY, a set of guidelines articulating
the criteria of eligibility of beneficiaries and provisions were worked out in detail. The
guidelines have undergone revisions and certain clauses have been modified for both
LPS and HPS states.
Both ASHA intervention and JSY are in operation for over a year and the IPS are in
different stages of implementation. To understand the status and the processes of
implementation in the states of Rajasthan, Madhya Pradesh and Orissa, MOHFW
sought assistance of UNFPA. UNFPA prepared the Terms of Reference for the study
and commissioned it through a professional research agency Centre for Operations
Research and Training (CORT) based in Vadodara, Gujarat.
Objectives of the Study
The common objectives for both ASHA and JSY were as under:
1. review adaptation of the national guidelines by states and operation of the same
2. study programme management processes (planning, MIS and supervisions, etc.)
and institutional arrangements established for implementation of the schemes.
3. analyze funds flow mechanisms from state to district and to lower levels of service
delivery system and reimbursement.
4. ascertain the level of understanding about these two schemes amongst the
programme managers, service providers and other stakeholders
5. map community perceptions about the two schemes
For ASHA intervention study attempted to:
I
1. assess adherence with guidelines for community involvement / NGOs / CBOs in
the selection of ASHA
2. review the training strategy including design, plans, material developed, training
of trainers, quality of training and post-training follow-ups
3. analyze support of health system to ASHA
4. study engagement of PRI, NGO, SHGs and other CBOs engagement in extending
support to ASHA
gauge satisfaction of ASHAs with the delivery of scheme including that related to
5.
compensation / reimbursement.
2
For JSY, specific objectives were as under:
1.
2.
3.
4.
assess adequacy and simplicity of the processes set out by the state for claiming
benefits under JSY
examine the utilization of the scheme and analyze factors influencing impeding
utilization
review engagement of private sector including accreditation and compensation
analyze nature and scope of IEC interventions for raising awareness of JSY.
Study Design
The assessment of ASHA and JSY adopted a blended methodology and included
application of quantitative and qualitative techniques. The study covered three
districts of Rajasthan, selected on the basis of performance and represented good,
average and not so good performing districts. Secondary data on ASHA training and
JSY beneficiaries was collected, analyzed and categorized. After discussion with state
officials, the study districts were finalized. Likewise, procedure of district-level
consultation was undertaken in each of the selected district to select the two blocks.
Thus, in all six blocks from three districts were covered in Rajasthan.
Study Area
The report is based on the
assessment study conducted
in
Rajasthan
covering
Bhilwara,
Jaisalmer
and
Udaipur districts.
PUNJAB
RAJASTHAN
District Map
A
P
A K I
S
T
A H
Hanuman^arh
HARYANA
Chunj
Jhunjhu.'iun'
ftikaner
rx
e
•
DT I AR
PRADESH
3f
Jaisalmer
03';: 3
The Sample
Bhargtp'Jf
Jaipur
Ohauipur
The sample covered in the
rarauli ■i’
Toni.
■.3«’3i tufediwpur
state included ASHAs and
Pali
Banr.-r
Bundi
beneficiaries of JSY. Several
Bhihcara
■ ■' Jalor
,
.
1
Baran
people associated with the
Kaisarr.aM
- /Kota
$ir>hi
scheme such as state and
Cjiittdu'garti
Jhalamar
Udaipur
district
programme
Oahgarpu! • ’
'
managers,
block-level
MADHYA PRADESH
Ban^ara
< Study Districts
providers, trainers of ASHA,
Auxiliary
Nurse
Midwife
(ANMs), members of Panchayati Raj Institutions (PRIs), AWW, Community Based
Organizations (CBOs), and community members were interviewed and included in the
I
study.
Interviews of ASHAs: From each of the six study blocks, 30 ASHAs fulfilling the
selection criteria were interviewed. To cover 30 ASHAs, 30 villages were visited in
each of the study block, which included one CHC village, 2 PHC villages, 9 sub-centre
villages (3 SCs within each selected PHC/CHC), and 18 remote villages (2 remote
villages from each of the selected sub centre). In all, 173 ASHAs who had undergone
first round of training and had been active in the six months prior to the survey were
interviewed, while the remaining seven were not available or had opted out.
3
Interviews of beneficiaries of JSY A sample of 240 beneficiaries at the rate of 40
beneficiaries per block who had availed benefits of JSY in the six months prior to the
survey were included in the study. From each of the study block, 40 JSY beneficiaries
were interviewed. Altogether, 248 JSY beneficiaries who availed services under the
scheme could be contacted and interviewed.
Other stakeholders: In addition to quantitative survey of JSY beneficiaries and ASHAs,
other people including state and district programme managers, block-level providers,
CBOs, AWWs and community members were also
trainers of ASHA, ANMs, PRIs,
I
interviewed (Table 1.1).
The State Secretary-Family Welfare and
MD-NRHM, Director, Family Welfare; and
ASHA and JSY nodal officials were
interviewed. Specific questions related to
the
implementation
of the
scheme,
processes involved and challenges faced
■MhI
Type of stakeholders
Qualitative study
State officials
District level officers
Block level provider
Trainers of ASHA
PRI/NGO/SHGs/AWW
ANMs
Community based
organizations
Community members
Quantitative survey
ASHA functionaries
| JSY Beneficiaries
Number of stakeholders
interviewed
5
15
17
8
24
49
13
were addressed to them. The state
mentoring group for ASHAs was also
approached and discussions regarding
adaptation of national guidelines, selection
and training of ASHA, suggestions and
26
challenges were held. District officials and
three block development officers were
173
interviewed regarding the utilization of the
248
scheme, profile of the beneficiaries, and
steps required for future improvement of the programme. In each block, ASHA
trainers and facilitators were approached to understand the implementation of the
training programme, participation of the ASHAs as trainees, training pedagogy and
logistics. Again, at block level, members of Panchayati Raj Institutions, NGOs, and
Self-Help groups, CBOs, ANMs and AWWs were interviewed to assess the networking
of ASHA, its benefits and challenges.
Awareness and understanding of the scheme at the community level is important for
effective utilization of the scheme. Key informants from the community including
both male and female in each district were asked about their awareness of the
programmes, attitude, and utilization.
Study Tools
In collaboration with the professionals from UNFPA, Ministry of Health and Family
Welfare, and GTZ, CORT developed the study tools. Several questions were openended. For qualitative in-depth interviews, guidelines were used for collecting the
requisite information from the stakeholders. These guidelines facilitated in the
comparison and analysis of data across respondents within the state. The type of
queries differed depending on the type of stakeholder including adaptation of the
national guidelines, programme management processes, funds flow mechanisms,
community perceptions about ASHA and JSY.
4
Field Operations
Experienced Field Manager and Field Coordinators from social sciences coordinated
the entire fieldwork. Fifteen field investigators, males and females were trained at
Baroda for 5 days to conduct the fieldwork. CORT and UNFPA professionals briefed
them at Udaipur before launching the fieldwork in January 2007.
At the grassroots level, female field investigators interviewed JSY beneficiaries.
Supervisors checked the selection of the eligible sample and ensured that the
questionnaires were filled accurately and completely. UNFPA professionals actively
participated during the fieldwork, facilitated the fieldwork and helped in ensuring the
quality of data. Back-checks were conducted to ensure consistency in the data at site
thereby ensuring quality, validity and reliability.
Ethical considerations
MOHFW and UNFPA informed the authorities of the selected states, districts and
blocks about the study and the need to share the information about ASHAs and JSY
beneficiaries with the research team of CORT. The field coordinators ascertained that
consent procedures were pursued and that privacy and confidentiality was ensured
during interviews to minimize the potential for distress, if any. The research staff did
not share individual information obtained during the study with the staff of any other
organization.
Data Management and Analysis
CORT’s in house specialist, who has been involved in the complete analysis of largescale surveys like NFHS and RCH, handled the data management and analysis. The
CORT programmer prepared data entry screens for the study using CS Pro. A data
entry package developed by CORT for the study checked range and consistency
during data entry. To ensure quality of data entry, data wasi entered twice and
' i was jointly developed by CORT,
analyzed using SPSS package. The analysis plan
with the UNFPA and their
UNFPA and GTZ. Preliminary results were shared
s...
suggestions and feedback were incorporated in the final report.
Presentation of the Report
The report has five chapters. The present chapter gives a brief introduction of ASHA
component and JSY and the study design for assessment. Chapter 2 elucidates
programme inputs and processes adopted in implementation of the scheme in
Rajasthan. ASHA’s profile, selection, training, knowledge about different aspects of
reproductive and child health and other related issues are discussed in Chapter 3
while utilization of JSY by the beneficiaries, their views about the scheme and
suggestions are discussed in Chapter 4. Chapter 5 is on recommendations and
programmatic interventions for enhancing ASHA intervention and JSY.
5
Chapter 2
Operationalization of ASHA Intervention and JSY
Adaptation of ASHA Intervention
The national ASHA guideline covers various elements and includes roles and
responsibilities of ASHA, institutional mechanisms, selection and training of ASHAs,
work arrangements and linkages with Anganwadi workers and ANMs, compensation
to ASHA, fund-flow mechanism and monitoring and evaluation.
Adaptation of guidelines by the state went through a process and evolved gradually.
The number of ASHAs to be recruited was worked out according to the national norm
of one ASHA for every 1000 population. The State Institute of Health and Family
Welfare (SIHFW - an autonomous body in the department of Health and Family
Welfare, Government of Rajasthan an apex training/research/consulting institution)
was responsible for training ASHAs.
The National Institute of Health and Family Welfare (NIHFW), (an apex national
institution) organized Training of Trainer’s (ToT) workshop and the staff members of
Rajasthan SIHFW were trained as trainers. SIHFW prepared a training agenda, and
following a cascade approach, trained 100 district level staff members for four days
within three months. These trainers were to train the district and block teams.
While this training was underway, the state thought of institutionalization of ASHA
intervention through a convergence model. This was deliberated and there was
consensus among the senior officers of both the Secretariat and the Directorate.
Incidentally, the then Secretary of Family Welfare was the State NRHM Director as well.
This facilitated the process.
At
the
Secretariat
level,
the
health
department
held
discussions
with
their
counterparts from Department of Women and Child Development (DWCD). As NRHM
promotes inter-sectoral convergence, the idea was to involve this important
development department with an impressive Integrated Child Development Scheme
(ICDS) network. After several rounds of discussions with the DWCD and meetings at
higher levels and concurrence from political level, the state decided on an integrated
approach. In Rajasthan, apart from Anganwadi worker (AWW) and helper, an
additional human resource named as ‘Sahyogini’ is working at each Anganwadi centre
(AWC) for community mobilization under the DWCD programme. Considering the
similarity of roles of ASHA under NRHM and Sahyogini under DWCD, it was decided
that only one worker named as ASHA Sahyogini would work for community
mobilization for health and Women and Child Department. Each ASHA Sahyogini
would cover geographical area catminus with Anganwadi centre. ASHA Sahyogini
would receive honorarium from DWCD for the work assigned as Sahyogini whereas
she will be entitled to receive performance based incentives under NRHM program.
In Rajasthan, according to state officials, around 43,000 ASHAs are required for
complete coverage of the state as per national norms. DWCD has 32,000 Sahyogmi
workers in the 32 districts. Therefore, it was decided that the balance of around
11,000 would be selected as ASHAs and upon establishment of more Anganwadi
'
as all Sahyogini’s
Centres; they would be converted as Sahyogini by --------DWCD. Just
become Sahyoginis
in future. The
became ASHAs, it was possible for ASHAs to L___
. decision of the state to introduce such a scheme, was indeed innovative.
Subsequent to these decisions, institutional arrangements and management processes
were initiated. Given the scale and magnitude of ASHA trainings, it was necessary to
have an apex advisory body. A think-tank group in the form of State ASHA Mentoring
Croup was set up and the State Resource Centre (SRC), (state-level resource agency
working on the National Literacy Mission) was chosen as a secretariat for mentoring
group. Thus, ASHA Resource Centre (ARC) was established within SRC. ARC became the
fulcrum of activities for ASHA intervention. Terms of reference of the mentoring group
and resource centre were worked out and finalized (Refer Annexure 2).
The Mission Director-NRHM is Chairperson of state ASHA mentoring group, whereas
Director-SRC and ARC is convener. This group has representation of state officials,
development partners and NCO representatives. In all, there are about 20 persons in
the state ASHA mentoring group. The group is to oversee the implementation and
facilitate in developing policy guidelines and be a support mechanism for
intervention. The mentoring group is expected to meet at least once in a quarter.
The ARC has three persons on board now and includes-a Project Officer, a Research
Data Analyst and a Computer Programmer who work full time. ARC is responsible for
adapting the national training modules and materials, translating modules into local
language, organizing training and workshops for state and district trainers, ensuring
training of ASHAs, involving NGOs, monitoring and supervision including developing
of reporting formats and registers, and documentation of the processes. ARC was
made responsible for orienting Panchayat officials and other key stakeholders, and
the Director, ARC functions as member secretary of ASHA mentoring group.
The ARC is technically required to report to the Mission Director NRHM. It works in
convonance with, both the State Programme Management Unit (SPMU), and District
Programme Management Unit (DPMU). The ARC has to rely on DPMU for below district
level activities. The participation of block level workers and block facilitators is vital
for ARC. Considering the enormity of tasks and scope of ARC activities, the block
level participation needs to be more specified. Even the national guidelines
emphasized the block level facilitators’ role in implementing ASHA intervention.
As an important initial task, the state! nominated the state ASHA nodal officer
responsible for implementation of ASHA intervention. The adolescent reproductive
and sexual health (ARSH) consultant at SPMU has been entrusted with additional
responsibility as
as ASHA
ASHA nodal officer. One of the responsibilities of nodal officer is to
responsibility
closely interact with ARC and plan the intervention jointly. The state nodal officer is
supported by SPMU, and by DPMU at the district level; monitoring and supervisory
support comes from the Chief Medical and Health Officer (CMHO) and facilitated by
8
the DPMU with the CMHO being the district nodal officer. As there is no presence of
ARC structure at the block level, the DPMU through the block medical officers and
other supervisory staff, and NCOs working in the area, provides support and report
on routine basis to the SPMU and ARC.
The ASHA selection process was initiated in places where Sahyogini was not available.
The selection criteria as per the national guidelines were that the ASHA worker should
be resident of the village, between 25 and 45 years, and should have completed eight
standards of education. The state found it difficult to find women in adherence with
such requirements in tribal districts.
The guidelines specified the role of DPMU Manager, an NCO, and a Nodal Officer,
preferably senior officers in-charge of the block, and the block medical officer in the
selection of ASHAs. Their involvement in the selection process was seen at places
where Sahyoginis were not present. The selection of ASHA Sahyogini was facilitated
by ANM and AWW. Local NGOs, community based groups, Mahila Samakhyas,
Anganwadis and community were involved in the selection process as well. The final
approval of the name of selected ASHA Sahyogini was made by gram panchayat
through gram sabha.
The compensation package for ASHA was finalized by the state and the ASHAs were
expected to get the following amount for different services
■
■
Compensation under JSY-Rs. 600/- in 2 installments in rural areas of Rs 350
for transport and Rs. 250 for accompanying to institution for delivery whereas
Rs. 200 for urban area.
Motivation for Sterilization: Rs. 50 for male and Rs. 25 for female
■
■
Motivation for night delivery: Rs. 100 in selected institutions
Complete ANC and PNC for home deliveries-Rs 50
Referral for cataract to government or private hospitals-Rs. 1 75
■
■
DOTS treatment-Rs 250
Toilet promotion-APL families Rs. 30 and BPL families Rs. 20 and Rs. 10 per
■
month if continued for six months
Attending training or monthly meetings at PHC
■
Rs. 1 00 per day
Concurrently, review of the national training guidelines was undertaken. The national
guidelines recommended 23 days of training staggered over five rounds with the first
training lasting a week followed by four training of four days each. The state, instead
of a week’s training, decided on a six-day package for the first round and adapted
and translated the modules 1 and 2 received until then. The ARC, with the
involvement of NCOs, trained block level facilitators for six days for organizing ASHA
trainings in their respective areas.
Subsequently, the training of ASHAs was initiated. In each batch, 40 ASHAs were
trained. Table 2.1 reveals that the state need to recruit about 43,000 ASHAs during
the year. By October 2006, around 70 percent of ASHAs were selected and an equal
percentage of the selected ASHAs were trained.
9
Table 2.1: Number of ASHAs selected and trained in Rajasthan
up to October, 2006
__
Percent
trained
(against
the
selection)
73.3
23443
Trained in
Selection target Selected up
to October, first round up
(06 - 07)_
to October,
2006
Urban Rural
2006
Total number
of ASHASahyogini
Udaipur
Bhilwara
Jaisalmer
4279
42592
32000
In the districts under
study, Udaipur recruited
half of its proposed
but
was
numbers
by
training
saturated
most of those recruited.
Similarly,
Bhilwara
selected
about
twothirds of its requirement
and
trained
about
seventy percent ASHAs,
93.8
1206
1286
2410
136
71.0
743
1046
1556
110
39.1
128
327
486
0
while Jaisalmer reached about two-thirds of its requirement but trained less than 40
percent of those selected. The pace of selection was slow in the districts and varied in
terms of completion of training. The COI has sent finalized training modules for the
subsequent rounds as well. While Udaipur performed better than the state average in
terms of the proportion trained out of the selected, Bhilwara was around the state
average and Jaisalmer fell short. At the time of fieldwork for the study, Swasthya
Chetna Yatra (Health Awareness Campaign) was underway and it was used for
propagating and promoting JSY. This has been briefly discussed later in this chapter.
It was hoped that the state would be able to meet their requirement of recruiting and
training 43,000 ASHAs by mid 2007.
As the state had taken a lead in demonstrating inter-sectoral convergence, we were
curious to know how it was translated at the field level. The block-level functionaries
commented that convergence and appropriate mechanisms were in place. However,
one of them stated:
"Sahyogini being an employee on the pay-rolls of DWCD is more loyal and
committed to her department and its officials. Instructions from her parent
department are honoured first and the others follow later, however,
important it may be. The informal instruction in the field is that forenoon
should be devoted for Anganwadi work and the afternoon for motivational
work as ASHA. In the process, Sahyogini is putting very little time in the
afternoon, as she in inundated with registers and reports supplied by her
department. Instructions by health department on meeting with clients and
motivating them for services gets neglected and more importantly,
accompanying pregnant women for institutional delivery on working days is
restricted. This has resulted in some undercurrents between the two
departments ”.
"The undercurrents mentioned will be apparent when the monthly meeting
that has been proposed is going to start. The roaster for block level meetings
has been prepared and will be starting soon. ASHAs are expected to attend
the meetings and the DWCD officials are going to be there. So, let’s wait and
see how it is going to shape. It is likely that we may be able to resolve most
of the issues. ”
10
We wanted to know whether the higher ups at the district and state were aware of
such issues. We were informed that this reached the state officers informally.
Regarding the actions initiated and whether they had any exchanges with their
counterparts from DWCD or in the SMG, it was mentioned that there was no
systematic review of the intervention undertaken till then. In fact, the SMG had not
met even once in the quarter. The last time SMG met was in November 2006 when the
newJSY national guidelines were discussed, revisions were expected to suit the state
context and a circular was issued.
Given these circumstances and our observations, it may be inferred that the state
made concrete efforts to operationalize the ASHA intervention. In the process of
doing so and in addressing the core inter-sectoral convergence strategy of NRHM, the
state definitely took the lead. SMC and ARC were constituted and the terms of
reference of both were specified. However, the structure of ARC and the nature and
scope of work below district level is a matter of concern. Also, interface between ARC
and DPMU needs clarity. Given the roles and responsibilities of various tasks and with
monthly meetings to be initiated at block-level, block seems to be the nucleus of
activities and the structure does not depict involvement of any block functionary.
Hence, there is a need for reviewing the structure and make necessary changes for
effective and decentralized management of the intervention. Perhaps ASHA mentoring
group can provide guidance to state in terms of how to engage block level health
structure, bring on board block facilitators and set up clear reporting mechanisms.
Another important area that needs mention is the revision of Sahyogini curricula of
DWCD. Since the state has already decided and has issued Government Orders of
Sahyogini working as ASHA, the ASHA training component could be included as part
of the future induction training programme of Sahyogini by DWCD. This needs to be
deliberated in detail as it has implications on the overall job profile of ASHA
Sahyogini.
Adoption of JSY Guidelines
In accordance with the national guidelines, there is a JSY nodal officer nominated
from the state medical directorate to oversee JSY activities. The nodal officer works
full-time and the SPMU, set-up for effective implementation of Reproductive and
Child Health Programme, provides support for JSY. At the district level, the
Reproductive and Child Health Officer (RCHO) or an officer of a similar rank is made
responsible for JSY intervention. The Programme Manager of DPMU supports JSY
district officer. JSY is linked with the block medical officer-in charge responsible for
both performance and financial monitoring. At the peripheral or community level,
ANM is held responsible and is supported by her supervisor. ANMs closely work with
ASHAs and Anganwadi workers and interact with PRI members for promoting the
scheme.
Through circulars and discussions in the monthly meetings, the state informed the
health care providers of JSY and districts/blocks were asked to follow a similar
procedure. The orientation of the scheme to Anganwadi workers took place during
block-level monthly meetings and ANMs during their routine interactions. However,
orientation of the other important stakeholder, that is the PRIs, took place on ad hoc
11
basis during their interactions with block functionaries. ANMs were instructed to talk
to PRIs and other community stakeholders during their field visits.
In addition, inter-personal and group communication was given priority to publicize
JSY activities and was reinforced through mass media activities such as hoardings at
strategic locations, posters, wall paintings at health facilities and public places.
Survey teams mentioned having seen paintings on JSY specifically, on payment of
cash assistance to the beneficiary. This apart, NGO’s and ASHAs were also given IEC
materials and were asked to publicize the scheme in their area of work. Even though
efforts were made by the state to generate demand for services, there has not been
any formal orientation of the scheme to PRI Representatives, who are the source of
information at the community level. This is a matter of concern. JSY guideline
proposed that the money should be placed in the joint account of Sarpanch and ANM.
Hence, it becomes imperative to equip them with the minute details of the scheme,
. and
above all
revisions, how the funds would be drawn from the account etc.
------------- for
seeking their support in promotion of institutional deliveries.
During discussions with state officers, it emerged that the MOHFW has revised JSY
guidelines four times. Two of which had direct bearing on the state for being
classified in the LPS category. The first one came along with the launching of the
intervention while the other was issued much later sometime in September 06
wherein the eligibility criteria, cash assistance and their disbursement were revised.
;
As per the present
national guidelines
Total
Total
for
LPS,
age
restriction that was
1200
2000
Institutional delivery
500
19 years or less,
Home delivery (only for
BPL pregnant women)
two
more
than
home
births, women! from BPL families have all been removed (Table 2.2). For
deliveries, assistance of Rs. 500 has been sanctioned only for BPL women in both
Table 2.2: Cash Assistance Package for JSY Beneficiarh
Particulars
Rural areas
ASHA’s
Mother’s
package package
600
1400
500
Urban areas
Mother’s ASHA’s
package package
200
1000
rural and urban areas. In the context of revised guidelines, a state officer said:
“Improving the guidelines is good for the programme but practically
changing now and then creates confusion not only at the field level but even
at programme level. Dissemination of previous guidelines by the state
followed a process. Districts were communicated through circulars and
responsible authorities were asked to share the information with staff
members during monthly meetings or similar interactions. Trainers of ASHAs
were informed too and were asked to include m the training curricula. With
the revision, we have repeated this process and have explained about the
changes. However, during field visits, we often hear about different amounts
being quoted. It will take some time for new guidelines to sink m. ”
With reference to new guidelines, the issues related to time frame of payment to the
beneficiaries came up. A block-level accounts person in Udaipur district opined that
time of payment to the beneficiary has to be increased from one week to two weeks
after delivery. This was a deviation from national guidelines (even the earlier) wherein
12
it is maintained that single total payment should be made at the time of delivery. The
state officials had discussions with GOI after the new guidelines came into effect in
November 2006 and the payment within a week of delivery was agreed upon. During
discussions, it came to our notice that transport payment to beneficiaries in case
where ASHA had not accompanied for institutional delivery, was not made to the
beneficiary. With the revision of guidelines, the amount of Rs. 300/- was to be paid to
the beneficiary even in case ASHA do not accompany pregnant women for institutional
delivery. Since, the cut-off of selection of beneficiaries was six months prior to the
survey, this element of transport reimbursement in accordance with the new
guidelines could not be effected.
With reference to the fund
flow, the state worked out its
mechanism along the guideline
of the national government.
However, at the field level,
been
there
have
some
in
modifications
terms
of
payment
advance
of
recoupable
money
to
the
ANMs. The national guidelines
provided
that
advancing
recoupable money in the range
of Rs. 5,000 to 10,000 to
ANMs, should be deposited in
the joint account of ANM and
state
felt
The
Sarpanch.
instead
and
otherwise
suggested that the untied
FUND FLOW FOR JSY SCHEME
n
I
I
MRS: Medical Relief Society
money given as part of NRHM
could be used and upon
submission of expenses, the ANMs could be reimbursed immediately (Refer Fund
Flow Chart). When this issue was discussed with the block level officer, he suggested:
“ANMs are handling accounts and substantial money for the first time. They
have not been oriented of how to handle and what transactions are involved
and how to maintain the expenditure statement and cash book. Moreover,
ANMs find it difficult to withdraw money due to fixed ceiling amount. Beyond
that ceiling amount, ANM has to seek signature of the joint signatory who in
this case is the Sarpanch. Experience has been that Sarpanch are reluctant to
sign and have lot of queries. It would be good if ANMs and Sarpanch are
jointly imparted training on how to manage the funds and maintain the
expenditure ”
13
Concerning the monitoring of JSY, the CMO of Jaisalmer district said
"In our district, we have tied up JSY monitoring with routine monthly field
visits of my officers and DPMU. Whenever my staff and I visit the field, we
look into their cashbook register, tally it with delivery register and talk with
the beneficiaries if they are available at the facility on the day of visit. In
addition, we also undertake random check ofJSY beneficiary in the field and
find out details about cash assistance, amount received, when received and
so on, whether ASHA accompanied or not and any problems faced in the
facility and so on."
The CMO also said that there was lot of cash flow and disbursement involved in the
scheme and therefore it was necessary to monitor it at different levels. On the quality
care of deliveries happening in institutions, the state has done very little. With the
uptake of institutional delivery services expected to increase under JSY and human
resources being constant, it becomes important to monitor the quality of services
rendered by the public health facility. Hence, it is necessary to set-up an appropriate
system for monitoring quality of services within JSY. Regarding the quality, CMO of
Jaisalmer district stated.
“As long we don get to hear of major complications or eventuality, the
presumed to be reasonably good. Up gradation and
services can be
i
strengthening of facilities and capacity building of human resources are
underway and we are certain, that would be able to ensure good quality of
care".
Other districts reiterated this view as well.
Regarding quarterly progress and financial reports, the statistical assistants and
account persons at district and blocks levels were of the view that each time data on
beneficiaries was collated, reconciliation between performance and disbursement had
to be made. An integrated format that could cover both performance and
disbursement was recommended by Udaipur district. The DPMU of the district felt that
this would reduce the time in reconciliation and running around and both information
could be maintained and shared. The integrated format has been recommended to
the State Government and the idea has been well received.
Rajasthan has tried out an innovation in JSY implementation. The state has launched
JSY Helpline on experimental basis in one block of each district with the help of NGO.
JSY helpline aims at promoting emergency referral and ensuring safe delivery of
women with obstetric emergencies at the identified block health facilities. The NGOs
ensure networking with transporters and health care providers. This intervention is in
operation for several months and the state officials seem to be happy with the
progress. The intervention is regularly monitored but it would be worthwhile to
undertake an independent assessment of how this intervention has fulfilled its
objectives. It is to be noted that JSY help-line blocks were not a part of the study
sample.
14
Swasthya Chetna Yatra
State government organized Swastya Chetna Yatra (health awareness rally) in
December 2006 covering all the districts and all the villages of the state. The rally was
jointly organized by the Health and Family Welfare department, ICDS, Ayurved,
Panchayati Raj, Education and Rajaswa department.
The main objective was
■
■
to impart knowledge about different health scheme’s availability
to create awareness about nutrition, increase community involvement in
■
celebration of health days and
to create awareness and promote voluntary blood donation
Rally also propagated free health check-ups at health centre through street play and
role plays. Besides through rally, the health staff attempted to identify ASHAs and
propagate and publicize JSY. It can be said that, because of this rally, men & women,
and old & young in the community learnt about details of JSY and involvement of
ASHA
Another option provided in the national JSY guidelines is related accreditation of
private institutions for delivery services. The guideline for accreditation could not be
accessed, but it was mentioned by a state official that it should be a 24x7 days
service having services of a gynaecologist, an anaesthetist, and a surgeon who could
perform caesarean section. Further, the facility should have blood transfusion facility;
proper OT and labour room with power back up. In Rajasthan, the process of
accreditation of private institution has just begun with the listing exercise and this
aspect has been highlighted in the revised JSY guidelines circulated in November
2006. The guideline suggests listing of private facilities not only at district
headquarter but also at sub-district and block levels. According to the state official:
‘Efforts are underway but we are finding difficulty to even identify one such
institution per district in Rajasthan that comply with the accreditation
norms. ’
Private sector engagement in JSY has to be given impetus and the state could review
and modify the guidelines of accreditation depending on feasibility. If the present
norms of accreditation, as stated by the state official are applied to public health
institutions, there could be very few institutions eligible under JSY. So, the state could
consider modifying the norms for accreditation of private sector institutions.
Rajasthan has made efforts to operationalize and implement JSY. They have adhered
to and adopted the national guidelines and subsequent revisions to the state context.
In addition, the state has tried out convergence between health and ICDS department
and an innovation in the form of JSY help-line by involving NGOs. In terms of
disbursement of cash advances to ANM and payments to beneficiaries, they are
extremely cautious and have built a cut-off of a week for payment to beneficiaries.
These could be some areas where further clarification could be sought and
appropriately intervened.
15
Chapter 3
Engagement of ASHA in the National Programmes
One of the core strategies of the NRHM is to develop a sizeable force of village-based
women activists, as ASHAs, who would be able to create demand for effectively and
timely utilization of health care services. At the same time, it was felt that ASHA
would act as an interface between vulnerable communities, especially women and
children, and with the health care providers.
In order to enable the ASHAs to perform their roles; an induction training of 23 days
spread over 12 months was proposed and was staggered into five rounds beginning
with one week training followed by four rounds of training of four days each. Such
schedule of trainings would help ASHAs to practice whatever they learned in earlier
training and to come back for next training keeping in mind their own work environ in
villages. It was expected that by training the ASHAs, they would be able to facilitate
implementation of the Village Health Plan along with Anganwadi worker (AWW), ANM,
functionaries of other Departments, and Self Help Group (SHG) members under the
leadership of the Village Health Committee of the Panchayat. In addition, ASHA
guidelines proposed provision of a Drug Kit containing generic AYUSH and allopathic
drugs for common ailments, oral pills and condoms so that they could provide
general health care for minor ailments and act as depot holders for oral pills and
condoms.
This chapter describes the socio-demographic profile of ASHAs, their motivation to
become ASHAs, selection process, training, and gauges the knowledge retention
regarding antenatal and childcare. Their roles and responsibilities, the way they
motivate clients and ensure services are discussed. ASHAs last clientele (to
understand the nature and range of interactions); networking with key stakeholders,
cash assistance received by ASHAs, their supervision and monitoring are also
presented.
Background Characteristics of ASHA
In all, 173 ASHAs could be interviewed from the three districts of Rajasthan. The
ASHAs interviewed were around 26 years and had nine years of schooling. Given the
educational attainment of women in the state, this was highly encouraging.
Most of the ASHAs interviewed were married (95 percent), while five percent were
divorced, widowed or separated. Thirty-two percent belonged to scheduled caste/
tribe, which was slightly more than the proportion of SC/ST population in the state.
About the place of residence of ASHAs, most resided in the village/town where they
worked, while about six percent came from nearby village/town. The eligibility criteria
for ASHAs listed that an ASHA should be eighth class pass, aged between 25 and 45
years and preferably married resident of the village (Table 3.1).
Table 3.1: Profile of ASHA functionaries in Rajasthan,
2007 (Percentage)
Total
Profile__________ _________
173
Total number of ASHAs interviewed
Age of ASHA (in completed years)
18-19 years
20 - 24 years
25 - 29 years
30 - 34 years
35 years or more
Mean (years)__________ __
Years of schooling completed
Below 8th std
8th std
Secondary (9-10 std)
Higher secondary (11-12 std)
Undergraduate and above
I
Mean (year of schooling)
Caste/tribe of ASHA
Scheduled caste
Scheduled tribe
Other backward classes
Others
2.3
35.3
41.0
13.9
7.5
26.1
2.9
49.7
31.2
9.2
6.9
Coing by the criteria, it is felt that
there was relaxation of the eligibility
norms. Another important statistic not
presented in the table reveals that 16
percent of ASHAs did not fulfill one or
the other requirement for becoming
an ASHA because they were either
more than 45 years, had not studied
up to 8th standard or were not
residents of the village. It appears that
these criteria were relaxed for some
tribal districts where it was difficult to
identify ASHAs. This may be due to the
fact that minimum age criterion for
Sahyogini selection is 21 years.
9.2
Majority of ASHAs were in reproductive
17.9 ages and over four-fifths of them had
13.9 a child. On average, ASHAs had 2.2
37.6 living children. One of the questions
30.7
posed to ASHAs who had a child was
•
• question was not related to
the place where they delivered the last child.—
This
from the perspective of behavioural change
programmatic aspects but was important
i .
’ ) understand ASHA’s behaviour and practice,
because, it was imperative to
of
3
ASHAs
Interestingly, two out c,
- ---- - had delivered at home, which was in line with the
trends observed in the state and mirrors community behaviour and experiences. On
the whole, it can be inferred that the selection criteria that were proposed in the
national guidelines were adhered to by the state and relaxed in tribal districts.
Another question posed to the ASHAs was their work-status prior to becoming an
ASHA. Almost half of the ASHAs were economically active before they were selected
as ASHA. They worked as a ‘Sahyogini’assisting anganwadi worker at the Anganwadi
Centre located in the village. These Sayoginis are selected by the State Department of
Women and Child Welfare and get Rs 500 per month as honorarium.
Regarding duration of work as ASHAs, it was found that on average, they had worked
for nearly six months and two-fifths had more than six months of work experience.
The table further depicts that more than half of ASHAs had not earned money since
the time they started working as ASHAs. This was evident even among those who had
worked for more than six months though the proportion was marginally smaller in
comparison to ASHAs who had worked for less than six months. ASHAs who reported
having earned money through their work stated their monthly earning to be around
Rs. 340/ while ASHAs who worked for six months or longer reported their monthly
average earning to be over Rs. 360/. These findings point to marginal difference in
earning between the two groups of ASHAs (Table 3.2).
18
One of the findings is that majority of ASHAs did not earn anything till the time of
survey. If this trend continues, it would be difficult to sustain their interest and they
may even opt out. There should be well-designed strategy to introduce ASHAs to
community. Engagement of PRIs and health functionaries would be vital in doing so.
Duration since working as an ASHA worker (in months)
Total
Less than or equal More than 6 months
to 6 months
Particulars
Approximate monthly income from ASHA
work (in rupees)
Rupees 250 or less
251 -500 rupees
501 - 750
No amount earned
Do not know/can’t say_______________
Total
23.7
12.4
4.6
56.7
3.1
100.0
(97)
321.3 (39)
Mean rupees earned per month
19.7
18.4
6.6
52.6
2.7
100.0
(76)
359.6 (34)
22.0 (38)
15.0(26)
5.2 (9)
54.9 (95)
2.9 (5)
100.0
(173)
339.1 (73)
About ASHA: Their Selection and Motivation to Work
It is important to understand the selection processes followed and motivating factors
for village women to be
the
ASHAs.
Half
of
respondents first came
to know about the ASHA
from ANM and nearly a
from
the
quarter
worker/
anganwadi
In
most
supervisor,
were
they
cases,
motivated to attended
family
training
by
members.
|
~
:
Particulars
_____________ ________________
Total number of ASHAs interviewed___________________
Ways got selected as ASHA*
On account of netaji/politician/surpanch gram sabha
Was working as anganwadi Sahyogini
ANM helped me in getting selected
I think because of my good nature/ I am literate
Others/husband/father-in-law/CDPO/block facilitator
Percent mentioned that Gram Sabha approved their name
Reasons for wanting to be an ASHA*
Want to serve/help the poor community
Source of income
Save children / For the benefit of children
Learn new things / to remove misconception
Others / reducing population growth rate_____________
* Multiple responses
Total
173
52.6
31.8
15.0
7.5
4.6
97.1
73.4
29.5
17.9
10.4
3.5
The respondents were
asked how they were
selected as ASHAs. Majority (53 percent) of the ASHAs stated that elected
representatives; sarpanch or Gram Sabha selected them followed by the government’s
decision to select Sayoginis working in anganwadi centers. Barring these two
responses that accounted for 85 percent of selection, ANMs help was stated in 1 5
percent of cases (Table 3.3). In almost all the selections, ASHAs mentioned that the
Gram Sabha approved their names. As regards the motivation factors for wanting to
be an ASHA, altruism was most important factor stated, followed by source of income
and supporting family and children.
19
Training of ASHAs
As per national guidelines, each ASHA should have attended seven days of induction
modified by the state and instead of seven days the state decided
training. This was
to do six days training. No
Table 3.4: Topics covered in the training of ASHA in
specific rationale was given for
Rajasthan, 2007 (Percentage)
Total reducing the duration by one
Particulars_________________________________
173 day. Table 3.4 shows that 95
Total number of ASHAs interviewed_____________
percent of ASHAs interviewed
95.4
(165)
Percent ASHAs attended ASHA training__________
attended the induction-training
Topics covered during training for ASHA*
83.0
Women and health (FP, ANC, breast feeding)
programme in the past one75.8
58.2
45.5
36.4
30.3
20.0
19.4
13.3
10.3
9.1
6.1
Infant and child care (immunization)
HIV and AIDS
ASHA (my eight tasks)
National Rural Health Mission (NRHM)
Disposal of waste water/clean drainage
Nutrition
Anganwadi centers
Water supply at home /safe drinking water
Organizing a group meeting
Curative care
Reproductive and sexual health problem
Others /Adolescent education /Mgt. of
diarrhea/pneumonia
Percent mentioning that the logistic arrangements
at the place of training were adequate
Sitting arrangement
Size of the room was adequate
Accommodation facilities
Arrangement for food
___________________
* Multiple responses______________________ _
5.4
93.3
95.2
90.3
94.5
year.
ASHAs
who
attended
the
induction training were asked
about the topics covered. The
spontaneous responses included
women and health, infant and
childcare, HIV and AIDS and the
eight tasks of ASHA. Other
responses
related
to
determinants of health such as
water
and
sanitation,
and
nutrition was citied infrequently.
During monthly meetings an
attempt should be made to
orient them in these areas and
i
in
addressing
common problems. It
the importance of mobilizing community action
inferred that retention of knowledge of the topics covered during the training
that was imparted about six months ago, was good.
The ASHAs were further asked about the logistical arrangements during training.
Most of the ASHAs appreciated arrangements at the training site and nine out of 10
reported that sitting arrangement, accommodation, food, and size of the room were
good and had no suggestions to offer. Only a few (3 percent or less each) suggested
for proper arrangements of beds/bed sheets, access to latrine/bathroom, more space
in the training room, need to tackle the water problem, and for proper food
arrangements. A few ASHAs mentioned TV, electricity, and fan during training. Good
logistic arrangements during training contributed to enhancing learning.
The NGOs in the state were engaged in organizing trainings for ASHAs at block level.
Their enthusiasm to be associated with a national programme may have been
reflected in the form of better arrangements.
20
Quality of Training
The Government of Rajasthan adopted training manuals given by Government of
India. To understand the quality of training, training pedagogy and their views about
the trainers, ASHAs were asked a series of
Table 3.5: Teaching Aid used for training of
questions. Majority of ASHAs found the
ASHAs in Rajasthan, 2007 (Percentage)
training to be participatory and said that Particulars____________________
Total
165
the trainers encouraged them to ask Number attended training program
in
last
one
year
________________
questions and answered their queries
properly. The trainers used charts/ models Training aids used in the training*
87.6
Posters
to explain the topics (98 percent). ASHAs
67.1
Lectures
recollected the use of other materials such Flip charts
51.6
46.6
as posters (88 percent), lectures (67 Pamphlets
40.4
percent) followed by flip charts, pamphlets, Role plays
13.7
TV/video/CD
and role-plays (Table 3.5). Some (less than
10.6
Folk songs
14 percent) ASHA mentioned the use of Book/module/guideline
4.3
3.7
TV/video, folksongs, and books/module. Others_______________________
Nine out of 10 ASHAs found the training * Multiple responses
materials to be either very good or good and useful.
Payments during training: Table 3.6 depicts that of the 165 ASHAs who attended
training; more than four-fifths of them received payment at the end of the induction
training, while the remaining reported that they did not receive the payment. As per
training guidelines prepared by the state, each ASHA should have received Rs. 100 X
number of days attended training + Rs. 100 towards transportation cost. That is, in
all it should have been Rs. 700/-. Majority (74 percent) of ASHAs mentioned having
received Rs 600 - 630 for attending 6 days of training, while one ASHA was given
more than the sanctioned amount.
Discussions with the trainers and
finance personnel revealed that the
ASHAs were paid at the rate of Rs. 1 00
per day for attending the training and
transport reimbursement was done on
actual basis. Concerning non-payment
Table 3.6: Payments received during training by ASHA
_______ in Rajasthan, 2007 (Percentage)
Total
Particulars___________________________
Number of ASHAs attended training______
Average amount received during training
No amount received
Received amount due (Rs. 1 00 x number of
days attended training as DA + Rs. 100
transportation)
Received amount less than due*
Received amount more than due
165
17.0
to about 1 7 percent of ASHAs, it was
found that one batch of ASHAs (n =
8.5
73.9
28) who
underwent training
in
0.6
Jaisalmer district six months prior to
the survey, was not paid at all.
605.4
Mean (in Rupees)
Discussions with district officials
revealed that advance money was not released in time and hence payment could not
be made. ASHAs were therefore informed that they would be paid when the second
round of training was conducted. This indicates necessity of monitoring training
arrangements and programmes by DPMUs.
21
Use of reading material: ASHAs were given reading materials/guidelines immediately
after their training. In this context, a question was posed to ASHAs whether they had
received it and if so, whether they could show the same to the survey team. Eightysix percent of the ASHAs confirmed having received the reading materials. It was
encouraging to find that two-thirds of them were able to refer to the reading material
and the remaining could follow the same to some extent. Time constraints, small
child or difficulties in comprehension were few reasons for not referring to the
reading material. On the question regarding physical verification of reading materials,
60 percent of ASHAs who had received the reading materials could show the same to
the field investigators.
Knowledge of ASHAs
Antenatal and Child Care Services Knowledge of ASHAs was assessed by series of 10
questions related to their roles in ANC
Figure 3.1 : Scoring knowledge of
and Child Care. Each correct response
ASHAs in Rajasthan
was given a score of one mark and equal
Grade B
29%
weight age was given. Later, the scores
were categorized into Grade 0 -All
Grade A
Grade C
correct responses, Grade A- 8-9 correct
59%
6%
responses,
Grade
B
6-7
correct
responses and Grade C- 5 or less correct
Grade
responses. Majority (59 percent) of the
'O'
ASHAs scored Grade A, 29 percent were
6%
in Grade B while the remaining 12
percent were equally distributed between Grades C and O. In other words, more than
6 out of 10 ASHAs had reasonably good knowledge of antenatal and childcare
services. These findings indicated reinforcement of knowledge gained in the first
round of training.
pregnancy. Delivery Complications and action s ASHAs need to know about the
complications that women may experience during pregnancy. Questions related to
complications and their management were posed. A large proportion of the ASHAs
commonly cited swelling of hands and feet, excessive bleeding, followed by paleness,
convulsions, and visual disturbance, feeling uneasy and vomiting as pregnancy
related complications.
ASHAs were asked what they would do if they recognized such complications.
Majority of the ASHAs said that they would immediately refer the pregnant woman to
the nearest public/private facility or accompany the pregnant woman to facility.
Forty-five percent of the ASHAs said that they would ask the pregnant woman to
consult the ANM the next day (Table 3.7). Considering the fact that any delay in
seeking care would jeopardize the health of women, this finding was alarming and
need to be addressed in subsequent monthly meetings. Simple job aids can also be
developed for reminding ASHAs about course of action in the event of pregnant
women with specific complications.
Particulars___________________________ ——
Total number of ASHAs interviewed
Total
173
Complications women can experience during pregnancy*
Swelling of hands and feet
Excessive bleeding
Paleness/Anaemic
Convulsion
Visual disturbance
Feel uneasy
Vomiting
Abdomen pain
Weak or no movement of foetus
Others (body, back pain, abnormal position of foetus, fever)---------------------------------------------------Actions supposed to be taken, if ASHA recognize complications signs in a pregnant woman*
Immediately refer to the nearest functional FRU (Upgraded CHC, Sub divisional/district hosp.)
62.4
42.8
36.4
27.7
19.7
19.7
6.9
5.8
19.1
59.0
45.1
Ask to consult the ANM the next day
Refer to government accredited hospital
9.2
Take her to the nearest functional FRU
Refer to private accredited hospital
Others (send to ISMP/Quack/Hakim/Vaid/Provide transport money)_______________ ________
* Multiple responses
81.5
_________________________
8.1
1.7
5.2
_
Regarding the knowledge about complications at the time of delivery, ASHAs said that
common complications during delivery were excessive bleeding (67 percent),
convulsions
(29
percent),
anaemia
Total
among mothers or Particulars____________________ ___________________
173
Total number of ASHAs interviewed________________
abnormal position of
Complications during delivery *
the
foetus
as
67.1
Excessive bleeding
28.9
mentioned by every Convulsions/fit
30.1
fifth ASHAs (Table Anaemia / weakness of the mother
20.2
3.8). Other reasons Abnormal position of the foetus
6.9
for fatal
outcome Tetanus
6.9
Lack of foetal movement or foetus dies in womb
26.6
could be swelling on Others/ abdominal pain, fever, headache, BP problem
2.9
hands
and
feet, Do not know
______
weakness
of
the * Multiple responses
mother,
abdominal
pain, tetanus, fever, lack of foetal movement or death of foetus in mother’s womb,
and blood pressure problem. Prolonged labour as a complication was not mentioned
by ASHAs and this could be life threatening if not managed in time. There was
therefore, a need to cover this important aspect in the subsequent rounds of training.
Knowledge about Newborn Care: Regarding newborn care, majority of ASHAs rightly
said that newborns are most likely to die soon after birth (67 percent), followed by a
quarter of ASHAs reporting deaths in first week of life. As far as ASHAs knowledge
about vaccines was concerned, ASHAs knew about BCG and DPT, however their
knowledge about OPV and Measles was 71 and 62 percent respectively (Table 3.9).
23
Table 3*9: Knowledge about likelihood of neonates dying after birth in
Rajasthan, Z007 (Percentage)
Total
Particulars_______________________
Total number of ASHAs interviewed
Period (in life) when newborns are most likely to die
173
Soon after birth / first day of birth
67.1
24.3
4.6
12.7
2.3
Within one week of birth
Between one to two weeks of birth
Between 3 4 weeks of birth
Others
Do not know/can’t say _________
5.8
The knowledge of ASHAs
on child immunization
and schedule needs to be
strengthened in the next
training
round
of
about
specifically,
adverse
and
schedule
following
events
immunization.
Knowledge about tasks to be performed by ASHAs
The study explored ASHAs familiarity with their tasks. ASHAs responded by
mentioning accompanying delivery cases, creating awareness about health/HIV and
—----------------------------- counseling while a lesser
number believed assisting
Figure 3.2: ASHAs' awareness about her responsibilities
ANM in village health
planning,
mobilizing
community
to
utilize
83
Accompany delivery cases/ANC cases
health and immunization
56
and
creating
Create awareness on health/HIV
services
on basic
awareness
Counselling
sanitation and personal
as
other
hygiene
Village health planning
responsibilities. Very few
ASHAs
mentioned
Mobilize community to utilize health
39
services
motivation of clients for
family
planning
or
25
Help in immunization program
provision of oral pills and
Create awareness on basic sanitation &
condoms and post-natal
24
hygiene
care
as
their
15
Promote good health practices
responsibilities.
15
Provide basic curative care
Family planning
0
20
40
60
80
100
These could be areas on
which the next round of
training It could
appears that thrust on
implementing
JSY
by
programme managers resulted in “top on recall” response for accompanying delivery
cases.
24
focus.
asked about their own work. It was observed in Table 3.10 that most of
They were
10 Feeiing of working as ASHA in Rajasthan, 2007 (Percentage)__[
them were proud of
Total
their newly acquired Particulars_______________ __________________ ________
173
status
and
social Total number of ASHAs interviewed_____________________
Reasons for feeling good about being an ASHA*
obligation of serving
48.6
It is good that poor people will get benefits
16.2
the poor. Increase in Increases knowledge and understanding of ASHA
15.0
knowledge and respect Get money
15.0
from the community Villagers respect/support / acknowledge work
8.1
Knows about antenatal and natal care/Reduces misconception
were
the
stronger
It is necessary to create awareness among illiterate/ignorant
factors in comparison people
8.1
8.7
with earning money. People in the village recognize ASHA/ know families, doctor
Reasons
for
not
feeling
good
about
being
an
ASHA
These
“motivational
10.4
pegs” needs to be Lot of work and running around
* Multiple responses___________________ ______________
reinforced
for
sustaining their interest on long-term basis.
Organization of Work by ASHAs
The ASHAs were asked how they organize their work. Almost all the ASHAs said that
they visited house to mobilize women and children to seek health care. Six out of 1 0
ASHAs mentioned that they facilitate immunization sessions conducted at the
anganwadi centre and more than 3 out of 10 mentioned that they accompanied
women for delivery. Likewise, few of them mentioned helping in organizing of village
health day. In responding, the ASHAs confused the activities they perform with the
activities they may or ought to perform. However, most of them depended on inter
personal contact as the mode of organizing different health care services, though this
is not there in the national guidelines. The ASHAs repeatedly visit the houses of the
clients and motivate them to avail services and on the day of immunization or village
health day, an advance visit is made to remind and motivate the community to avail
the services.
Availability and Utilization of Drug Kits
It was planned to provide ASHAs with drug kits with few medicines for minor
ailments. To promote community based contraceptive availability, oral pills and
condoms were made available. States were given flexibility to procure drugs and
make them available to ASHAs at the end of training itself so that they could
familiarize themselves. The state provided the following drugs:
->
->
->
-»
ORS Powder
Paracetomol-500 mg
Tab Dyclomine HCL-1 Omg
Cotton Wool Absorbent (500gms)
-> IFA (large)
Ordinary Bandage
25
' ' '
The drug kit in addition
toi what has been listed above includes more items of
Disposable Dai Kits, ISM preparation of iron, Povidine Ointment, Thermometers,
Condoms and Oral pills. Addition of Dyclomine HCL in ASHA kit was not
recommended by COI, as symptomatic treatment of abdominal pain may mask some
underlying signs.
The study revealed that only one- fourth of the ASHAs received drug kit, immediately
after training. Another 37 percent ASHAs received drug kit much later after their
training and the remaining were yet to3 receive it. Non-availability of drug kits, long
after induction trainings was a matter of
c concern. Availability of drug kit helps ASHAs
in not only attending some primary medical care needs, but also builds confidence of
community in ASHAs as some one available in “ hour of need”.
Among the ASHAs who received drug kit, majority used the medicines available in the
kit at some point in time. There were no problems of stock outs as Anganwadi
workers, ANMs or others replenished medicines at PHCs/SCs. An Anganwadi worker
said:
“Drug kits containing medicines and contraceptives were provided to the
ASHAs in April 2006. Since ASHA is also a Sahyogini replenishment of
medicines is not an issue because of our daily interaction at the centre.
ASHAs usually collect medicines from ANM and me. During campaigns, she is
also provided with medicines from the health institutions and Mahila Ba!
Vikas. ”
The anganwadi worker concluded
that state government’s
decision
to select
Sahyogini’s as ASHAs was a pragmatic decision and resulted in effective convergence.
ASHAs Clientele
ASHAs were asked about their last client, to get an idea of profile of clients and range
of services provided (Table 3.11). On average, the last client availed services from an
ASHA around 20 days prior to the interview date. This was an interesting finding and
ran counter to the usual argument of “overloading or inundating” ASHAs with variety
of activities.
Concerning the profile of the last client who visited ASHA, it was observed that the
average age of women was 25.8 years. Four out of 10 cases were SC/ST and an equal
number belong to OBC group. This indicated that ASHAs reached the disadvantaged
population. As far as provision of services for the last case was concerned, mobilizing
children for immunization (35 percent) was most common. This was followed by
advice about place of delivery (20 percent), IFA tablet distribution (16 percent) and
primary medical care (1 7 percent). These findings indicate the potential role for ASHA
in terms of provision of primary medical care for women and children in rural areas.
26
Regarding ASHAs role in JSY, few questions were asked. Eighty-six percent of the
Table 3. H: Brief details of ASHAs interaction with her last client,
ASHAs had handled cases
Rajasthan ,2007 (Percentage)
since
they
started
Total
Particulars
_________________________________
functioning and 40 percent
173
Total number of ASHAs interviewed___________________
of the total ASHAs had Average number of days ago when the last client
20.0
actually stayed with the availed services from ASHA_________________________
women at the place of Caste of the client
17.4
delivery. They said that the Schedule caste
20.1
Schedule
tribe
last JSY beneficiary was
42.3
OBC
accompanied I1
/? months
20.1
General_______________
_ _______________
(44 days) prior to the date Reasons for the interaction or ASHAs contact with her*
34.9
of interview. Half of them Immunization
20.1
Delivery/to
get
advice
about
place
of
delivery
stayed with the women at
16.1
IFA tablet distribution
the place of delivery and
Collect medicines for fever, back pain, vomiting, pain in
the number of days of stay lower abdomen
1 7.4
8.0
ranged between one and Registration of pregnancy /antenatal care/check-up
six
with
the
average Information regarding sterilization/getting OCP,
2.7
duration of stay being 1.4 condom
2.0
Routine contact
days. In a village with a
5.3
Others- did not get money after delivery
population of 1000, with Duration of days ago when ASHA last accompanied a
44.2
the birth rate of 30 per woman for delivery (in days)
86.1(149)
annum, the average births Number of ASHAs who had handled a JSY case
47.0 (70)
per quarter would be 7-8. Percent ASHAs who stayed with JSY beneficiary at the
place of delivery
__________________________
If we take BPL population to
1.4
Average number of days ASHA stayed with JSY
be one-third in Rajasthan, beneficiary at place of delivery
I
ASHAs are nearly capturing Range (minimum maximum days) ______________
___________
all women eligible under * Multiple responses
JSY. However, recently all
population groups have been made eligible for benefits if availed institutional delivery
services under revised JSY guidelines.
Cash Remuneration Received by ASHAs
All the ASHAs were asked about the
cash incentives received by them. As
can be seen from Table 3.12, only
four out of 10 ASHAs received some
cash remuneration while majority
were yet to receive the same, despite
the fact that they had assisted in
promoting institutional delivery or
had rendered some health services.
Table 3.12: Cash Remuneration Received by ASHA in
Rajasthan, 2007 (Percentage)
Particulars
_______ ______
_ Total
Total number of ASHAs interviewed_______
173
Percent received any cash incentive money
41.6(72)
as ASHA till now___________________
Services for which ASHA received cash
incentive money*
Immunization of children
Attending JSY beneficiary
Family planning cases
DOTS treatment______________________
75.0
50.0
2.8
1.4
Three-fourths of the ASHAs received * Multiple responses.
remuneration for immunization of
children and half of them for attending to JSY beneficiaries. Only a few ASHAs were
paid for family planning cases or for providing DOTS treatment. The state government
has fixed rates for each of the activities and accordingly payments are made.
Regarding the mode of payment, ANM (50 percent) was commonly mentioned as
making payment followed by Medical Officer of CHC/PHC (24 percent) and doctor or
staffs at the institutes (17 percent). Two-fifths of the ASHAs received the
remuneration immediately on submitting the accounts while 36 percent received the
same within a month and the remaining 25 percent after a month. The main reasons
for the delay in payments were: no or less advance money at the facility (5 5 percent),
delay in approval process, signing authority not being available or delay in payment
by ANM.
The ASHAs who had received money had on average earned about Rs. 400/(calculated on the basis of cases motivated in the three months prior to the survey)
while the projected estimate of the maximum the ASHAs could earn is three times
more. Majority of the ASHAs were satisfied (43 percent) or somewhat satisfied (36
percent) with the remuneration received, mainly because ‘they could earn extra
money’ (39 percent) or it gave them an opportunity to learn many new things and
work within the village. In contrast, one-fifth of the ASHAs were not satisfied with the
cash assistance as it involved ‘too much of work for too little money (21 percent),
and that the money was not given on time (1 5 percent). It was felt that some ASHAs
were favoured even if activities did not occur. It is obvious that streamlining of fund
flow is necessary so as to ensure timely disbursements. ASHAs are bound to loose
interest if performance based incentives are not dispersed within stipulated time.
There are incidents of nepotism and favour in some cases. High level of satisfaction
(satisfied and somewhat satisfied) with remuneration owes itself to the fact that
Sahyoginis received Rs 500 each month for their work at AWC in the village as well.
Interface and Monitoring System
In the guidelines it is stated that ASHAs are expected to facilitate the work of ANM
and Anganwadi workers by mobilizing pregnant and lactating women and children for
RCH services on immunization and Village Health and Nutrition days and help in
updating household/eligible couple registers.
ASHAs were asked about supervision and monitoring system. Few ASHAs maintained
information related to ANC (name, address, EDD, registration, weight), immunization
of children and delivery in a book/personal diary and shared with ANMs and
Anganwadi workers. This was possible because a substantial proportion of ASHAs
selected in Rajasthan work as Sahyogini. In Rajasthan, ASHAs responsibilities are
more and they are accountable to DWCD functionaries and staff members and report
routinely to their parent departments. Majority of them reported that they regularly
met with Anganwadi workers and ANMs. The activities undertaken were reviewed,
discussed and problem-solving exercise was undertaken. For instance, if ASHA
identified a pregnant woman who had refused antenatal services, ANM along with
ASHA visited the household and advised the person to avail necessary services.
Supportive supervision and discussion in meetings held regularly formed the
supervisory mechanism in the study area.
28
This apart the ASHAs were asked whether any district or block officials visited the
place in the past 3 months. Majority (56 percent) of the ASHAs said that ‘nobody ever
visited since they started working’, while a quarter of them mentioned visits by senior
officials. Advance and prior information on their visits was communicated to the
ASHAs. The ASHAs were happy that such supervisory visits would be more productive
in enhancing the quality of work and would facilitate their position and work in the
community.
Support Mechanisms and Networking of ASHAs
Figure 3.3: Networking of ASHA with
stakeholders
(Percent meeting the stakeholders)
ASHAs cannot work in isolation.
They need to have a congenial and
collaborative environment at the
local
level.
As
community
ownership, participation and inter
sectoral
convergence
are
key
components stated in NRHM, ASHAs
were asked about the pattern of
working
and
networking
with
various stakeholders and the role of
stakeholders as understood by them
95
ANM
1 94
66
PRI
55
33
SHC
33
(Figure 3.3 and Table 3.1 3).
Village mandal
ZJ-
■ l2
It is evident that nine out of 10
ASHAs reported having interacted
with Anganwadi workers and ANMs, Health and sanitation
committee
followed by interactions with PRI
40
60
80
100
20
0
(66 percent), PHC staff members (5 5
percent), SHGs and Block facilitators (33 percent each). Interaction with other
stakeholders such as village mandal, NGO staff members and Health and Sanitation
z
Committee was limited.
A sizeable number of ASHAs had met Anganwadi workers and ANMs more frequently
than the other stakeholders. ASHAs met the Anganwadi workers almost daily and it
was more of a weekly and monthly interaction with the ANM. Probably, meeting ANM
was tied to ANMs visit to the village. In case of village mandal, only a few ASHAs
interacted but, the frequency of meetings was good.
Stakeholders
AWW ANM
94.2 94.8
Percent ASHA who met
stakeholders _________________ (163)|(164)
Frequency of meeting stakeholders
90.2 42.1
Daily / Weekly once
6.7 54.2
At least once a month
3.7
3.1
Less frequently________________
* Multiple responses
ini NGO SHG
32.9
(57)
54.9
(95)
Health & Village
sanitation mandal
committee
11.6
6.9
1 1.6 32.9 65.9
(20)
(12)
(20) (57) (114)
8.8
64.9
26.3
16.8
73.7
9.5
0.0 17.5
45.0 79.0
3.5
55.0
Block
facilitator
29
PHC
staff
PRI
staff
0.0
72.1
7.9
8.3
66.7
25.0
30.0
45.0
25.0
____
National and State mention bi-monthly or monthly meetings of all ASHAs at block
PHC level. Rajasthan issued these guidelines in November 2006. During the fieldwork,
study teams did not learn of any monthly meetings. Perhaps, it would take some time
to ensure regular organisation of monthly meetings.
It is essential for ASHAs to understand role of other stakeholders with whom they
interact. ASHAs were clear about the roles of Anganwadi and ANMs and to an extent
about the role of PRIs in facilitating work. Regarding the roles of other stakeholders
such as NGOs, SHGs, only a few ASHAs were aware and it seems that this critical
element has not been dealt with during the first round of training. As convergence
and collaborations are the motto of good governance, this element has to be
reiterated in the next round of training. Efforts have to be made by senior supervisory
officers to orient them about the roles of other stakeholders, common areas of work
and how they could perform together or complement each other.
On the whole, discussions with other stakeholders revealed that ASHAs made efforts
to promote government health schemes and were recognized in the community. The
views of stakeholders about the ASHAs interact are summarized below.
PRIs
According to the six PRIs interviewed from six blocks, the community held the ASHAs
to be good and realized that ASHAs did useful things, motivating women for
institutional delivery and informing people about JSY. Some (two of the six) of the PRIs
did say that community was not happy with the ASHAs because they did not pay
regular household visits and did not do their job properly. It is not mandatory for
ASHAs to make home visits, yet they probably made contacts only by visiting
beneficiaries personally. Perhaps, the orientation training of PRIs might not have
discussed the roles and responsibilities of ASHAs in detail. PRI members suggested
that ASHAs should be given fixed monthly payments and timely reimbursements and
they would facilitate her work by talking to the community. They also suggested that
there should be a dress code for ASHA, so that people in the community recognize
them easily.
Non-Governmentai Organizations
Three district NGOs were interacting with ASHA and efforts were made by NGOs to
involve ASHAs in their programme activities. The NGOs said that their interactions
were limited and more ad hoc, but since the inception of the programme, ASHAs have
done what none of us could do. Appreciating the work, an NGO staff said:
"Until now no delivery from this village took place outside the village. With
continuous motivational effort of ASHA andJSY, women from the village have
started going to the institution for delivery, fke have also noticed an increase
in the immunization of children".
30
In another case, an NGO representative remarked:
"Just 15 days ago, a BPL woman was taken to Pokharan for delivery. Her
newborn was sick and had to be referred. ASHA took the baby to Jodhpur for
further treatment".
Similar such incident was mentioned by another NGO:
"This is an incident that happened more than one and a half months ago. AH
family members of the pregnant woman were working on the farm and the
woman developed labour pains. Since it was an emergency and ASHA
couldn’t wait for the family members to arrive, she alone shifted the woman
to the institution for delivery. Both the mother and child are doing well and
the family is indebted to ASHA
ANM
In each block, ANM was contacted to get the names of the ASHAs and discuss the role
of ASHAs and their interactions. ANMs confirmed that ASHAs took part in all the
stated activities. In words of an ANM,
"It is beneficial to have ASHAs. Earlier when I was alone, I was not able to
cover all the areas. Now through ASHAs we are able to cover the entire area.
She goes there and motivates people to avail services. Most benefit till now
has been for immunization programme and antenatal check up<.
Another ANM said:
"Most important is that she is from the same village. So she enjoys good
cooperation from the people in the village. For example, it has helped me a
lot and I could reach out to women from the tribal (BhH) community with the
help of ASHA and explain about the national health programmes and the
benefits under it. ASHA followed up with my visits and was able to motivate
women for institutional delivery!'
While these were the positive experiences, there were instances where ASHAs received
benefits without performing due to their proximity to local power.
31
pH
Gh-n
Anganwadi workers
All
the
six
Anganwadi
workers
interviewed knew about JSY and ASHA
programme in detail. They met ASHAs
almost every day or every alternate day.
Every first Thursday of the month was
observed as immunization day jointly by
ANM, AWW and ASHA. ASHAs came to
AWW regularly for getting records
checked. Both, AWW and ASHA worked
together during Swasthya Chetna Yatra.
AWWs opined that such an arrangement
was beneficial, mainly for ensuring
better coverage of women; poor women
got quality services and nutritional
food, and all the benefits of JSY. A
demand for services was created as was
AWW and ASHAs work together to
Celebrate immunization day
Organize health camp
Participate actively in Swasthya Chetna Yatra
Create awareness about the programme
Identify pregnant women
Attend gram sabha meeting
Organize health camps
Take care of antenatal women
Timely immunization of children
Household survey of the village
Discuss about institutional delivery
Weighing children
Maintains records
Provide curative medicines
Provide nutritional supplements
Explain about malnutrition and balanced diet
Door-to-door visits
Awareness about HIV/AIDS
reflected by an AWW:
understand and
and have
started coming
coming to us on their own. They
“"Now
Now people
people understand
have started
ask for immunization, iFA tablets, and are prepared to go for institutional
delivery”.
Intersectoral linkages were evident at the grassroots level. Such linkages and
networking had an advantage in creating demand by bringing about community
awareness, on the one hand, and increasing utilization of the services on the other.
Both implementation and monitoring of the scheme at the village level would prove
beneficial to the community and could lead to community mobilization and better
uptake of health services and overall development of the villages.
Strengthening of ASHA Intervention as Perceived by ASHA
All the ASHAs were asked strengthening intervention and challenges they faced. The
ASHAs interviewed opined that their engagement as ASHA was useful and most of
them thought that their overall knowledge and skills as ASHA worker were being
utilized. Majority of the ASHAs felt that they required more practical training
(Table 3.14).
Seven out of 10 ASHA had suggestions to offer. The common suggestions for
improving the ASHA intervention were related to enhancing cash assistance, giving
complete information during trainings, and teaching aids, role-plays, drama and
practical training. One-sixth of the ASHAs suggested that the scheme should be
propagated more on TV, in newspaper, camps and rallies. Others suggested monthly
payment, dai training, dress code and more incentives for motivating sterilization
cases.
32
Competition among ASHAs, breaking the social and cultural taboos practiced by the
community regarding
or
weighing
immunizing the baby,
institutional deliveries
were
major
reasons
apart from opposition
Table 3.14: Suggestions for further strengthening their work as. ASHAs and
challenges faced by ASHA in R^jastharb_2007_(Percent^g^
Total
Particulars_______________ ____________
173
Total number of ASHAs interviewed
71.7
Percent giving suggestion for improving JSY
(124)
Suggestions made by ASHA for improving the scheme*
35.5
Cash assistance should be more
not willing to work as Should give complete information
30.6
26.6
ASHA. Besides, delay Should use posters, role play, drama for training ASHA
20.2
in payment to JSY Should get good/practical training for ASHA
16.1
More propagation/advertise on TV/newspaper/camp/rally
beneficiaries
and
8.9
Should get monthly payment
constant
reminders
8.1
Dai should be trained
6.5
from them indirectly Facilities should be improved
3.2
Some
officials/doctors/nurse
should
talk
to
village
people
to
hampered the work,
complained explain JSY
ASHAs
3.2
ASHA should have a dress code
sterilization
that
2.4
Arrangement of transportation/van
9.6
by Others**____________
cases motivated
_______________________ ___ ___
were
being Challenges faced by ASHA*
them
24.9
registered by ANM. It Other ASHAs take away my cases
19.7
Village people are not ready for institutional delivery
also came to light
1 5.6
Women do not listen regarding weighing baby/immunizing child
doctors
that
few
1 1.0
My husband / family do not like my job
9.2
handle I have to listen to complaints from community for delay in
refused
to
cases payment
complicated
2.3
and then taking the Opposition from community/illiterate people
12.7
Others
beneficiary elsewhere
4.0
Do not know
_____________________ ____
resulted in awkward * Multiple responses
situations. It can be **People should recognize ASHA, good behaviour at the place of delivery,
more incentive for
inferred that ASHAs availability of lady doctor, dai kit for ASHA, and
sterilization, should get joining letter soon
work
has
to
be
complemented by rigorous and overarching behavioural changes by communication
from
the
family
for
campaigns. ASHAs should be given proper recognition so that they are respected as
important resources on health related issues in the community.
the training of ASHAs progressed well. The state modified the training
To sum-up,
module of GOI and compressed the first round of training from seven to six days.
Initially SIHFW was entrusted the responsibility for conduct of training, however mid
way ARC was asked to organize trainings with the help of NGOs. Engagement of NGOs
at the block level for organizing trainings resulted in improved logistical and training
arrangements and ASHAs were happy with the training pedagogy. ASHA’s knowledge
on various reproductive and child health aspects was good, however, there was need
for strengthening non-RCH components and other determinants of health.
generate demand and mobilize clients for reproductive and child
ASHAs were able to
health services. ASHAs also started accompanying few beneficiaries for institutional
deliveries. In executing their role as ASHAs, they networked with various stakeholders
other than Anganwadi worker or ANM and community has started recognizing them
for their work. It was observed that PRIs and others lacked precise knowledge on the
33
functioning of ASHAs and expected them to make home visits. ASHAs mentioned
areas of strengthening logistic arrangements that need to be taken up in the next
round of training. Performance based cash payments to ASHAs were untimely and
there were delays in payment. Only a small proportion of ASHAs were able to earn
money while majority of them were yet to start earning. This emerged as a serious
concern as in absence of regular cash in hand, it would be difficult to sustain interest
of ASHAs. One can hope that with change in eligibility criteria for JSY and including all
women, ASHAs would be in position to make more money for each woman escorted
by them.
34
Chapter 4
Beneficiaries of JSY in Rajasthan
The JSY beneficiaries were interviewed to ascertain their awareness, and the kind of
support received from ASHA, Anganwadi workers and ANM. The study examined the
processes of claiming benefits, difficulties faced in availing services/benefits, and
overall client satisfaction. The findings of interviews with 248 JSY beneficiaries from
the three districts who had availed JSY help in the six months prior to the survey are
presented. The study covered 40 JSY beneficiaries from each of the six blocks.
Background information of JSY Beneficiaries
Table 4.1 gives the characteristics of JSY beneficiaries. The mean age of the women
was 24.6 years. Above three-fourths of
the women were aged 20-29 years,
and one-sixth were aged 30 years or
more. Majority of the JSY beneficiaries
were illiterate (68 percent) or had
studied only up to primary and middle
level (22 percent). Less than 10
percent had studied above secondary
Table 4.1: Background information of JSY beneficiaries,
Rajasthan, 2007 (Percentage)
Total
Particulars____________________ _______
248
Total number of JSY beneficiary interviewed
Age of JSY beneficiary in completed years
6.0
< 19 years
43.1
20 - 24 years
32.7
25 - 29 years
18.2
30 years and above
level.
Mean (in years)________________
Years of schooling completed
Illiterate
Up to primary or middle (1-8 std)
Secondary and above___________
Religion
Hindu
Muslim_________________ ______
Caste
Scheduled caste
Scheduled tribe
Other backward classes
General
Do not know__________________
Monthly family income (in rupees)
<1000
1001-2000
2001 +
Eight out of 10 beneficiaries were
Hindus and the
remaining were
Muslims. Given the caste break-up of
24.6
68.2
22.2
9.6
83.9
the state against those who were
16.1
randomly selected in the survey, it can
be inferred that JSY has addressed its
16.9
cause
of
covering
socially
dis
16.9
50.0
advantaged communities, as one-third
13.3
of the beneficiaries were from SC and
2.8
ST categories. This observation is in
line with the caste composition of the
16.5
state. According to 2001 Census, 30
56.9
26.6
percent of the state
population
belonged
to
SC
and
ST.
The
2043
Mean (in rupees)
beneficiaries largely represented lower
income groups. It appears that JSY was able to address the core issue of social equity.
Awareness about JSY
All JSY beneficiaries were asked
Figure 4.1: Time when the beneficiary heard
how and when they came to know
about the JSY
of JSY. Figure 4.1 reveals that 7 out
of 1 0 beneficiaries heard about the
After
scheme during pregnancy, about
delivery
two after their delivery and only
19%
one had heard about JSY before
During
pregnancy'
pregnancy. The beneficiaries were
69%
asked about the sources from
Before
being
where they came to know of JSY
pregnant
(Table 4.3). It was observed that
12%
ANMs were the main source of
information followed by ASHAs (24 percent). Other functionaries like doctors and
anganwadi workers propagated JSY to about 12-14 percent of JSY beneficiaries while
an insignificant number of beneficiaries mentioned relatives and gram Panchayat. The
role of media was limited, as only three percent stated radio or television and 10
percent beneficiaries reported hoardings at health facilities.
Table 4.2: Sources of information about JSY in
______ Rajasthan, 2007 (Percentage)
Particulars________________________
Total
Total number of JSY beneficiary interviewed
248
Source from where heard about JSY*
ANM
71.0
24.2
ASHAs
Doctor
13.7
Anganwadi Centre/Worker
1 1.7
4.4
Relatives (parents, sister-in-law)
2.4
Gram Panchayat
2.8
Radio/ TV
Others / Hoardings at SC/PHC etc.
10.1
0.8
Don’t Rem ember___________________
Things heard about JSY*
Free institutional delivery services for poor
71.4
women with monetary benefits
Get/receive money
33.9
Promotion of institution delivery
23.0
Benefit of mother
18.5
For poor family
16.9
Family planning / population stabilization
10.5
2.8
For intake of nutritious food
1.2
Others___________________________
* Multiple responses
Other responses about JSY (Table
4.2) indicated that majority (71
percent) of the beneficiaries heard
that
JSY
provided for
free
institutional delivery services for
poor women
with
monetary
benefits. About 34 percent heard
that they would get some money
and another 23 percent mentioned
that the scheme was for promotion
of institution delivery. Others
understood JSY as one for benefit
of mothers and poor families,
while few linked it with family
planning
and
population
stabilization.
There is no doubt that ANMs and
ASHAs have made lot of efforts to
propagate the scheme at the
community level. Whatever the
beneficiaries understood and reported seems to be their own interpretation of the
scheme. Some of the respondents believed that the scheme was for family planning,
which needs to be corrected. Communication interventions should focus on
disseminating unambiguous and consistent message about the scheme.
36
Process of Registration under JSY
Registration under JSY is pre requisite to availing the benefits, and more so for
monitoring of the activities. Half of the beneficiaries had themselves approached
someone in the health department
for JSY registration, and health
functionaries
approached
the
remaining
half.
ANMs/LHV
(70
percent), doctors (1 5 percent), and
ASHA/Anganwadi workers
(13
percent) were responsible for ANC
registration.
Table 4.3: Process of registration under JSY of the
beneficiary in Rajasthan, 2007 (Percentage)
Particulars___________________________________
Total nurnber of JSY beneficiaries interviewed
Person who registered respondent for JSY
Doctor
LHV/ANM/FHW
Anganwadi worker
ASHAs
Others________ __
_______________________
Stage of pregnancy when registered for availing
Total
248
1 5.4
70.0
4.9
8.5
1.2
One-third registered in 1st trimester,
benefits of JSY
29 percent registered in the second First trimester
33.2
in
3rd Second trimester
29.2
15
percent
trimester,
14.6
Third
trimester
percent
whereas
1 1
trimester,
10.5
After delivery
registered after delivery. Thirteen
12.6
Do not know
percent did not know when they Place where respondent was registered
registered for availing benefits of JSY District/sub district hospital
4.0
21.1
(Table 4.3). Further probing on the Community Health Centre
12.6
place of registration revealed that 24 PHC
19.8
Sub centre
percent were registered at home;
15.8
Anganwadi centre
around one fifth each at the CHC, At home
24.3
2.4
sub-centre, and 13 to 16 percent Others______________________________________
27.0
were registered in the PHC and Percent who got a JSY card
Anganwadi centres respectively. Presuming that early registration (first trimester)
would have motivated them to seek full schedule of ANC, which would have better
results in terms of outcomes of pregnancy.
The study revealed that only 27 percent of JSY beneficiaries had JSY cards, and the
field team could verify only 1 8 percent of them at the time of the survey. In half of the
cases (48 percent), JSY cards were facilitated by ASHA. None, except one beneficiary
faced difficulty in procuring JSY card because ASHA and ANM did not support, as BPL
card was not available with the woman.
Utilization of ANC Services by JSY Beneficiarieis
The beneficiaries were asked about the antenatal services utilized by them. Six out of
10 women, the beneficiary themselves contacted someone from the health
department while the remaining were visited by health personnel. On average, the
first contact was made at 3.3 months of pregnancy with a median value of 3 months.
Regarding motivation to avail antenatal services, the study indicated that women were
influenced by the ANM/FHW, husbands, and by ASHAs. Self-motivation was another
prominent response.
As can be seen from Table 4.4, 9 out of
10 JSY beneficiaries had antenatal
check-ups and that too three times or
more.
Among
those
who
availed
Total number of JSY beneficiaries
248 antenatal services, majority visited the
interviewed______________ ____________
Number of times antenatal check-ups done
district hospital/ CHC (51 percent),
1 1.3
None
PHC/sub-centre
(45
percent),
and
3.2
1 time
Anganwadi centres (9 percent). One18.1
2 times
20.6 tenth of the women received antenatal
3 times
44.8 care at private hospitals or at home.
4 or more
2.0
I don’t remember
Husbands, mother-in-law/sister-in-law,
and
ASHAs accompanied the beneficiary
4.0
Mean (number of times)
for ANC visit(s). Other family members
accompanied the women for ANC visits as well. Two-fifths of women incurred some
Table 4.4: Number of antenatal check-ups during
index pregnancy, Rajasthan, 2007 (Percentage)
Total
Particulars _____________ ___________
expenses
expenses during antenatal visits including doctors’ fees, laboratory tests, transport
costs etc. The average amount spent during ANC period including doctors fees,
laboratory test was Rs. 1 408.9 approximately.
These findings seem to be exaggerated. In comparison, the Government of India’s
District Level Household Survey (DLHS), 2002-04 indicated that the antenatal
coverage in Bhilwara, Jaisalmer and Udaipur was between 36 percent and 87 percent
and ‘three or more times’ coverage ranged between 1 8 and 47 percent. Since the
disbursement of cash to ASHA was linked with antenatal, prenatal and BCG
vaccination, there could have been over reporting but on the other hand, the mean
number of times visited was around four times. Given these differences in results
between the two surveys, and considering the pre-conditions of linking payment to
ANC services, the finding were indicative of increasing ANC coverage in the study
area.
In all, 11 percent (n = 28) of them did not avail of any antenatal care services during
index pregnancy. These are difficult cases. ASHAs were able to identify these women
and efforts would have to be made to cater to this specific segment of the population.
ASHAs could enlist support of PRI members to persuade, cajole or motivate these
women for seeking ANC. In fact, cross-tabulation analysis depicted that, ASHAs made
more contacts with resistant communities and those from SC/ST and low-income
groups (Refer Appendix tables)
Table 4.5: Role of ASHA in micro birth planning for JSY
_____ benefidary, Rajasthan, 2007 (Percentage)
Total
Particulars________________ ____________
248
Total number of JSY beneficiaries interviewed
Percent discussed about micro birth planning
during the antenatal period*
Date of next check-up
Place of next check-up
Place of delivery
Expected date of delivery
Place of referral, if complications arise
85.9
63.3
61.3
54.8
1 1.3
* Multiple responses
38
Role of ASHA in Micro -Birth
Planning
Micro-birth
planning
includes
discussion and deciding the date of
next check-up, place of next check
up, place of delivery, expected date of
delivery, and place of referral, in case
of complications. Majority of the
ASHAs during their interactions with
the beneficiaries discussed one or all
aspects of micro-birth planning. They discussed the date (86 percent) and place (63
percent) of next antenatal check-up, and 55-61 percent discussed the expected date
of delivery and place of delivery, but only 11
percent talked about the places of
referral in case of complications (Table 4.5).
Forty percent of beneficiaries were informed by ASHAs about four or more aspects of
micro-birth planning, 20 percent were given half of the information, while the
remaining 32 percent were told about only one or two aspects of micro-birth
planning. Nine percent of JSY beneficiaries said that no aspect of micro birth planning
was ever discussed. Birth planning being one of the key elements for avoiding one of
the four delays is an area that could be taken up during the subsequent rounds of
ASHA training and by ANMs and Anganwadi workers with whom the ASHAs interact
frequently.
Intention and Actual Place of Delivery
The
asked
where
respondents
were
about
the
place
they
intended
to
deliver and against it, the
place where they actually
cross
was
delivered
WiiwlwWfflW
Place where Delivered
Total
Institutional At home
Intended place for last delivery
Institutional
At home__________________
Total
___
136 (54.9) 1 1 (4.4)
37 (14.9) 64 (25.8)
173 (69.8) 75 (30.2)
147(59.3)
101(40.7)
248 (100.0)
tabulated. It was found
that of the 248 beneficiaries interviewed, 147 (59 percent) intended to deliver in
institutions and the remaining (41
percent) wanted to deliver at home. It was
observed that 1 73 (70 percent) delivered in institutions and the remaining 30 percent
at home. In other words, between intention and actual practice there was a shift of 1 1
percent from home to institution. Majority of the deliveries took place in CHC/PHC.
Table 4.7: Motivation for institutional delivery among JSY beneficiaries
who had institutional delivery, Rajasthan, 2007 (Percentage)
Total
Particulars__________ ______________________________
173
Total number of JSY beneficiaries who had an institutional
Motivation and
Decision making for
Institutional Delivery
It
was
important
to
analyze
the
motivating
factors
and
decision
involved
making
deliveries
institutional
(Table
observed
in
4.7).
It
that
was
monetary
benefit offered in JSY was
reported by as many as
56
percent
of
the JSY
beneficiaries, followed by
44 percent stating better
access
to
institutional
delivery within
the area
as major motivators for
opting
for
institutional
delivery____________ ________________________ ____
Motivation for opting for institutional delivery*
Money available under JSY
Better access to institutional delivery services in the area
Support provided by ASHA
Support provided by health personnel
Previous child was born in an institution
Safe delivery of child/safety of both mother and child
Complicated delivery, had health problem, white discharge
Others / Previous history of still birth/miscarriage
Person who finally decided for institutional delivery*
Self
Husband
Mother-in-law
Father-in-law
Relatives/neighbours/users of the scheme
ASHAs
ANM
Others______________________________ ____________
* Multiple responses_______________________________
39
56.1
43.9
22.0
7.5
8.1
7.5
4.6
5.2
59.0
74.6
30.1
4.0
20.8
3.5
5.8
1.2
delivery. This was followed by previous experience of institutional delivery,
complications or still birth/ miscarriage and safe delivery of child and mother etc. All
these responses of motivation cited by beneficiaries were internalized on the basis of
their personal experiences. However, the interesting external motivating factor was
the support provided by ASHA (22 percent) and other health personnel (8 percent).
Further analysis of data on the background of beneficiaries in terms of education and
caste and income did not reveal major differences though the percentage varied
(Appendix Table 10). The responses of money available and access cut across all
segments.
In the final decision-making, husband, self, mother-in-law and relatives/ neighbours
or prior users of the scheme led to institutional delivery. The role of ASHAs and health
providers was insignificant. It is clear that just motivation of the beneficiary may not
suffice and other decision-makers in the family do matter. Some special efforts to
address this segment ought to be looked into.
Process of Arranging Transport to Reach Health Institution
Some of the major delays in accessing health services during delivery are, time taken
in recognizing the problem, arranging the transport, travelling time, and delay in
getting services after reaching the ultimate place of delivery. All the beneficiaries
reached the ultimate place of delivery directly from home travelling an average
distance of 11.6 kms from residence to the institution.
Table 4.8: Process of arranging transport to reach health institution,
Rajasthan, 2007 (Percentage)
Particulars_______________ ______________ ___________
Number of JSY beneficiaries who had institutional delivery
Percent who directly came from home to the place of delivery
Average distance to the place of delivery from respondent’s
residence (in kms)
Do not know-calculated by omitting this_________________
Mode of transport used to reach the ultimate place of
delivery*
Car/Jeep
Walking
Auto rickshaw
Motor cycle/scooter
Tempo/tractor
Bullock/Camel cart/chakda
Bus___________________ ___________________________
Persons who all facilitated in arranging the transport*
Family members
ASHAs
ANM/Health worker
TBA
Panchayat members/SHGs
Anganwadi worker
Others
_____________________________
_______________________
Percent mentioning that arranging transport was pre-planned
and necessary arrangements were made beforehand________
* Multiple responses _________
40
Total
173
100.0
1 1.6
12.2
60.7
15.6
6.4
5.8
5.8
4.0
1.7
82.9
8.2
4.8
3.4
2.7
1.4
3.4
22.6
Majority (61 percent) used
car or jeep to reach the
place
of delivery,
16
percent walked down (3
cases walked between 3-5
kms), while 6 percent or
less used auto rickshaw,
motor
cycle,
tempo,
tractor, bullock/camel cart
or
chakda
to
cover
distance up to 10 kms to
the
place
of
delivery
(Table 4.8). For 1 1 or
more kms mainly car,jeep
or tempo were used to
reach the ultimate place of
delivery. Family members
mainly
arranged
the
transport. ASHAs, trained
dais, Panchayat members,
self-help
group,
and
Anganwadi workers also
played a role in arranging
the transport. Despite the
programme interventions and availability of ASHA, only 23 percent of JSY beneficiaries
mentioned that the arrangements were pre-planned. This could be an area of
strengthening and can be linked as part of micro-birth planning orientation.
The average time taken to arrange the transport to the place of delivery was
estimated to be 27.8 minutes, ranging between 1 minute (to make a call) and 6 hours.
Again, it took on average more than half an hour (31.8 minutes) to reach the place of
delivery from the time the transport facility reached the beneficiary. The time taken to
travel to the place of delivery ranged between 5 minutes to 3 hours (Table 4.9).
Around 10-12 percent respondents did not know details about the distance travelled,
or time taken in arranging the transport and reaching the place of delivery.
■■
•
■
•
2007-____
Total
Particulars
Number of JSY beneficiaries who had institutional delivery_______________________________
173
Average time taken to arrange the transport since respondent decided to visit the ultimate
place of delivery (in minutes)
Range (Minimum - Maximum)
Do not know/can’t say________________________________________________________________
27.8
1 - 360
1 1.6
Average travel time taken to reach the ultimate place of delivery (From the time the
transport facility reached the respondent) (in minutes)
Range (Minimum - Maximum)
5
Do not know/can’t say________________________________________________________________
Average cost incurred for transportation to reach the ultimate place of delivery (in rupees)
Range (Minimum - Maximum)
Do not know
31.8
180
9.6
280.2
10 - 2050
19.9
On average, the beneficiaries spent Rs. 280.2 on transport to reach the place of
delivery. Nine out of 10 beneficiaries paid money for the transport expenses on their
own and an insignificant proportion were reimbursed later by either ASHA or ANM.
Eighty percent of those who paid on their own had made prior cash arrangements for
transport. It was noticed that in the previous guideline issued by the state, transport
reimbursement was not done at the institutions and ANMs were expected to do so.
Realizing gaps in reimbursement of transport to beneficiaries, the state sanctioned an
amount of Rs. 300/- and instructions were issued in form of circulars for reimbursing
at the facility in case ASHA has not accompanied the beneficiary.
Difficulties Faced in Reaching the Place of Delivery
Under JSY, it is planned that ASHAs would provide a referral slip to women for their
easy access to place of delivery and help in case of complications. JSY beneficiaries
were asked about their transport to the place of delivery, role of key stakeholders in
arranging for transport, and difficulties faced. Study found that less than five percent
of JSY beneficiaries were given referral slips by ASHA or other health personnel to
help them access delivery services. About nine beneficiaries, who had institutional
delivery, had some difficulty in reaching the health institution. In five cases, it was too
late in the night and transport was not available immediately, whereas in one case the
respondent did not have sufficient money. Issue of referral slip and payment of
advance transport money to the beneficiary or keeping some advance money with
ASHAs to be given to women, are few operational issues that could be considered.
41
Persons Accompanying JSY Beneficiaries to the Health Institution
Regarding ASHAs accompanying JSY beneficiaries to the places of delivery, it was
found that 19 percent of the beneficiaries reached the place of delivery between
midnight
and
early
morning.
Table 4.10: Persons accompanying JSY beneficiaries to the
Spouses accompanied three-fourths
health institution, Rajasthan, 2007 (Percentage)
the
women,
other
family
Particulars_______________________________________ Total of
Number of JSY beneficiaries delivered in institution
173 members
and
mother-in-law
Timing of the day when JSY beneficiary reached the
accompanied about 51-53 percent,
place of delivery
and mothers accompanied one-fifth
6 AM - 1 2 noon
28.3
them
(Table
4.10).
ASHAs
1 2 PM 6 PM
26.0 of
6 PM 1 2 AM
27.2 accompanied 18 percent women to
1 2 AM - 6 AM____________________________________ 18.5 the health institution for delivery,
Persons who all accompanied JSY beneficiary to the
while Dai, ANM and Anganwadi
health institution*
worker accompanied 10, 6, and 4
Husband
72.3
women
respectively.
Other family members
53.2 percent
Mother-in-law
50.9 Needless-to-say that the presence
Mother
20.2 of
ASHAs
facilitated
obtaining
ASHA functionary
17.9
services at the place of delivery, as
TBA/dai
9.8
ANM/Health worker
6.4 confirmed by most (90 percent) of
Neighbour or other
4.6 the 31 JSY beneficiaries escorted by
Anganwadi worker_______________________________
3.5 ASHA. They helped in expediting
Number of JSY beneficiaries accompanied by ASHA
31
registration and other administrative
Percent of ASHA who facilitated in obtaining
90.3
activities
(68 percent), spoke to the
services for JSY beneficiary on accompanying them
medical personnel (46 percent), and
* Multiple responses
helped in getting JSY cash assistance
(43 percent). A few provided psychological and moral support.
Quality of Services Available at the Place of Delivery
The study tried to ascertain the quality of services at the place of delivery like,
promptness in attending the delivery case, waiting time, person attending the delivery
and average stay in the hospital following the delivery. Twenty-one percent of the
women did not know about the time taken to complete the registration process,
others said that, on average, it took 12.3 minutes to complete the administrative
process. It took another 12.7 minutes of waiting until someone attended JSY
beneficiary.
Most (95 percent) of the deliveries
were normal, three percent were
______
Particulars
Total caesarean, and two percent were
Norm aide live ry (n = J 6£)
15.2
assisted deliveries. The doctor
Assisted (forceps, centouse, vacuum) (n
31
49.7
conducted 31
percent of the
Caesarean (n = 6) __________
188.0
deliveries at the institution, while
ANM, nurse or LHV conducted two-thirds of the institution deliveries. On average,
women were discharged within 22 hours (or on same day) after delivery. Further
analysis showed that a woman with normal delivery was discharged within 1 5.2
hours, around 2 days for assisted delivery and after 6 days for caesarean (Table 4.1 1).
Going by the GOI norms, the minimum duration of stay recommended for normal
s was
42
delivery is 48 hours. Thus, there was a departure from the prescribed norms.
Government of India should tackle this in subsequent discussions with the state.
Payments Incurred for Services at the Health Centre
It is necessary to know the expenses incurred by women to avail certain services at
the health institution. Table 4.12 shows that majority of the women (64 percent) had
to pay for services at the
Table 4.12: Payments incurred for services at the health centre,
health centre, mostly for
Rajasthan, 2007 (Percentage)
Total
medicines/IV fluids (94 Particulars
—
173
and Number of JSY beneficiary delivered in institution
delivery
percent),
64.2
(60 Percent who had to pay for services at the health centre
charges
operation
(111)
(less Number of JSY beneficiary delivered in institution
Others
percent),
173
than 12 percent) paid for Specific services for which were charged
93.8
food,
accommodation, Medicines/IV fluids
59.8
laboratory
tests
and Delivery/caesarean /Operation charge
1 1.6
Food charges
diagnostic or sonography
10.7
Accommodation charge
9.8
tests. On average, JSY Laboratory test
9.8
beneficiary
spent
Rs. Diagnostic/sonography
2.7
_________________________
1277.6 for the index Paediatric care
1277.6
Average total amount spent for the index delivery (in rupees)
delivery. One-fifth of the
20.4
Do not know _________ ________
women did not know
about the expenses3 incurred and hence were omitted while calculating average
finding could not be probed further in the field during
amount spent. This iimportant
,
the survey activities. There is a need to examine this aspect in detail because the
scheme is meant for the poor. The poor have started accepting services, the
motivating factor has been the monetary incentive, and if they incur non
reimbursable expenses as observed, it would be difficult for ASHAs and ANMs to deal
at the field level.
Satisfaction with the Services at the Piace of Delivery
Despite additional expenses, it was observed that almost all JSY beneficiaries were
satisfied
with
the
services r Table 4.13: Satisfaction with the services at the place of
available at the place of delivery.
deliveryt Rajasthan, 2007 (Percentage)
The reasons were good behaviour Particulars_______ ___________________________ Total
173
of the health staff and doctors, Number of JSY beneficiary delivered in institution
Percent satisfied with the services available at the
cleanliness maintained at the
97.7
place of delivery
health facility, and counselling Reasons for satisfaction with the services at the place
about
follow-up
visits, of delivery*
72.8
breastfeeding,
immunization, Health staff and doctors were courteous
37.0
Counselled
about
follow
up
visit
family planning, newborn care,
36.4
Health facility was clean
and diarrhoea management (Table Counselled for breast feeding/immunization
26.0
4.13). A few others (2 percent) Counselled for family planning
6.9
2.3
expressed dissatisfaction with the Counselled for newborn care, diarrhoea management
—
services as the staff members ‘ Multiple responses
rude, facilities were not clean or adequate and quality of services was poor. On
were r
the other hand, majority of the ASHAs during their interviews reported that the
cooperation received at the place of delivery was very good (33 percent) or good (55
43
percent) while a few expressed their apprehension regarding cooperation received at
the place of delivery.
Persons who Assisted Home Delivery and Views about TBA
Of the 75 deliveries conducted at home, majority were attended to by the TBAs and
LHV/ANM/Nurse (Table 4.14). The beneficiaries also mentioned assistance of friends
and relatives.
Table 4.14: Persons who assisted Home delivery and views about TBA,
Rajasthan, 2007 (Percentage)
Particulars
Persons who all assisted the delivery*
Doctor
LHV/ANM/Nurse
ISMP doctor
TBA
Friends/relatives
_______________
Others________________ _______________ _ _______________
Number reporting delivery at home___________________________
Percent opined that TBA can provide all necessary midwifery services
Total
2.7
33.3
1.3
73.3
33.3
13.3
75
31.5
Reasons for saying that TBA can provide necessary midwifery
services*
TBA is easily accessible
TBA charges less money
Traditionally has been conducting deliveries in the family
TBA has better knowledge of the cultural practices and follows it
Better comfort level with TBA
Others________ _______________
_____________ ________
* Multiple responses_________________________________________
32.1
32.1
32.1
28.2
29.5
2.6
All the JSY beneficiaries
who delivered at home
were asked to give their
opinion about the role of
TBA in providing the
necessary
midwifery
services.
Every
third
beneficiaries
believed
that
TBA/dai
could
provide all the necessary
midwifery services. They
mentioned
that TBAs
were easily accessible,
charged less money, had
been
traditionally
conducting deliveries for
other family members,
were familiar with the cultural practices, and women felt more comfortable with TBA
around (than doctor or nurse).
Dynamics of Delivery at Home - Who all prefer delivering at Home?
Analysis was undertaken to understand those who delivered at home and their access
to the health system. The analysis presented in Table 4.15 clearly shows that every
third women who had
------------------------- -------------—— ------ ------- - —Table 4.15: Background information of JSY beneficiary ,
no formal education or
Rajasthan, 2007 (Percentage)
had studied up to
Institution At home Total N
primary, delivered at
Percent not attended formal education or
192
34.4
65.6
studied up to primary
home. It is surprising
56
16.1
83.9
Middle level or more________ _________________
that even among the
Percent belonged to
every
sixth
84 literate,
41.7
58.3
Scheduled caste / Scheduled tribe
124 woman in Rajasthan
25.8
74.2
Other backward classes
40 preferred to deliver at
20.0
80.0
High caste Hindus/general_____________________
248
1642.0
2221.2
Average monthly family income (In Rs.)
home.
Caste
wise
break-up shows that 42 percent of the women belonging to SC/SC delivered at home
as against 26 percent belonging to other backward classes and 20 percent of the high
caste Hindus. Income wise, women who had home deliveries had an average monthly
family income of Rs 1,642 as against Rs 2,221 among women who had institutional
deliveries.
44
No doubt, women with lesser education, from SC/ST and lower economic status
preferred home deliveries but there were substantial proportion within these
categories that opted for institutional deliveries. The issue of home deliveries was
probed and JSY beneficiaries who delivered at home were asked their reasons.
The reasons for not preferring institutional delivery were fear of hospitals/fear of
needles, injections and equipment, belief that women get better care at home, poor
cleanliness at hospital and fear of doctors and other staff members. These three
responses contributed to about half of the responses. There were more
apprehensions among women who delivered at home in comparison with their
counterparts who delivered in institutions. Family opposition and hospital expenses
were other important reasons. Thus, apprehensions of visiting health institutions, fear
of injections, needles, equipment and service providers, and cost incurred on services
are the reasons rather than other elements listed as reasons in Table 4.16. It can be
said that the apprehensions of the beneficiaries prevent them from utilizing
institutional services, which should be attended to.
Table 4.16: Perceived reasons for women to deliver at home despite cash assistance being paid under
JSY for institutional delivery, Rajasthan, 2007 (Percentage)
_
Particulars_________________ ___________________________ ____________________
Reasons for preferring home delivery*
Fear of going to hospital / needle, injection, equipments
Women believe they get better care at home/no cleanliness maintain at hospital
Fear of doctor, nurse
Illiteracy and lack of understanding of the importance of institutional delivery
Total
22.7
25.3
12.0
14.7
13.3
Opposition from family members
There are expenses in the hospital /Home delivery is cheaper
10.7
10.7
Because of poverty
Unaware about JSY
Unavailability of transport facility on time
Because of stitches / fear of caesarean
Dai (TBA) takes better care while assisting delivery
4.0
9.3
8.0
9.3
5.3
Clinic far away/much distance
If there is any complication they go to hospital or contact us
8.0
Prefer home delivery by dai
Don’t get time to go at hospital/delivered before due date
5.3
2.7
1.3
Staff is not cooperative/rude
Others**
Do not know
Total
____________
__
_______________________
5.3
8.0
75
* Multiple responses
**Fear of bad omen, most go to hospital, fear of dai, dai does not allow to go to hospital, ANM prescribes home
delivery, nobody at home to accompany for hospital, didn’t get money for institutional delivery, shy of going to a
doctor for delivery, roads are bad, ANM told us to give money at home
45
Mode of Payment and Difficulties Faced
The study reveals that 85 percent of the beneficiaries received JSY cash assistance for
delivery. Three-quarters of the women who delivered at home as against 88 percent
of
those
who
delivered
at
Particulars________
Institution At home Total
Percent received JSY cash assistance for delivery
88.4
76.0 84.7
institutions received
(153)
(57) (210)
JSY cash assistance
Number of JSY beneficiary_____________________
173
75
248
(Table 4.17).
Time when received the money
Before the delivery
Immediately after or within a week after delivery
Much later___________________________________
4.0
45.0
51.0
5.3
7.0
4.3
34.8
61.0
It is remarkable that
all JSY beneficiaries
Person who gave cash assistance to JSY
received
cash
beneficiary
assistance in one go.
ANM
50.3
87.7 60.5
However, the timing
CMC / PHC doctor / MO
26.8
0.0 19.6
Staff at Health Centre / Accountant
14.4
3.5 1 1.5
of receiving cash
Panchayat
1.4
0.0
5.3
was significant. Four
ASHA
1.3
0.0
1.0
out
of
10
Others / do not know_________________________
7.2
3.5
6.2
beneficiaries
Place where received cash assistance money
At home
24.2
26.3 24.8
received before the
Place of delivery
0.0 24.3
33.3
delivery or within a
Within the village
7.2
31.6 13.8
week of delivery and
CHC/ PHC / Sub-centre
31.6 28.5
27.5
the
remaining
Camp
5.2
8.8
6.2
Do not know_________________________________
received much later.
2.6
1.8
2.4
Average amount received byJSY beneficiary
Break-up
between
(in rupees)___________________________________
885.7
496.2 780.3 institution and home
i! Multiple responses
deliveries indicated
that half of the beneficiaries who delivered in institutions received cash assistance
within a week of delivery while only 12 percent received for home deliveries. In
majority cases, especially home deliveries, ANMs was the main source of cash
disbursement, and for institutional deliveries, it was ANM followed by medical officer
at the CHC/PHC and accountant.
87.7
Place of disbursement of cash assistance depended on the place of delivery. The
findings are in conformity with the fund flow mechanism set up by the state. Most of
the home delivery beneficiaries received payment in the village of their residence
while institutional delivery beneficiaries were paid at the place of delivery or at PHC/
CHC/SC or by the ANM. The beneficiaries, who delivered in institutions, were given
vouchers with discharge. This voucher along with verification of ANM or ASHA was
mandatory for release of payment. In few instances; ANM accompanied beneficiaries
spouse or relatives and in several other cases, vouchers were collected and submitted
by the ANM at the facility, cash was collected and distributed to beneficiaries at their
residence. Multiple channels of disbursement were followed and the state made
efforts to ensure payments.
On average, a JSY beneficiary who delivered in an institution received, Rs. 900 while
home delivery beneficiaries received around Rs. 500. Since beneficiaries covered were
given cash assistance at different points in time (survey included beneficiaries who
46
had delivered six months prior to it, conducted between January and March), it was
difficult to relate to the different guidelines because some of them received Rs. 700
when the scheme began, which was increased to Rs. 1,400. There could have been
spill over of few cases.
Most
(96
percent)
of
the
beneficiaries felt that the process
in disbursing cash assistance was
simple. Eight out of 210 (4
percent) of them who received
incentive for delivery reported that
they had problems in getting
money. They did not get their
payment when they needed it most
and had to visit the facility several
Figure 4.2: Sufficiency of cash incentives
received by JSY beneficiary
Sufficient
48%
Somewhat
sufficient
36%
Not
sufficient
16%
times.
The adequacy of cash incentives
______________________
has to be interpreted with caution
as the amount has doubled since the inception. Given whatever was offered at that
time, one-sixth of beneficiaries said that the cash assistance was not enough to meet
the expenses. Others thought that it was sufficient (48 percent) or somewhat
sufficient (36 percent).
Explaining the process of payment at the health institution, an Account Officer said,
“Our cashier makes the payment. A discharge slip is required with signature
of the medical officer in-charge. Then the Babu (local term for Clerk) fills m a
form, and attaches discharge slip and ANC card to ensure that full ANC care
has been received by the beneficiary. Only those JSY beneficiaries who
received full ANC care get the cash assistance. The form is also signed by
ANM or ASHA who accompanied JSY beneficiary and the beneficiary herself.
This process takes a long time".
It appears that in order to get the incentives, full ANC care is essential and hence
women ensure that they get full ANC care so that they get total cash assistance.
Use of Cash Assistance Received for Delivery
The beneficiaries were asked ‘how did they use the money received underJSYTl\bout
two-fifths of them purchased consumables for the family and bought medicines/
tonics for self and child, while one-fourth said that they used it for self-nutrition or
the husbands took it away. A few (6 percent) saved it, while only one percent used the
money for medical expenses for delivery. According to the Anganwadi workers,
women used cash assistance for buying medicines, household expenses, to meet
expenses during delivery, and some women used it to repay loans taken for meeting
delivery expenses. The cash assistance was beneficial to poor women.
47
Appreciation of JSY by the Beneficiaries
Most women were satisfied with JSY and they would recommend relatives or friends/
neighbours to be beneficiaries under JSY as they received cash immediately on filling
forms. The cash received helped them to meet additional expenses incurred at
hospital. Besides, they had safe deliveries in the hospitals and staff members and
nurses were good. They received nutritious diet and the newborn was looked after.
Women also appreciated that immunization of babies was initiated and were
explained details. While these were views of majority of them, a few (miniscule
proportion) did not appreciate the scheme because they did not receive the cash
assistance. Few others said that they preferred home deliveries by Dai. They said that Dai
understood social and cultural customs better than doctors did, and family members
could relate better to Dai who was from the community. They added that even home
deliveries were compensated so why worry about the difference in assistance. In this
environment, it would be difficult for an ASHA like person to cope up and hence they
should be empowered to discuss finer aspects of going for institutional deliveries and
bring such cases to the notice of supervisory health officials.
Impact of JSY on Institutional Delivery
JSY beneficiaries were asked about place of delivery of the last child born prior to the
index child. Of the total 1 73 JSY beneficiaries interviewed, 1 66 had history of previous
birth more than one and half
Table 4.18: Shift In the place of delivery before and after JSY in
years
ago.
These
166
____________ Rajasthan, 2007 (Percentage)
beneficiaries were considered
Place of delivery for last (JSY) child
Particulars
and cross-tabulated by place
Total
Home
Institution
of delivery of previous child
Place of delivery for last
but one child
with that of the index child.
54 (32.5 )
8 (4.8)
46 (27.7)
Institutional
This would indicate whether
50 (30.1) 112 (67.5)
62 (37.4)
Home
there has been any shift in
166
58
108
Total
(100.0)
place of delivery since the
(34.9 )
(65.1)
inception of JSY. It was observed that 54 JSY beneficiaries (33 percent) had gone to
institutions even for their previous delivery, while the remaining 1 1 2 (67 percent)
were home deliveries. In case of index pregnancy, 108 births (65 percent) were
institutional and remaining 58 births (35 percent) were home deliveries. Institutional
births were around one-third for the last birth that had doubled for the index
pregnancy. Sixty-two women shifted from home to institution between two deliveries
mainly because of money available under JSY (n=33, 53 percent), better services at
hospital (n=27, 44 percent) and support provided by ASHA (n = ll, 18 percent).
Consequently, there has been a substantial decline in home deliveries. The findings
cannot be generalized because the sample had confined to only those who had
availed JSY benefits. Yet by comparing with their past behaviour, there has been
substantial change and the results could be considered as indicative.
To substantiate the finding, service statistics on institutional deliveries for the three
selected districts and the state were analyzed for three years from 2004-05 to 200607, that is, one year before and one year after JSY intervention (Table 4.19). It is
found that in 2004-5, about 3.83 lakh institutional deliveries took place in public
sector institutions and in the subsequent year, there was a marginal drop of 0.25
48
percent. However, in 2006-7, one year following the launch of JSY, the performance
was 5.20 lakh. In other words, the performance increased by more than one-third
over the 2005-6 performance.
Table 4.19: Performance of Institutional Deliveries in Public Sector,
Rajasthan, 2004-7 (percentage)
percent increase/ decrease
Percent increase/ decrease
2004- 2005- 2006District
between
2005^6 and 2006-7
between
2004-5
and
200576
Q5
P^__ 07
_______________________
36.08
_
___________________
7.21
14712
10084 1081 1
Bhilwara
_____
__
42.62
__________ 1 1.38
3741
2355
Jaisalmer
2623
____________ 59.47
______ IJ 0J 8
22588 22628 .36086
Udaipur
35.97
-0.25
Rajasthan 383086 382128 519579
Likewise, increase in institutional deliveries was witnessed in the study districts.
Based on observations from the survey and service statistics, it can be inferred that
JSY has had an impact.
Role of ASHA in JSY
ASHAs, as expected, had heard about JSY during induction training and were later
briefed about it by various health functionaries, the most common being the ANM.
ASHAs were clear about the different activities they were to perform in JSY. This is
evident from the beneficiary assessment wherein it was found that they were
supportive right from pregnancy to childbirth in at least one-fourth of deliveries.
ASHAs were aware of their roles and responsibilities in JSY regarding antenatal
services, complications during pregnancy and child-birth and thereafter, micro
planning, referral care, arranging for transport, accompanying women for deliveries
to institutions and ensuring child immunization services. However, their knowledge
about eligibility criteria of beneficiaries and the amount to be paid to them for
institutional and home deliveries was inadequate. This is understandable because JSY
guidelines had undergone four revisions since inception and in LPS, there were two
revisions related to payment.
Post-natal care was the most infrequently discussed topic. It was mentioned neither
by beneficiaries nor by ASHAs. Interestingly, the state had provided cash incentive of
Rs. 50 to ASHA for rendering post-natal care, but it did not come out clearly during
the interviews. What came out during discussions on post-natal care with ASHAs, was
related to breast feeding, child immunization, new-born care and follow-up advice.
Analysis of cash incentive earned by ASHAs pointed to only two things and that was
related to delivery services and child immunization. It is felt that post-natal care
might not have been emphasized much in comparison with delivery and other
elements. There is a need for reorientation on this important aspect because of its
direct relevance on maternal mortality.
All in the community and health functionaries recognized the services of ASHAs. Her
role in motivating beneficiaries for institutional delivery services and accompanying
them to institutions has emerged significantly. Given proper support from the health
system and other stakeholders and strengthening her hands with effective
49
behavioural change communication, the role of ASHA in promoting institutional
deliveries will be more visible in near future.
It can be inferred that the state has been able to disseminate the scheme through
various inter-personal and mass-media activities. Most of the beneficiaries heard
about JSY during their pregnancy and their knowledge about the scheme was
incomplete in respect to the content of JSY guidelines. ANMs and ASHA were the
sources from whom majority beneficiaries became aware of the scheme and its
benefits. Reach of other media was limited. As far as uptake of services by
background characteristics of beneficiaries was concerned, one could say that JSY has
been able to address its objectives of promoting institutional deliveries, among the
poor and socially disadvantaged population. ASHAs have explained micro-birth
planning aspects in part to the beneficiaries and accordingly worked out details of
institutional deliveries. It appears that more thought needs to be given for
operationalizing micro-birth planning to make this a distinct activity.
Most of JSY beneficiaries were satisfied with the services at the institution and were
happy with the courteous behaviour of the staff members. The transport cost for
reaching the facility in majority of cases was not reimbursed either at the facility or
later and cash assistance for delivering in the institution was received within a week
of delivery or much later. Nonetheless, the beneficiaries were satisfied and as
satisfied users, they expressed that they would be recommending institutional
deliveries within their community. The major triggering factors for availing
institutional delivery facility were the cash incentive, accessibility and availability of
health staff and support of ASHA, while the reasons for not availing institutional
delivery services despite the cash assistance were fear of visiting hospital, behaviour
of doctors and other staff. When beneficiary’s place of delivering the child prior to the
index birth was compared with the index birth, there was a clear shift from home to
institutional delivery indicative of impact of JSY. Thus, it can be inferred that JSY has
been able to address its objectives and given further impetus by streamlining
payment related mechanisms, and undertaking demand generation activities, the
performance could be further enhanced.
50
Chapter 5
RECOMMENDATIONS
Summary of Findings
Rajasthan has made concerted efforts to operationalize ASHA intervention and JSY.
National guidelines of ASHA and JSY, were reviewed, adapted and translated to suit
the local context. The State has also thought through of setting up an institutional
modality for nesting ASHA intervention in an inter-sectoral convergence environment.
The state took a policy decision for selecting Sahyogini of Anganwadi Centre as
ASHA-Sahyogini. This has been hailed as a major step facilitating convergence at the
cutting edge level. State ASHA Mentoring Group was constituted with representation
from DWCD, Health Department, NGOs and Development Partners with clear terms of
reference. However, the meetings of this group do not take place on regular basis.
Likewise, ARC has been set up to function as Secretariat of ASHA intervention. While
SMG provides mentoring support and is a policy advisory group, ARC has been
mandated to organize and deliver ASHA intervention right from selection, training to
monitoring and supervision and updating the progress and informing SMG on a
periodic basis. Thus, the state has sent out very clear signals in terms of focus on
convergence and at the same time achieved synergies.
The state modified the book number 1 and facilitators, guide of GOI and compressed
the first round of training from seven to six days. Initially, SIHFW was entrusted with
the responsibility for conducting the training, however mid way through ARC was
asked to organize trainings with the help of NGOs. Involvement of NGOs at block level
for organizing trainings have resulted in improved logistics and training
arrangements and ASHAs were happy with the training pedagogy. ASHA’s knowledge
on various reproductive and child health aspects is good, yet there is need for
strengthening non-RCH components and other determinants of health.
a
ASHAs were able to generate demand and mobilize clients for reproductive and child
health services. ASHAs also started accompanying few beneficiaries for institutional
deliveries. In executing their role as ASHAs, they networked with various stakeholders
other than Anganwadi workers or ANM and the community has started recognizing
them for their work. It was observed that PRIs and others lacked knowledge on the
functioning of ASHAs and expected them to make home visits on regular basis.
Performance based cash payments to ASHAs were untimely and there were delays in
payment. Only a small proportion of ASHAs were able to earn money while majority of
them were yet to start earning. This emerged as a serious concern, because in the
absence of remuneration, it would be difficult to sustain interest of ASHAs for long.
One also hopes that with change in eligibility criteria for JSY, ASHAs will be able to
make money for each woman in delivery escorted by them.
and
15^0
About JSY, the state was able to disseminate JSY through various inter-personal and
mass media activities. Most of the beneficiaries had heard about JSY during their
pregnancy and their knowledge about the scheme was incomplete. ANMs and ASHA
were the sources from whom majority beneficiaries became aware of the scheme and
its benefits. The scheme will benefit from investment in ANMs and ASHAs
reorientation in the form of FAQs about the scheme for effective transmission of
unambiguous messages. Reach of other media was limited. One can conclude that JSY
was able to address its objectives of promoting institutional deliveries among the
poor and socially disadvantaged population. ASHAs explained micro-birth planning
aspects partially to the beneficiaries and accordingly worked out details of
institutional deliveries. It appears that more thought needs to be given to
operationalizing micro birth planning and efforts have to be made to project it as a
distinct activity, distinguishable from the routine messages.
Most of JSY beneficiaries were satisfied with the services at the institution, as the staff
members were courteous. The transport cost for reaching the facility in majority of
the cases was paid by the beneficiaries and only a few were reimbursed. This is an
area of concern where further explanation need to be sought. Concerning cash
assistance to the beneficiaries delivering in institutions, majority were given within a
week of delivery or much later. The beneficiaries were satisfied and as satisfied users,
they expressed that they would recommend institutional deliveries within their
community.
On the role of the state in respect to involvement of private sector in JSY, very little
has been done. A medical professional expressed that private sector presence in most
of the districts of the state was minimal and the accreditation criteria seem to be
stringent to it. However, some headway is being made and listing of private facilities
has been initiated. Overall, the major triggering factors for availing institutional
delivery facility were the cash incentive, accessibility and availability of health staff
and support of ASHA. The reasons for not availing institutional delivery services
despite the cash assistance were fear of visiting hospital, behaviour of doctors and
other staff.
Recommendations
These recommendations stem from analysis of the findings and discussions with
stakeholders. These findings are organized in three clusters such as policy;
programme related and demand side issues.
Policy
The state took a major policy decision of forging inter-sectoral convergence with
DWCD with institutionalization in perspective and looked forward to implementing
ASHA intervention by setting up of ARC within the state resource centre. This was
indeed a remarkable decision and the study suggested for certain areas requiring
attention. They are.
52
1. SMG last met in Nov 2006 and the meeting of the group is yet to be held this
year. SMG being think tank can offer guidance on implementation issues
related to health department officials complaining about Sayoginis division of
work, acceleration of pace of trainings, integration of ASHA trainings with
Sahyogini trainings, accountability and spending more time on ICDS activities.
These issues could have been given priority and resolved. SMG should also
suggest communication strategy for the interventions.
2. ARC is seen as an implementation arm for ASHA intervention. Non-availability
of ARC network in the districts remains an issue. It appears that interface of
ARC with DPMUs through SPMUs or directly needs clarity in terms of reporting
arrangements. The present structure of ARC depicts direct monitoring of
ASHAs by DPMU, while the national guideline has stressed the role of block
facilitators in monitoring, supervising and providing mentoring support to
ASHAs. As continuing education of ASHAs through monthly PHC level meetings
has been proposed, there is a need to look into the existing structure and
involve block facilitators in accordance to the national guidelines.
3. The findings from the study clearly suggest the need for effective engagement
of PRIs in implementation of ASHA and JSY. District Health societies should
ensure active participation of PRIs at different levels. In fact, SMC should
develop a guidance note on design of activities to facilitate PRIs engagement at
different levels. This will also take cognizance of critical support the PRIs are
to offer for formulation of village health plans, use of untied funds etc.
4. Another important area that did not emerge in the study but is worth
mentioning is the revision of Sahyogini curricula of DWCD. Since the state has
already decided and has issued Government Orders of Sahyogini working as
ASHA, the ASHA training component could be included as part of the future
induction training programme of Sahyogini. This topic could be taken up for
discussion in SMG.
5. A new addition in JSY guideline is the provision of Rs. 1,500/- to a private
practitioner attending complicated deliveries in public health setting. So far, no
money was spent under this provision. SMG should also provide guidance note
on how this facility can be utilized by public system doctors. This will entail
clear definitions of complications, setting up procedures for hiring private
doctors and assigning responsibilities amongst staff members.
Programme Management
1. The state has nodal officers for ASHA and JSY who are involved in all the
activities like development of annual plans, implementation, review,
monitoring and supervision. District and state health action plans for NRHM
should reflect on ASHA and JSY interventions including activities and financial
requirements. This will facilitate results based management. It is a matter of
concern that only one round of training was completed although GOI has
finalized and disseminated book 2, 3 and 4 as reading material for ASHA. ARC
S3
should be entrusted with the responsibility of developing consolidated state
work plan for ASHA, while district plans should be developed by the DPMUs,
based on the guidelines formulated by ARC.
2. Monthly meeting with ASHAs at the PHC level has been proposed in the state
guidelines. State guidelines are elaborate and provide information about
agenda items, participants and financial resources. Continuing education is an
important component and has to be supplemented with appropriate reading
materials/on the job tools that are easy to comprehend. Hence, it is
recommended that ARC should put together appropriate reading materials to
be shared with ASHAs during the monthly meetings. This will also help in
reinforcing knowledge in key areas.
3. Issues related to timely payments after training and ensuring availability of kits
during training also need immediate attention. Study findings indicate non
receipt of payments by ASHA at least in one district. The supply of drug kits to
ASHAs was done much later after the training. This has to be streamlined so
that ASHAs can be explained the contents of kit and its use. One of the
observations relates to inclusion of drug Dyclomine HCL-lOmg in the kit. This
drug is supposed to be made available only through prescription and is not an
over-the-counter (OTC) drug. It is expected that state authorities would review
contents of the drug kit in light of these observations.
4. Timely payments to ASHAs and JSY beneficiaries are necessary for sustaining
interests of ASHAs for mobilizing women to seek institutional delivery services.
The study found that payment to ASHAs were delayed in several instances,
despite clear instructions for immediate payment. Likewise, payment to JSY
beneficiaries were proposed. The new guidelines suggest that payments
should be made immediately at the facility itself. Our finding is that, there is
scope for causing ambiguity regarding payments. State should issue a
guideline for making payments and same should be widely publicized in terms
of entitlements
5. The Support Mechanism to ASHA has been designed by GOI and shared with
the states. After reviewing the ARC structure, it is clear that Rajasthan has not
followed it and the role of block facilitators has been kept at the minimal level
after the training. The national guidelines clearly state that for every 10 ASHAs
there has to be a block facilitator who would be responsible for supporting
her. The involvement of DWCD members and PRIs in block and district
monitoring should be ensured and implementation related issues could be
deliberated and resolved. The state should work out ways for strengthening
the support system. By doing so, it will strengthen ASHAs and recoil effects
would enable improvements in utilization of other health services and JSY
uptake.
6. One of the areas where very little work has been done is involvement of private
sector in providing institutional delivery services. The state could initiate
accrediting private sector facilities in the districts with significant presence of
54
private sector. As of now amount of money for cash assistance has been
increased substantially and given the prevailing charges for a normal delivery,
which is around Rs. 1 000/- to 1 500/- in a sub-district private facility, there is
definitely scope for increasing number of institutional deliveries through the
private sector.
7. Innovation in the form of JSY help-line through NGOs has been experimented
by the state and one; block of each district is covered. However, before the
state decides on replication or up scaling, a proper assessment should be
undertaken.
8. State may also like to consider organizing exchange visits of ASHAs to
neighbouring districts, so they learn from each other and also build a network.
Block facilitators /NCOs can be identified for organizing such activities.
Demand Generation
Need for proper programme related communication has been observed at various
levels: providers, stakeholders including community. The state government
introduced the ASHA intervention and JSY and followed the routine track of publicity
without getting into the nitty-gritty’s of how the communication strategies could be
made effective. Communication interventions were limited to disseminating
guidelines in the form of circulars and some mass media activities in the form of wall
paintings and billboards.
The way the state has gone about has resulted in incomplete dissemination of
messages. Neither the key stakeholders such as PRIs, SHGs and others nor the
community have complete knowledge of roles and responsibilities of ASHA or finer
details of JSY. Overall, there was no Behavioural Change Communication (BCC) plan
for publicizing ASHA intervention and JSY. Moreover, there was no conscious effort
for disseminating messages during Village Health and Nutrition Day, Immunization
Sessions or RCH Camps. Hence, it is suggested that the following be done:
1. Prepare a comprehensive BCC annual plan for ASHA intervention and JSY
spelling out BCC objectives, key messages, target audience using different
communication medium, when and by whom undertaken, and at what levels.
In doing so, State may consider seeking professional inputs in formulating the
communication strategy.
2. Study findings indicate women having apprehensions about deliveries in
hospitals for whatever reasons. Communication strategy should attempt to
address myths and misconceptions about hospitals/health centres. Satisfied
users of hospitals could be involved in sharing their experience and motivating
women to deliver in hospital.
3. To ensure consistency in messages delivered through different information
sources, state should develop appropriate media briefing kits, and orientation
packages for different stakeholders in the form of Frequently Asked Questions
55
(FAQs). The information package should also detail the role envisaged for
different stakeholders in ASHA and JSY.
4. The State should conduct orientation programmes for medical and health
department, DWCD, PRI members and other stakeholders for effective
dissemination of both schemes. Civil society groups and networks of NCOs can
be engaged to reach out to vast number of stakeholders.
5. A wallpaper for ASHAs/AWWs and PRIs on a periodic basis documenting
success stories, profiling role models and also providing a platform for
exchanging views and experiences can also be an effective medium .
56
ANNEXURE1
IE
BSSSSS -■
: ig
Education status
Total number
ofJSY
beneficiary
interviewed
Mean monthly
family income
(rupees)
Illiterate
1-8
9+
168
56
24
■rcentages)
eficiaries by ba
Total
Caste category __________ Income level
10012000 2001 +
ST
OBC General <1000
SC
42
42
127
37
141
41
66
248
800.0 1680.1 351 5.5 2043.1
1 787.9 2350.9 3125.0 201 1.9 1713.1 2015.4 2545.3
* 2: Early registration during index pregnancy by background charac
Caste category
Education status
Total number of JSY
beneficiary interviewed
Month of index pregnancy
when realized that women
could be pregnant
< 2 months
3rd month
4th month or later
Do not know
Illiterate
1-8
9+
SC
Total
Income level
10012000 2001 +
ST OBC General <1000
168
56
24
42
42 127
37
41
141
66.7 71.4 83.3 81.0 59.5 66.9
29.8 17.9 12.5 16.7 31.0 29.1
1.2 3.6 4.2 2.4 0.0 2.4
2.4 7.1 0.0 0.0 9.5 1.6
75.7
16.2
2.7
5.4
73.2
24.4
2.4
0.0
63.8
29.8
2.1
4.3
66
248
78.8 69.4
16.7 25.4
1.5 2.0
3.0 3.2
Table 3: Contacts with health personnel during Index pregnancy by background characteristics
(Percentages)
Total number of JSY
beneficiary interviewed
Total
Income level
Caste category
Education status
10012000 20014
Illiterate
1-8
9+
SC
ST OBC General <1000
168
56
24
42
42 127
37
41
141
46.4 33.9 12.5 35.7 59.5 40.2
24.3
46.3
41.8
33.3 39.8
48.2 66.1 87.5 61.9 35.7 55.1
75.7
53.7
51.8
66.7 56.6
66
248
Percent contacted by someone
or self contacted health
personnel during last
pregnancy
Somebody from health
department contacted
JSY beneficiary contacted
somebody
No contact made
Number of JSY beneficiary
who had contact with health
5.4
0.0
0.0
2.4
4.8
4.7
0.0
0.0
6.4
0.0
3.7
I 59
56
24
41
40
121
37
41
132
66
239
27.0 28.6 58.3 24.4 25.0 27.3
37.7 39.3 33.3 29.3 37.5 41.3
16.4 16.1 8.3 19.5 1 5.0 16.5
18.9 16.1 0.0 26.8 22.5 14.9
54.1
35.1
8.1
2.7
34.1
29.3
19.5
1 7.1
27.3
37.9
1 5.2
19.7
34.8
42.4
13.6
9.1
30.5
37.7
1 5.5
16.3
3.3
2.6
3.3
3.4
3.1
3.3
19.5 32.1 54.2 29.3 5.0 24.0
0.6 3.6 0.0 2.4 2.5 0.8
64.2 64.3 37.5 56.1 77.5 63.6
6.9 0.0 4.2 4.9 10.0 3.3
8.2 0.0 4.2 4.9 5.0 8.3
0.6 0.0 0.0 2.4 0.0 0.0
51.4
5.4
0.0
0.0
14.6
0.0
65.9
12.2
7.3
0.0
21.2
2.3
66.7
3.8
6.1
0.0
42.4 25.9
1.3
0.0
48.5 61.5
3.0 0.5
5.9
4.5
1.5 0.4
86.5
8.1
5.4
92.7
4.9
2.4
90.2
8.3
1.5
92.4 91.2
4.5 6.7
3.0 2.1
personnel__________________
Stage of pregnancy when first
contact was made
< 2 months
3rd month
4th month
5th month or later
Mean_______________
3.4
3.3
2.5
3.6
3.6
Person with whom had first
contact with
Doctor
LHV
ANM/FHW
Anganwadi worker
ASHA worker
Others_____________________
Percent advised by the health
personnel for antenatal
check-up
Yes, advised for ANC
No, not advised
Do not know/can’t say
89.9 94.6 91.7 95.1 87.5 92.6
8.2 1.8 8.3 4.9 7.5 6.6
.8
1.9 3.6 0.0 0.0 5.0
58
0.0
43.2
Table 4: Details of antenatal check-ups during index pregnancy by background characteristlcs^^^^^
Total number of JSY
beneficiary interviewed
Percent availed of any
antenatal check-up during
index pregnancy________
Month of pregnancy when
availed antenatal care
services for the first time
< 2 months
3 4 months
5 6 months
7,h month or later
Do not know
Mean (month)_____
Number of times of
antenatal check-ups
1 time
2 times
3 times
4 or more
I don’t remember
Mean (number of times)
Place where received
antenatal care*
District/sub district
hospital
Community Health Centre
PHC
Subcentre
Private hospital
Anganwadi centre
At home
Others
____________
Total
Income level
Caste category
Education status
10012000 2001 +
Illiterate
1-8
9+
SC
ST
OBC General <1000
168
56
24
42
42
127
37
41
141
85.1 94.6 100.0 92.9 83.3 87.4
(143) (53) (24) (39) (35) (111)
94.6
(35)
87.8
(36)
85.1
(120)
54.2 20.5 17.1 29.7
45.8 46.2 60.0 55.0
0.0 25.6 14.3 10.8
0.0 7.7 5.7 4.5
0.0 0.0 2.9 0.0
45.7
48.6
5.7
0.0
0.0
38.9
41.7
16.7
2.8
0.0
24.2
53.3
15.8
5.8
0.8
31.3
59.4
6.3
3.1
0.0
28.6
53.2
13.2
4.5
0.5
3.3
2.8
3.3
3.5
3.1
3.4
3.6
0.0 5.1 5.7
31.4
18.0
4.2 33.3
12.5 15.4 20.0 27.9
83.3 43.6 40.0 49.5
0.0 2.6 2.9 0.9
0.0
2.9
20.0
71.4
5.7
2.8
1 1.1
44.4
41.6
0.0
4.2
27.5
18.3
47.4
2.5
3.1
12.5
20.3
61.0
3.1
3.6
20.5
23.2
50.4
2.3
27.3 20.8
51.0 62.3
1 5.4 13.2
5.6 3.8
0.7 0.0
3.5
3.4
4.9 1.9
22.4 22.6
26.6 18.9
44.1 52.8
2.1 3.8
2.5
3.9
3.6
248
88.7
97.0
(220)
66
(64)
4.2
5.3
3.5
3.6
4.0
4.7
3.7
3.8
4.5
4.0
7.0 13.2
33.3
5.1 22.9
9.0
14.3
8.3
1 1.7
12.5
1 1.4
38.5 45.3
13.3 18.9
36.4 18.9
7.0 1 1.3
12.6 9.4
10.5 1 1.3
2.1 0.0
37.5 48.7 14.3 45.0
12.5 17.9 8.6 13.5
12.5 10.3 54.3 29.7
5.4
20.8 15.4 5.7
9.9
0.0 10.3 14.3
0.0 10.3 1 1.4 9.0
2.7
0.0 0.0 0.0
40.0
20.0
30.6
2.8
47.2
8.3
19.4
2.8
5.6
38.3
13.3
31.7
6.7
10.8
15.8
0.8
48.4
23.4
1 5.6
15.6
4.7
1.6
0.0
40.0
14.5
29.5
9.5
10.5
9.5
1.4
3.7
59
25.7
20.0
8.6
8.6
o.o|
Table 5: Persons motivating for antenatal check-ups during index pregnancy by background
characteristics
(Percentages)
10012000 2001 +
Illiterate
1-8
9+
SC
ST
OBC Genera[ <1000
143
53
24
39
35
111
35
36
95.1 96.2 95.8 97.4 85.7 97.3
(136) (51) (23) (38) (30) (108)
97.1
100.0
92.5
(34)
(36)
(1 1 1)
58.8
0.0
29.7
5.4
35.3
19.4
0.0
27.8
13.9
5.6
50.0
Anganwadi worker
ASHA worker
22.2
4.6
38.0
13.0
4.6
38.9
6.5
.0 10.5 13.3
10.3 5.9
17.6 21.6 13.0 13.2 20.0 22.2
5.9
13.9
6.3
8.8
I 1.1
Other family members/
relatives/friends__________
4.4
5.6
0.0
2.8
Number of JSY beneficiary
who availed antenatal check
up___________ _ __________
Percent influenced or
motivated by someone to
avail antenatal check up
Total
Income level
Caste category
Education status
120
64
220
98.4 95.5
(63) (210)
Persons who influenced or
motivated respondent’s
decision to go for antenatal
check-up*
Self motivated
No one
Husband
Mother-in-law
Doctor
LHV/ANM/FHW
29.4 27.5 52.2 39.5 23.3
3.7 5.9 0.0 7.9 0.0
31.6 54.9 56.5 34.2 40.0
12.5 9.8 4.3 10.5 10.0
.0
2.9 0.0 8.7 2.6
47.1 37.3 17.4 34.2 66.7
4.3
5.9
7.9
Percent incurred any
expenses for receiving
31.4
40.5
3.2
46.0
3.8
40.0
9.9
11.1
1 1.0
1.8
41.4
3.2
2.9
36.5
41.4
19.8
7.9
19.0
8.1
18.1
4.5
6.3
4.8
Total
Income level
Caste category
Education status
Number availed of any
antenatal check-up during
index pregnancy_________
3.3
52.9
5.9
0.0
41.3
10012000 2001 +
Illiterate
1-8
9+
SC
ST OBC Ceneral <1000
133
49
24
35
32 105
34
36
106
64
206
40.6 34.7 83.3 37.1 21.9 48.6
58.8
33.3
36.8
62.5
44.2
59.4 65.3 16.7 62.9 78.1 51.4
9.5
7.5 2.0 20.8 5.7 3.1
8.6
0.0
2.9
5.3 6.1 12.5
4.8
5.7
6.3
4.2
4.5 6.1
6.7
0.0
5.7
3.8 6.1 8.3
9.4
14.3
1
7.1
8.2
33.3
1 5.8
3.7 6.2 4.2 0.0 3.1 4.7
41.2
63.9
5.6
60.4
53.9
5.6
8.3
0.0
3.8
2.8
6.6
37.5
7.8
10.9
11.1
10.4
5.6
7.5
antenatal checkups_______
Average amount spent
during ANC period
including fees, laboratory
test
No expense
< 1 00 rupees
1 01 - 250 rupees
251 - 500 rupees
501 - 750 rupees
751 or more rupees
Do not know
60
8.8
8.8
2.9
2.9
26.5
8.9
8.5
6.3
4.7
28.1
4.7
7.8
6.3
4.9
4.9
16.0
6.3
■■
<;.-
Total number of JSY
beneficiary interviewed
Percent not availed antenatal
care services during index
pregnancy________ ________
Reasons for not availing any
antenatal care services*
Not necessary
Not customary
Cost too much
Too far/no transport
No time to go
Family did not allow
Lack of knowledge
Others
50
so a
Total
Income level
Caste category
Education status
Illiterate
1-8
9+
SC
ST OBC General <1000
168
56
24
42
42
14.9
(25)
5.4 0.0
(3) (0)
10012000 2001 +
127
37
41
141
66
248
7.1 16.7 12.6
(3) (7) (16)
5.4
(2)
12.2
(5)
14.9
(21)
3.0
(2)
1 1.3
(28)
64.0 66.7 0.0 66.7 71.4 62.5
24.0 33.3 0.0 33.3 14.3 25.0
16.0 66.7 0.0 0.0 14.3 31.3
8.0 33.3 0.0 0.0 14.3 12.5
36.0 0.0 0.0 0.0 28.6 37.5
16.0 0.0 0.0 33.3 0.0 18.8
12.0 0.0 0.0 33.3 14.3 6.3
20.0 33.3 0.0 33.3 0.0 25.0
50.0
50.0
0.0
0.0
50.0
0.0
0.0
50.0
20.0
0.0
20.0
0.0
80.0
20.0
0.0
20.0
71.4 100.0
23.8 100.0
0.0
23.8
0.0
14.3
0.0
23.8
0.0
14.3
0.0
14.3
0.0
23.8
64.3
25.0
21.4
10.7
32.1
14.3
10.7
21.4
(Percentages)
i-:..
Caste category
Education status
Total
Income level
10012000 2001 +
Illiterate
1-8
9+
SC
ST OBC General <1000
Total number of JSY
beneficiary interviewed__
168
56
24
42
42 127
37
41
141
Time when heard about JSY
Before being pregnant
During pregnancy
After delivery
Do not know/can’t say
9.5 10.2
8.9 12.5 33.3 7.1
69.6 69.6 58.3 69.0 69.0 71.7
8.3 23.8 21.4 16.5
20.8 16.1
0.6 1.8 0.0 0.0 0.0 1.6
27.0
56.8
16.2
0.0
14.6
58.5
26.8
0.0
9.2
73.8
16.3
0.7
16.7 12.1
63.6 68.5
18.2 18.5
1.5 0.8
5.4
18.9
0.0
0.0
0.0
22.0
14.6
80.5
9.8
0.0
2.4
0.0
Q.o|
0.0|
0.7
0.0
0.7
22.0
12.1
73.8
1 3.5
1.4
5.0
9.2
0.7
6.1 2.0
3.0 0.8
4.5 1.6
30.3 24.2
9.1 1 1.7
59.1 71.0
16.7 13.7
6.1 2.4
4.5 4.4
12.1 8.5
1.5 0.8|
66
248
Sources of information of
JSY*
Radio
TV
Hoardings at SC/PHC
ASHA worker
Anganwadi worker
ANM
Doctor
Gram Panchayat
Parent, in-law, relatives
Others
| Do not know
0.0 8.3 0.0 4.8 0.8
0.6 0.0 4.2 0.0 0.0 0.8
0.0 3.6 8.3 0.0 0.0 1.6
22.6 28.6 25.0 19.0 28.6 26.0
4.2 19.0 19.0 9.4
14.3 7.1
54.2
64.3 92.9 70.9
76.8 60.7
12.5 14.3 20.8 16.7 0.0 15.0
1.2 0.0 16.7 0.0 2.4 0.8
1.8
3.0 8.9
6.0 16.1
1.8
0.6
2.4
0.0
8.3 14.3
4.8
4.2
6.3
4.7
o.o| 0.0 o.o| 1.6
61
2.7
5.4
18.9
2.7
54.1
21.6
10.8
5.4
;; ; >,
'..... L
Total
Income level
Caste category
Education status
10012000 2001 i
Illiterate
1-8
9+
SC
ST
OBC General <1000
168
56
24
42
42
127
37
41
141
10.8 19.6 37.5
0.6 0.0 4.2
74.3 64.3 45.8
5.4 3.6 4.2
8.4 10.7 4.2
0.6 0.0 0.0
0.0 1.8 4.2
16.7 7.1 15.9
2.4 0.0 0.0
69.0 78.6 68.3
7.1 1 1.9 3.2
4.8 2.4 1 1.1
0.0 0.0 0.8
0.0 0.0 0.8
21.6
2.7
62.2
0.0
10.8
0.0
2.7
4.9
0.0
78.0
7.3
9.8
0.0
0.0
13.6
0.7
74.3
4.3
6.4
0.7
0.0
25.8 15.4
1.5 0.8
53.0 69.2
4.5 4.9
12.1
8.5
0.0 0.4
3.0 0.8
2.4 3.6 16.7
18.0 21.4 41.7
9.0 19.6 20.8
24.0 14.3 4.2
16.8 17.9 4.2
26.3 23.2 12.5
4.8 2.4
31.0 7.1
14.3 2.4
14.3 35.7
9.5 23.8
26.2 23.8
0.0 4.8
5.6
19.0
14.3
16.7
0.0
32.4
16.2
18.9
2.4
14.6
2.4
2.1
22.1
10.0
20.7
9.1
4.0
22.7 21.1
24.2 12.6
13.6 19.8
16.7
24.6
3.2
10.8
21.6
0.0
22.0
31.7
0.0
14.3
27.9
2.8
15.2 15.8
12.1 24.3
2.4
3.0
Percent who got a JSY card
21.4 28.6 62.5
14.3 31.0 29.9
27.0
29.3
20.6
39.4 27.0
Percent showed JSY card to
the interviewer
Yes, JSY card seen
Yes have JSY card but not
seen
1 1.1 18.8 33.3
0.0 1 5.4 21.1
20.0
8.3
24.1
15.4 1 7.9
88.9 81.3 66.7 100.0 84.6 78.9
80.0
91.7
75.9
84.6 82.1
33.3 53.8 50.0
40.0
41.7
41.4
57.7 47.8
Total number of JSY
ben eficiar i e s Jn t e rv i e wed
Person who registered
respondent for JSY
Doctor
LHV
ANM/FHW
Anganwadi worker
ASHA worker
Others
Do not know
___
Place where respondent was
registered
Dist./sub-district hospital
CHC
PHC
Subcentre
Anganwadi centre
At home
Others____________________
Percent mentioning that
ASHA worker helped in
getting JSY card
3.6
0.0
0.0
44.4 62.5 40.0
62
26.8
66
248
ICS
(Percentages)
Illiterate
1-8
9+
SC
ST OBC General < 1000
168
56
24
42
42
Total number of JSY
beneficiaries interviewed___
10012000 2001 +
66
248
127
37
41
141
68.5 67.9 83.3 69.0 47.6 74.8
78.4
58.5
65.2
86.4 69.8
53.9 60.5 60.0 51.7 75.0 56.8
43.5 47.4 40.0 41.4 50.0 34.7
44.8
72.4
58.3
50.0
62.0
41.3
45.6 56.1
45.6 43.9
17.4 31.6 30.0 10.3 30.0 26.3
7.8 2.6 15.0 6.9 20.0 7.4
13.8
0.0
20.8
12.5
19.6
6.5
26.3 22.0
7.5
7.0
0.0 15.0
8.4
10.3
4.2
7.6
10.5
8.1
Percent who delivered at
institution__________________
Motivation for opting for
institutional delivery*
Money available under JSY
Better access to institutional
delivery services in the area
Support provided by ASHA
Support provided by health
Total
Income level
Caste category
Education status
personnel
Previous child was born in an
7.8
5.3 15.0
5.2
2.6
5.0 10.3 10.0
3.2
0.0
0.0
6.5
3.5
4.6
8.7
7.9
0.0
3.4
5.0
7.4
13.8
4.2
8.7
7.0
7.5
discharge
Previous still birth/
miscarriage/ caesarian
5.2
2.6
5.0
6.9
0.0
4.2
6.9
4.2
2.2
8.8
4.6
Others
Do not know/can’t say______
0.9
0.9
0.0
0.0
0.0
0.0
0.0
3.4
0.0
0.0
1.1
0.0
0.0
0.0
0.0
0.0
0.0
0.0
1.8
1.8
0.6
0.6
institution
Safe delivery of child/safety
of both mother and child
Complicated delivery, had
health problem, white
* Multiple responses
:':+:
i
IF WI v+w
Education status
Illiterate
1-8
s.. ...........
(Percentages) |
Total
Income level
Caste category
9 + SC ST OBC General <1000
10012000 2001 +
Number of JSY beneficiaries who
had institutional delivery_________
Percent given a referral slip to help
115
38 20 29 20
95
29
24
92
57
173
them access delivery services by
6.1
0.0 5.0 6.9 0.0 5.3
3.4
4.2
3.3
7.0
4.6
ASHA or health personnel________
63
Table 12: Process of arranging transport to reach health institution by background characteristics
(Percentages^
Total
Income
level
Caste category
Education status
10012000 2001+
ST OBC General <1000
SC
III iterate 1-8 9 +
Number of JSY beneficiaries
who had institutional delivery
Mode of transport used to
reach the ultimate place of
delivery*
Auto rickshaw
Car/Jeep
Motor cycle/scooter
Bus
Bullock/Camel cart/chakda
Walking
Tempo/tractor____________
Persons who all facilitated in
arranging the transport*
ANM/Health worker
Anganwadi worker
ASHA worker
Family members
Panchayat members/SHGs
TBA
Others__________________
* Multiple responses
57
173
95
29
24
92
0.0 7.4
55.0 62.1
5.0 6.3
0.0 1.1
10.0 3.2
25.0 14.7
5.0 5.3
6.9
65.5
3.4
0.0
0.0
13.8
10.3
0.0
62.5
4.2
4.2
8.3
16.7
4.2
5.4
60.9
2.2
2.2
4.3
18.5
6.5
10.5 6.4
59.6 60.7
12.3 5.8
0.0 1.7
1.8 4.0
10.5 15.6
5.3 5.8
6.7 6.2
6.4 3.0 0.0 0.0
0.0 2.5
2.1 0.0 0.0 0.0
0.0 1 1.1
9.6 9.1 0.0 8.0
79.8 87.9 89.5 84.0 100.0 75.3
0.0 4.9
3.2 3.0 0.0 0.0
0.0 3.7
4.3 3.0 0.0 8.0
0.0 4.9
3.2 0.0 10.5 4.0
4.0
0.0
4.0
96.0
0.0
0.0
0.0
0.0
5.0
20.0
75.0
5.0
5.0
5.0
5.3
1.3
6.7
80.0
2.7
4.0
5.3
5.9 4.8
0.0 1.4
5.9 8.2
90.2 82.9
2.0 2.7
2.0 3.4
0.0 3.4
115
38
20
29
3.5 15.8 5.0 6.9
61.7 50 75.0 55.2
3.5 7.9 1 5.0 6.9
0 0.0 6.9
2.6
4.3 5.3 0.0 6.9
18.3 13.2 5.0 13.8
6.1 7.9 0.0 3.4
20
Table 13: Persons accompanying JSY beneficiaries to the health institution by background characteristics
____
(Percentages)
Illiterate
1-8
9+
SC
Total
Income level
10012000 2001 +
ST OBC General <1000
115
38
20
29
20
Caste category
Education status
Number of JSY beneficiaries
delivered in institution
Persons who all accompanied
JSY beneficiary to the health
institution*
ANM/Health worker
Anganwadi worker
ASHA worker
Husband
Mother
Mother-in-law
Neighbour or other
Other family members
TBA/dai_________________
!_Multiple responses
95
29
24
92
57
173
8.7 2.6 0.0 3.4 10.0 6.3
5.2 0.0 0.0 3.4 10.0 2.1
20.0 21.1 0.0 20.7 5.0 22.1
69.6 73.7 85.0 69.0 90.0 63.2
16.5 26.3 30.0 17.2 15.0 24.2
49.6 60.5 40.0 55.2 55.0 49.5
6.1 0.0 5.0 0.0 5.0 7.4
54.8 42.1 65.0 48.3 40.0 56.8
7.0 23.7 0.0 13.8 0.0 1 1.6
6.9
3.4
10.3
93.1
13.8
48.3
0.0
55.2
6.9
8.3
4.2
16.7
66.7
12.5
54.2
4.2
37.5
12.5
6.5
5.4
19.6
70.7
17.4
48.9
6.5
56.5
5-4
5.3
0.0
1 5.8
77.2
28.1
52.6
1.8
54.4
1 5.8
6.4
3.5
17.9
72.3
20.2
50.9
4.6
53.2
9.8
64
i
Table 14: Payments made for services at the health center by background characteristics
Education status
(Percentages)
Total
Income level
Caste category
1001OBC General <1000 2000 2001 +
Illiterate
1-8
9+
SC
ST
115
38
20
29
20
95
29
24
92
57
173
65.2
(76)
55.3
48.3
(14)
65.0
(14)
61.1
(58)
89.7
(26)
54.2
(13)
63.0
(58)
70.2
(21)
75.0
(15)
(40)
64.2
(112)
56.6
81.0
46.7
64.3
57.1
55.2
69.2
69.2
53.4
65.9
59.8
13.2
9.5
0.0
14.3
0.0
12.1
1 1.5
30.8
3.4
14.6
10.7
94.7
14.5
9.2
3.9
9.2
90.5
4.8
9.5
0.0
4.8
93.3
6.7
92.9
14.3
21.4
0.0
28.6
92.9
7.1
21.4
0.0
0.0
91.4
13.8
3.4
1.7
6.9
100.0
100.0
30.8
7.7
0.0
23.1
93.1
6.9
8.6
3.4
3.4
92.7
12.2
93.8
1 1.6
12.2
2.4
14.6
9.8
2.7
9.8
Number of JSY
beneficiary delivered
in institution
Percent who paid for
services at the health
centre_____________
Specific services for
which were charged*
Delivery/caesarean
/Operation charge
Accommodation
charge
Medicines/IV fluids
Food charges
Laboratory test
Paediatric care
Diagnostic/
sonography_________
13.3
0.0
20.0
1.7
1 1.5
7.7
1 1.5
Average total
amount spent for the
index delivery (in
rupees)
Do not know________
1032.6 1 1 58.3 2600.0 1645.5 1486.4 1095.0 1376.3 1425.0 801.3 1740.0 1277.6
20.4
10.3
26.9
0.0 32.1
16.7
20.0 21.4 21.4
10.0
23.3
* Multiple answers
Table 15: Views about TBA among those who delivered at home and institute by background
(Percentages)
Total
I characteristics
Income level
Caste category
Education status
10012000 2001 +
Illiterate
1-8
9+
SC
ST OBC General <1000
168
56
24
42
42 127
37
41
141
8.3 38.1 28.6 32.3
(2) (16) (12) (41)
24.3
(9)
34.1
(14)
35.5
(50)
21.2 31.5
(14) (78)
Reasons for preferring TBA *
TBA is easily accessible
TBA charges less money
Traditionally has been
conducting deliveries in the
29.5 40.0 50.0 37.5 41.7 26.8
31.1 26.7 100.0 25.0 41.7 29.3
0.0 37.5 8.3 39.0
31.1 40.0
33.3
44.4
22.2
7.1
57.1
50.0
38.0
28.0
30.0
35.7 32.1
21.4 32.1
21.4 32.1
family
TBAs are better aware of the
cultural practices and follows
29.5 26.7
0.0 25.0 25.0 29.3
33.3
35.7
30.0
14.3 28.2
32.8 20.0
1.6 6.7
0.0 31.3 16.7 34.1
o.o| 6.3 0.0 2.4
22.2
28.6
0.0
28.0
2.0
35.7 29.5
2.6
7.1
Total number of JSY
beneficiaries interviewed
Percent opined that TBA can
provide all necessary
midwifery services__________
it
Better comfort level with TBA
Others____________________
36.3 26.8
(61) (15)
* Multiple responses
65
0.0
66
248
<9
.ackground character!
J
Education status
Caste category
Income level
Total
10012000 2001 +
Illiterate
1-9
9+
SC
ST
OBC General <1000
168
56
24
42
42
127
37
41
141
66
248
84.5
83.9
87.5
85.7
92.9
79.5
91.9
90.2
83.0
84.8
84.7
3.5
6.4
0.0
0.0
0.0
6.9
2.9
8.1
1.7
5.4
3.8
0.7
0.0
0.0
0.0
0.0
0.0
2.9
0.0
0.9
0.0
0.5
1 1.0
2.1
23.8
1 1.1
10.3
1 1.9
5.9
13.5
9.4
10.7
10.5
21.0
27.7
38.1
27.8
1 7.9
22.8
32.4
24.3
20.5
32.1
24.3
62.0
1.4
63.8
0.0
38.1
0.0
58.3
2.8
71.8
0.0
58.4
0.0
52.9
2.9
54.1
0.0
66.7
0.9
50.0
1.8
60.0
1.0
66.0
19.2
0.7
3.5
1.4
2.1
2.8
2.8
53.2
21.2
0.0
17.0
2.1
2.1
4.3
0.0
38.1
9.5
4.8
23.8
0.0
9.5
14.3
0.0
63.9
27.8
0.0
2.8
0.0
0.0
2.8
2.8
71.8
7.7
0.0
7.7
0.0
2.6
2.6
52.5
24.8
1.0
9.9
0.0
4.0
5.9
2.0
67.6
2.9
8.8
1 1.8
0.0
5.9
2.9
0.0
81.1
0.0
10.8
2.7
0.0
0.0
5.4
0.0
61.5
0.0
22.4
6.8
1.7
1.7
4.3
1.7
44.6
3.6
19.6
16.1
1.8
7.1
3.6
3.6
60.5
1.0
19.6
8.6
1.4
2.9
4.3
1.9
Do not know_________
18.0
9.9
18.0
28.0
1 1.0
6.3
7.0
2.8
27.7
10.6
6.4
23.4
14.9
10.6
4.3
2.1
57.1
4.8
4.8
9.5
14.3
4.8
4.8
0.0
30.6
1 1.1
5.6
30.6
13.9
2.8
2.8
2.8
1 5.4
2.6
33.3
17.9
2.6
1 5.4
12.8
0.0
27.7
13.9
10.9
21.8
13.9
3.0
5.9
3.0
17.6
2.9
8.8
35.3
14.7
14.7
2.9
2.9
21.6
8.1
16.2
45.9
0.0
8.1
0.0
0.0
20.5
10.3
16.2
18.8
15.4
7.7
7.7
3.5
33.9
8.9
7.1
23.2
12.5
5.4
7.1
1.8
24.3
9.5
13.8
24.8
1 1.9
7.1
6.2
2.4
Average amount
received by JSY
784.4 789.4 733.3 832.4 621.1 809.9
818.5
818.5
801.4
773.2 780.3
Number of JSY
beneficiary___________
Percent received JSY
cash incentive for
delivery______________
Time when received
the money
Much before the
delivery
Within a week before
the EDD
Immediately after the
delivery
Within a week after the
delivery
Much later
Others_______________
Person who gave the
cash incentive to JSY
beneficiary
ANM
CHC/PHC doctor/MO
ASHA
At Health Centre
Panchayat
Accountant
Others
Do not know_________
Place where received
cash incentive money
Place of delivery
At the PHC
Within the village
At home
CHC
Sub-centre
Camp
beneficiary
66
1.7
Table 17: Difficulties faced by JSY beneficiaries in getting cash incentive for delivery by background
characteristics
_
(Percentages!
Total
Income
level
Caste
category
Education status
10012000 2001 +
ST OBC General <1000
SC
Illiterate 1-9 9+
Number received JSY cash
incentive for delivery______
Responses on the
sufficiency of cash
incentive
Sufficient
Somewhat sufficient
Not sufficient
Do not know / can’t say
Ways money received under
JSY was utilized*
Purchased consumables for
the family
Bought medicines/tonics for
self and child
Used for medical expenses
for delivery
Husband took it away
Did not spend money
Use of self nutrition/fruit
Others
Do not know / can’t say
* Multiple responses.
56
210
101
34
37
117
57.4 33.3 36.1 43.6 49.5 58.8
27.7 47.6 38.9 46.2 34.7 26.5
14.9 14.3 19.4 7.7 14.9 1 1.8
0.0 4.8 5.6 2.6 1.0 2.9
42.7
38.5
14.6
4.1
40.5
40.5
13.5
5.4
47.9
39.3
1 1.1
1.8
51.8 47.6
26.8 36.2
19.6 13.8
1.8 2.4
39.4 40.4 33.3 33.3 43.6 36.6
47.1
35.1
39.3
41.1
31.7 46.8 71.4 30.6 30.8 46.5
35.3
37.8
34.2
50.0 39.0
2.0
2.9
2.7
0.9
1.8
29.6 19.1 9.5 36.1 28.2 22.8
6.3 6.4 4.8 2.8 7.7 4.0
28.9 19.1 28.6 22.2 30.8 25.7
1.0
0.7 4.3 0.0 0.0 5.1
1.0
2.8|
2.6
4.8
1.4 0.0
1 7.6
14.7
29.4
0.0
0.0
24.3
2.7
37.8
0.0
2.7
29.9
7.7
24.8
0.9
1.8
16.1 25.2
6.2
5.4
23.2 26.7
1.4
3.6
0.0
1.5
142
1 .4
47
2.1
21
0.0
36
0.0
67
39
0.0
39.0
1.4
ANNEXURE2
Government of Rajasthan
Directorate of Medical, Health and Family Welfare
Swasthya Bhawan, Tilak Marg, Jaipur
Office Orders
National Rural Health Mission (NRHM) has been launched to address the health needs
of rural population especially the vulnerable sections of societies. One of the major
components of NRHM is deployment of large taskforce of volunteers at grass root
level named as ASHA- Sahyogini (Accredited Social Health Activist). She will be the
link between the community and health institutions.
ASHA Sahyogini is a voluntary health activist selected by and responsible to the Gram
Sabha. She is envisaged at village levels, on a population of 1000; analogous to the
Anganwadi jurisdiction. Since she is expected to receive performance-based
emoluments from different Departments of the Government, it is important that all
these Departments are involved in finalizing the policy/mentoring framework of ASHA
Scheme.
The Mentoring Group is constituted at state level for strengthening ASHA- Sahyogini
Programme. This group will oversee the implementation of the scheme and facilitate
tank for the programme,
in developing the policy guidelines. It will act as a think
also provide technical inputs, and support mechanism.
The members of ASHA Mentoring Group shall comprise of the following
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
1 1 .
12.
1 3.
Mission Director - NRHM Chairperson
Director - DWCD
Director - PRI
Director - Rural Development
Director - PHED
Director- PH
Director -RCH,
Director - AIDS
Director - SIHFW
Additional Director, NRHM
Representative of RVHA, URMUL, ARTH, Seva Mandir, EKAT, Prayas
Representatives of UNFPA, UNICEF and EC
Director - State Resource Center - ASHA Resource Center - Convener
The Mentoring Group will meet at least once in three months to review and provide
inputs for the ASHA- Sahyogini Intervention.
Additional Director - NRHM
Dated-
No.
Copy to 1. P.S. to Principal Health Secretary
2. Secretary, FW and Mission Director - NRHM
3. All concerned member as above
4. Director- SRC- ASHA Resource Center- with the request to act as a facilitator
for Mentoring Group
Additional Director - NRHM
70
Mission Director - NRHM Chairperson
Directorate of Medical & Health Services Rajasthan
1
Swasthya Bhawan, Jaipur.
Contact No.
0141-2227722
2
Director - DWCD
Directorate of Women & Child Development Department
Behind Govt. Sr. Sec. Girls School, Gandhi Nagar.
Rajasthan Jaipur.
Contact Person - Anurag Bhadwaj
Contact no. 0141-2705561,2702243, 94140-71 933
3
Director - PRI
Directorate of Panchati Raj
Rajasthan Jaipur.
Contact No.
4
Director - Rural Development
Directorate of Rural Development Department
Contact No. - 0141-222791 5
5
Chief Engineer
Public Health Engineering Department (PHED)
Jal Bhawan , Near Railway Hospital, NBC Road Jaipur.
Contact Person & No. - 01 41 -2222053
6
Dr. O.P. Gupta
Director- PH
Directorate of Medical & Health Services Rajasthan
Swasthya Bhawan Jaipur.
Contact No. - 0141-2229858, 9829333936
7
Dr. S.P. Yadav
Director -RCH,
Directorate of Medical & Health Services Rajasthan
Swasthya Bhawan Jaipur.
Contact No. - 01 41-2228707, 9414-016297
8
Dr. Satish Sharma
Director - AIDS,
Directorate of Medical & Health Services Rajasthan
Swasthya Bhawan Jaipur.
Contact No. - 0141 - 222 3326, 9414-220624
71
9
Dr. Shive Chand Mathur
Director - SIHFW , Jhalana Institutional Area
Near Doordarshan Kendra Jhalana
Rajasthan Jaipur.
Contact No. 01 41 - 2701 938, 2706534
10
Dr. S.P. Sharma
Additional Director- NRHM,
Directorate of Medical & Health Services Rajasthan
Swasthya Bhawan Jaipur.
Contact No. 941 4-371 357
11
Representative
Rajasthan Voluntary Health Association (RVHA)
A-12 Mahaveer Udhyan Path, Bajaj Nagar,
Rajasthan Jaipur
Contact Person & No. Satyen Chaturvedi 01 41 - 2708006, 2706601
12
Representatives
United Nations Population Fund (UNFPA)
Shri Ram Pura Colony Opp. CM Residence
Rajasthan Jaipur
Contact No. 0141-2200028
13
Representatives
UNICEF
B-9 Bhavani Singh lane, Bhawani Singh Road,
Rajasthan Jaipur.
Contact No.01 41 -
14
Representatives
ARTH Society
39, Fatehpura, Udaipur.
Contact Person & No. Dr. Sharad Ayyangar 0294-2451066
1 5
Representatives
EKAT Bodh Gram
70/169, Patel Marg Maansarover Jaipur
Contact Person & No. Dr. Satyen Chaturvdei , 0141-2784443, 9414-076449
16
Representatives
PRAYAS
B-8 , Bapu Nagar, Saithi Chittorgarh
Contact Person & No. Pallavi Gupta , 01472-243788, 250044
72
17.
Representative
URMUL Trust
Urmul Dairy Campus near New Bus Stand, Bikaner
Contact No.- Arvind Ojha 01 51 -2523093, 2545097, 9414-1 37093
18
Representative
Seva Mandir Trust, Purana Fatepura
Udaipur.
Contact Person & No. - Neelima Khatan , 0294-2450960,
19
Director,
State Resource Center
7 - A , Jhalana Institutional area
Near Doordarshan Kendra Jaipur
Contact Person & No. - Shri Anil Roongta, 0 41-2707602, 9829064615
20
Dr. Kumkum Shrivastava (EC-SIP )
llnd Floor, Swathya Bhawan,
Directorate of Medical & Health Services Rajasthan
Swasthya Bhawan Jaipur.
Contact No.-
73
ASHA Resource Center for providing support to ASHA
Programme at State level
Introduction The Government of India and Government of Rajasthan has launched
the National Rural Health Mission (NRHM) to address the Health needs of rural
population especially the vulnerable sections of societies. The sub center is the most
peripheral level of contact with the community under the public health infrastructure.
This caters to the population norm of 5000, but is effectively serving much larger
population.
Currently Anganwadi workers under Integrated Child Development Scheme (ICDS) are
engaged in organizing supplementary nutrition programmes and other supportive
activities. The very nature of her job responsibility does not allow her to take up the
responsibility as change agent on health in a village. Thus, a new band of community
based functionaries, named as ASHA (Accredited Social Health Activist) is proposed to
fill this void.
ASHA will be the first port of call for any health related demands of deprived sections
of the population, especially women and children, who find it difficult to access health
services. She will be the link in between the community and health institutions.
ASHA is a voluntary health worker selected by the community through Gram Sabha on
the population of 1000; however, the selection criterion in tribal and desert area is
500. ASHA will not get any monthly honorarium but will get the performance-based
incentives. The detailed compensation package is worked out at state level
Status of ASHA intervention in the State - As per the guidelines, initially around
43,000 ASHAs will be selected in the rural areas of the State. In the State, more than
31,000 ASHAs have been selected through Gram Sabhas. Initially the training of 23
days in 5 rounds in a year (7 + 4+ 4+ 4+ 4 Days) will be given to ASHA. Second year
onwards refresher training will be given to the ASHAs. The training module for first
round of training is developed and State level, District level and Block level trainings
of trainer completed with the technical support of SIHFW.
Need for ASHA Resource Center - ASHA is at the base of NRHM pyramid and National
Rural Health Mission is looking at ASHA as a change agent in Health Sector Reform.
She will play a vital role in improving the health indicators of the State especially IMR
and MMR. She will also facilitate the improvement in service off take of the healthcare
institutions.
The State of Rajasthan is spread over a large geographic area with religious, social,
cultural, economic variations, so implementation of ASHA component in the state is a
challenging task. In this context, it is very important to provide technical inputs and
74
strong supportive mechanism to the programme so that expected results can be
achieved.
State Project Management Unit is established at state level under Mission Director
NRHM. SPMU is working as a technical and administrative body to implement the
activities of NRHM in the State. ASHA Resource Center (ARC) is conceptualized to
improve the quality of the programme. This Center will be established at state level
and will work under direction of Mission Director of NRHM
Functions of the ASHA Resource Center
1.
Technical backstopping in Training
The training of ASHAs is planned for 23
days in a year with refresher trainings every year. ARC will develop user-friendly
training methodology and the training modules, print the modules in prescribed
time, and disseminate the modules in the District. The modules are being
developed by MOHFW; GOI .These will be modified in the state context based on
functions of ASHA. ARC will also work on the training modalities and will provide
the supportive supervision to maintain quality checks and control at District and
Block level.
2.
Development of IEC material
ARC will be responsible for developing or
collecting the IEC material from different agencies for dissemination during the
training. The facilitation kit including flipbooks, chart, posters etc on different
related issues will be developed and disseminated. Need based IEC material will
be developed from time to time.
3.
It is planned to conduct bi - monthly
Planning of bi monthly Meeting
meeting of ASHAs at block level to resolve day -to day functional problems
faced by ASHA and to ensure the progress of the activities conducted by ASHA. It
is very important to revise the concepts and contents to improve the learning
process. The topics covered during the training will be revised in the bi monthly meeting. ARC will develop tentative monthly agenda for the monthly
meetings; provide required resource material and IEC material. It will develop
the monitoring mechanism for the meetings.
4.
srtmg formats and refipters
ASHA is envisaged as a
voluntary worker and to facilitate her work some very easy and basic reporting
formats and registers will be developed. The registers and the formats will be
used by ASHA only to streamline her priorities. ARC will develop the formats and
will orient ASHA for its utility and use.
5.
iq of Statistical Data and record
Based on reports and registers of
ASHA and other sources of data’s. ARC will compile the statistical data, analyze
the data and provide the feedback of the programme to the Mission.
ASHA is conceptualized as a
6.
volunteer responsible for the Health needs of the particular village, Dhani or
Mohalla. The credibility of ASHA in the community could be used by other
75
Development Departments to promote their objectives. ARC will coordinate with
different departments and facilitate empanelment of ASHAs in various other
programmes like Sarva Shiksha Abhiyan, Total Sanitation Programme etc.
7.
Involving NCOS to strengthen the programme -- Involvement of NGOs is an
important task in the implementation of ASHA programme. NGOs could support
the ASHA to work at community level or to develop capacities of ASHA etc. There
could be many roles of NGOs and the ARC would identify these roles. In
consultation of NRHM, the NGOs should be involved in the programme.
8.
Provision of Drug Kits
ASHA will provide the basic medical care to the
community. The drug kit with basic medicines and supplies will be provided to
all the ASHAs under NRHM. The drug Kit will consist of allopathic as well as
Ayush medicines. ASHA will charge the user fees from the community. Initially
the drug Kits are being provided by GOI. It may need state level modification /
supplementation. In such case, ARC will facilitate the procurement process and
supply it to ASHA. This is not one time activity and regular stocks should be
available with ASHA. ARC will develop the mechahism to maintain at least two
months stock of medicines with ASHA.
9.
Formation of VHC and VHT - NRHM is promoting the down - up approach for
implementation of different health programmes. It is proposed to form Village
Health Societies and Village Health Teams to address the health needs of the
Village. ASHA will be one of the important members of VHC and VHT. ARC will
be responsible for capacity building of ASHA so that ASHA could help in
planning and implementation of Health Programmes in the Village.
10.
Organize Monthly meeting of Mentoring Group
A Mentoring Group will be
constituted to provide overall guidance to the programme and act as a think
tank for the programme. The mentoring group will provide technical inputs and
support mechanism. ASHA Resource Center will conduct the monthly meetings
of the mentoring group and incorporate the valuable inputs provided by the
group in the programme.
1 1.
Provision of services of Helpline ASHA in near future will work in entire state.
There will be more than 50,000 ASHAs in the rural and urban areas of the State.
Time to time trainings or monthly meetings may not suffice the need of the
ASHA. So the ARC will form the helpline for the ASHA and associated
functionaries. ARC will respond to the queries or clarifications needed in the
field. ARC will ensure that the prompt help is provided to ASHA.
12.
Organizing ASHA Sammelam Exposure visits - There will be Sammelans at State
level, Zonal level and District level to share the experiences of ASHA and for
cross learning’s. ARC will organize such events with the help of State Society and
district Society. ARC will also organize the exposure visits with in the state and
outside the state.
76
13.
Facilitation of Focused Group Discussion in Villages - Focus group discussion is
a tool, which will be used for the assessment of the needs of the community and
ASHA. ARC will make a planning for Focused group discussion, organize it with
the NGO and prepare the requirement of the ASHA as well as Community.
14.
Other issues related tol the functioning of ASHA - Some of the functions of ARC
is mentioned above. The role of ARC is multifaceted and visualized in broader
sense. The functions of ARC could be revised as per the need and requirement
of the programme. Some new roles could also be incorporated.
Linkages of ASHA Resource Center - ASHA resource Center is a Hub for ASHA
Component under NRHM, which will work in close association with Mission DirectorNRHM. The administrative control on the ARC will be of the outsourced agency, but
the Mission Director will be involved in major decisions like recruitment of
professionals, budget etc however day to day functioning will be the responsibility of
outsourced agency. ARC will provide support to the districts through NRHM and all
the administrative guidelines will be issued through NRHM.
I
77
Flow Chart for linkages of ASHA Resource Center
Mission Director
State Project
Management Unit
*
♦
District Project
Management Unit
Functional ASHA
78
ASHA Resource
Center
Approved Budget Rrovisions for ASHA Resource Center
1.
Tentative Budget
Activity
No.
Personnel component
•
Project Officer - 18,000/- X 1 2
2,16,000
•
Data Assistant-1 1,000/-X 1 2
1,32,000
Rs 3,72,000/- + agency
charges 5 percent 1 8,600/Total Cost-3,90,600/-
Office attendant - 2000/- X 1 2 = 24,000/(all should be hired through an Agency)
2.
Office Expenses Telephone, Photostats,
Rs. 1,00,000/-
stationary
3.
Development of training modules, IEC material,
reporting formats, monitoring formats, Resource
Rs.7, 10,000/-
material for bimonthly meeting
•
Development of training modules- 5 Sets of 2
books Rs.30,000/- per book i.e 3,00,000/-
•
Development of IEC material Rs. 2,20,000/-
•
Development of Reports and formats,
monitoring formats, Rs.l ,00,000/Development of resource material forbid monthly meeting @ 1 5,000/— Rs- 90,000/-
4.
Monitoring and Supervision and NGO support
Rs. 3,20,000/-
Approx. 1 0,000 per district
5.
Operational Research and Documentation
Rs. 1,00,000/-
6.
ASHA Sammelan and Exposure Visit
Rs. 2,00,000/
7.
Contingency
Rs. 1,00,000/-
8.
Workshops and seminars
Rs. 3,00,000/-
9.
Total
Rs. 22,20,600/-
79
Position: 2590 (2 views)