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