About ASHA

SUPPORT MECHANISM FOR ASHA

One of the key strategies under the National Rural Health Mission (NRHM) is having a Community Health Worker i.e. ASHA (Accredited Social Health Activist) for every village with a population of 1000. Detailed guidelines have been issued by the Government of India in matter of selection and training of ASHA. The States have been given the flexibility to relax the population norms as well as the educational qualifications on a case to case basis, depending on the local conditions as far as her recruitment is concerned.

2. The above said guidelines also clearly bring out the role of ASHA vis-à-vis that of Anganwadi Worker (AWW) and the Auxiliary Nurse Midwives (ANM). The non-ASHA States (including the NE) have been advised that they could provide for similar link workers at the village level in the revised Project Implementation Plan for RCH-II in the current year. States like Andhra Pradesh and Haryana are already having the link workers. The 10 states where ASHA scheme is presently in place can select ASHAs in urban areas also as link workers subject to similar provisions being made in the State PIP for RCH-II in the current financial year.

3. The reports received from the States indicate that over 1, 20,000 ASHAs have been selected in the year 2005-06 and that they are being provided with orientation training as envisaged in the guidelines issued on ASHA. Now, a careful strategy needs to be devised for providing the necessary management

support to ASHA so that she is not left alone in the village without having any linkage with the health system.

4. The following set of guidelines are issued to enable the States to develop and put in place a proper support mechanism for ASHA.

The Government of India has set up an ASHA Mentoring Group comprising of leading NGOs and well known experts on community health. Similar mentoring groups at the State/District/Block levels could be set up by the States to provide guidance and advise on matter relating to selection, training and support for ASHA. At the District level, MNGOs and at Block level, FNGOs could be involved in the mentoring of ASHA. The State Govt. may utilize the services of Regional Resource Centre (RRC) and include them in the Mentoring Group at the State level.

As ASHA will be in the village on a permanent basis, she should be selected carefully through the process laid down in the first set of ASHA guidelines. It is possible that the selected ASHA drops out of the programme. It is, therefore, necessary to keep a record of such cases at SUb-Centre/ PHC level. In the above circumstance, a new ASHA could be selected from the panel of three names previously prepared on the recommendation of the Gram Sabha.

The guidelines already issued on ASHA envisage a total period of 23 days training in five episodes. However, it is clarified that ASHA training is a continuous one and that she will develop the necessary skills & expertise through continuous on the job training. After a period of 6 months of her functioning in the village it is proposed that she be sensitized on HIV / AIDS issues including STI, RTI, prevention and referrals and also trained on new born care.

Now, that ASHAs have been selected, the next step would be to familiarize her with the health status of the villagers and facilitate her adoption to the village conditions. Although, ASHA hails from the same village, she may not be having knowledge and information on the health status of the village population. For this purpose, she should be advised to visit every household and make a sample survey of the residents of village to understand their health status. This way she will come to know the villagers, the common diseases which are prevalent amongst the villagers, the number of pregnant women, the number of newborn, educational and socio economic status of different categories of people, the health status of weaker sections especially scheduled castes/scheduled tribes etc. She can be provided a simple format for conducting the surveys. In this she should be supported by the AWW and the Village Health & Sanitation Committee.

The Gram Panchayat will be involved in supporting ASHAs in her work. All ASHAs will be involved in this Village Health and Sanitation Committee of the Panchayat either as members or as special invitees (depending on the practice adopted by the State). ASHAs may coordinate with Gram Panchayats in developing the village health plan. The untied funds placed with the Sub-Centre or the Panchayat may be used for this purpose. At the village level, it is recognized that ASHA cannot function without support. The SHGs, Woman’s Health Committees’, Village Health and Sanitation Committees’ of the Gram Panchayat will be major sources of support to ASHA. The Panchayat members will ensure secure and congenial environment for enabling ASHAs to function effectively to achieve the desired goal.

(5) Maintenance of Village Health Register: A village health register is maintained by the AWW which is not always complete. ASHA can help AWW to complete and update this register by maintaining a daily diary. The diaries, registers, health cards, immunization cards may be provided to her from the untied funds made available to the Sub-Centres.

(6) Organization of the Village Health and Nutrition Day: All State Governments are presently organizing monthly Health and Nutrition day in every village (Anganwadi centers) with the help of AWW/ANM. ASHA along with AWW should mobilize women, children and vulnerable population for the monthly health day activities like immunization, careful assessment of nutritional status of pregnant/lactating women, newborn & children, ANC/PNC and other health check-ups of women and children, taking weight of babies and pregnant women etc. and all range of other health activities. The ANM and the AWW will guide the ASHA during the monthly health days. The organization of the monthly Health and Nutrition Days ought to be jointly monitored by the CDPO, LHVs, and the Block Supervisor of the ICDS periodically.

(7) Co-ordination with SHG Groups: ASHA would be required to interact with SHG Groups, if available in the villages, along with AWW, so that a work force of women will be available in all the villages. They could jointly organize check up of pregnant women, their transportation for safe institutional delivery to a pre-identified functional health facility. They could also think of organizing health insurance at the local level for which the Medical Officer and others could provide necessary technical assistance.

(8) Meeting with ANM: ANM should have a monthly meeting with the ASHAs stationed (5-6 ASHAs) in the villages of her work area at the Anganwadi Centre during the monthly Health and Nutrition Day to assess the quality of their work and provide them guidance.

(9) Monthly meetings at PHC level: The Medical Officer In-charge of the PHC will hold a monthly meeting which would be attended by ANM and ASHAs, LHVs and Block Facilitator. During this period, the health status of the villages will be carefully reviewed. Payment of incentive to ASHAs under various schemes could be organized on that day so that ASHA need not visit the PHC many times to receive her incentives. States may ensure that payment to ASHA are made promptly through a simplified procedure. During these meetings, the support received from the Village Health and Sanitation Committee and their involvement in all activities also should be carefully assessed. The ASHA kits also could be replenished at that time. Replenishment of kit should be prompt, automatic and through a simplified procedure.

(10) Monthly meetings of ASHAs: A meeting of ASHA could be organized on the day monthly meetings are organized at the PHC level to avoid unnecessary travel expenditure and wastage of time. The idea is that apart from the meeting with officials they should be given opportunity to share sometime of their own experience, problems, etc. They will also get an opportunity to independently assess the health system and can bring about much needed changes.

In addition to monthly meetings at PHC, periodic retraining of ASHAs may be held for two days once in every alternate month where interactive sessions will be held to help then to refresh and upgrade their knowledge and skills, as provided for in the original guidelines for ASHA.

(11) Block level management: At the block level, the BMO will be in overall charge of ASHA related activities. However, an officer will be designated as Block level organizer for the ASHA to be assisted by Block Facilitators (one for every 10 ASHAs). Block Facilitators could be appointed as provided for under the first set of guidelines on ASHA already issued to the States. The Block Facilitator may be necessarily women. However, male members if any, who may have already been appointed earlier as Block Facilitator may continue. The Block Facilitators would provide feedback on the functioning of ASHAs to the BMO & Block level organizers. They shall also visit the ASHAS in villages.

(12) Management Support FOR ASHA:: Officials in the ICDS should be fully involved in ASHAs activities and their support should be provided for at every level i.e. PHCs, CHCs, District Society etc. The management support which would be provided under RCH/NRHM at the Block, District & State level should be fully utilized in creating a network for support to ASHA including timely disbursement of incentives, at various levels. This support system should have full information on the number of ASHAs, quality of their out put, outcomes of the Village Health and Nutrition Day, periodic health surveys of the villages to assess her impact on community etc.

(13) Community monitoring: Periodic surveys are envisaged under NRHM in every village to assess the improvement brought about by ASHA and other interventions. The funding for the survey will be provided out of the untied funds provided to the Sub-Centre. The first survey would provide the base line for monitoring the impact of health activities in the village.

(14) Role of District Health Missions: The District Health Mission in its meetings will specially assess the progress of selection of ASHAs, their training and orientation, usefulness to the villages etc. They should also have a Cell in the DPU to collect all information related to ASHA and the community which should be available on the computer network. This information should be accessible by the State Health Missions as well as the Mission at the national level.

The success of NRHM to great extent depends on performance of ASHA and her linkage with functional health system. The health system has to give due recognition to ASHA and take prompt action on the referrals made by her; otherwise the system cannot be sustained. Every ASHA must be familiar with the identified functional health facility in the respective area where she can refer or escort the patients for specific services. The persons manning these health facilities should be sensitized to effectively respond to the instant needs of the local people. Funds available under IEC-programme may be used for education and publicity in respect of above services. The role of the State & District level Missions would be to provide support to ASHA from village to the district level without any blockage on the way.

The States may take appropriate steps to locally adopt these guidelines and make the ASHA scheme a complete success.

Factors Critical to the Success of ASHA

1. Selection of ASHA by prescribed process as per the ASHA guidelines.

2. Linkage with nearest functional health facility for referral services.

3. Identified transport for referral of cases from village to facility

4. Priority and recognition of cases referred by ASHA to MO / ANM.

5. Successful organization of monthly Health and Nutrition Day (in every village with the ANM / AWW).

6. Monthly meeting of ASHA at PHC.

7. Timely payment of incentives to ASHA.

8. Timely replenishment of ASHA kit.