One of the key components of the National Rural Health Mission is to provide every village in the country with a trained female community health activist – ‘ASHA’ or Accredited Social Health Activist. Selected from the village itself and accountable to it, the ASHA will be trained to work as an interface between the community and the public health system. Following are the key components of ASHA:
¨ ASHA must primarily be a woman resident of the village – married/ widowed/ divorced, preferably in the age group of 25 to 45 years.
¨ She should be a literate woman with formal education up to class eight. This may be relaxed only if no suitable person with this qualification is available.
¨ ASHA will be chosen through a rigorous process of selection involving various community groups, self-help groups, Anganwadi Institutions, the Block Nodal officer, District Nodal officer, the village Health Committee and the Gram Sabha.
¨ Capacity building of ASHA is being seen as a continuous process. ASHA will have t undergo series of training episodes to acquire the necessary knowledge, skills and confidence for performing her spelled out roles.
¨ The ASHAs will receive performance-based incentives for promoting universal immunization, referral and escort services for Reproductive & Child Health (RCH) and other healthcare programmes, and construction of household toilets.
¨ Empowered with knowledge and a drug-kit to deliver first-contact healthcare, every ASHA is expected to be a fountainhead of community participation in public health programmes in her village.
¨ 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.
¨ ASHA will be a health activist in the community who will create awareness on health and its social determinants and mobilise the community towards local health planning and increased utilisation and accountability of the existing health services.
¨ She would be a promoter of good health practices and will also provide a minimum package of curative care as appropriate and feasible for that level and make timely referrals.
¨ ASHA will provide information to the community on determinants of health such as nutrition, basic sanitation & hygienic practices, healthy living and working conditions, information on existing health services and the need for timely utilisation of health & family welfare services.
¨ She will counsel women on birth preparedness, importance of safe delivery, breast-feeding and complementary feeding, immunization, contraception and prevention of common infections including Reproductive Tract Infection/Sexually Transmitted Infections (RTIs/STIs) and care of the young child.
¨ ASHA will mobilise the community and facilitate them in accessing health and health related services available at the Anganwadi/sub-centre/primary health centers, such as immunisation, Ante Natal Check-up (ANC), Post Natal Check-up supplementary nutrition, sanitation and other services being provided by the government.
¨ She will act as a depot older for essential provisions being made available to all habitations like Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet(IFA), chloroquine, Disposable Delivery Kits (DDK), Oral Pills & Condoms, etc.
¨ At the village level it is recognised that ASHA cannot function without adequate institutional support. Women’s committees (like self-help groups or women’s health committees), village Health & Sanitation Committee of the Gram Panchayat, peripheral health workers especially ANMs and Anganwadi workers, and the trainers of ASHA and in-service periodic training would be a major source of support to ASHA.
Auxiliary Nurse Midwife (ANM)
The roles of Auxiliary Nurse Midwife (ANM) and ASHA have been integrated in various ways. The ANM will hold weekly/fortnightly meeting with ASHA, and provide on-job raining by discussing the activities undertaken during the week/fortnight and provide guidance in case ASHA encounters any problem. ANMs will also act as resource persons for the initial and periodic training and also ensure that during the training ASHA gets the compensation for performance and also TA/DA for attending the training schedule. She will also guide ASHA in bringing the beneficiary to the outreach session. She will utilize ASHA in motivating the pregnant women for coming to the Sub-Centre for initial check-ups and also take ASHA’s help in bringing married couples to sub centres and motivating pregnant women for taking full course of Iron and Folic Acid (IFA).
Anganwadi Worker (AWW)
The responsibilities of Anganwadi Worker (AWW) will guide ASHA in performing on health and integrated with the role of ASHA. AWW will guide ASHA in performing activities such as organising Health Day once/twice a month at Anganwadi Centre and orientating women on health related issues such as importance of nutritious food, personal hygiene, care during pregnancy, importance of immunisation etc. anganwadi worker will be depot holder for drug kits and will be issuing it to ASHA. The replacement of the consumed drugs can also be done trough AWW. ASHA will support the AWW in mobilizing pregnant and lactating women and infants for nutrition supplement. She would also take initiative for bringing the beneficiaries from the village on specific days of immunisation, health check-ups/health days etc. to Anganwadi Centres.
NRHM aims at empowering local governments to manage, control and be accountable for public health services at various levels.
The Mission envisages the following roles for PRIs
¨ States to indicate in their MoUs the commitment for devolution of funds, functionaries and programmes for health, to PRIs.
¨ The District Health Mission (DHM) to be led by the Zilla Parishad. The DHM will control, guide and manage all public health institutions in the district, Sub-Centres, PHCs and CHCs.
¨ ASHAs would be selected by and be accountable to the Village Panchayat. The Village Health Plan, and promote inter-sectoral integration.
¨ Each Sub-Cenre will have an Untied Fund for local action @Rs.10,000 per annum. This fund will be the ANM, in consultation with the Village Health and Sanitation Committee.
¨ PRI’s involvement in Hospital Management Committees for good hospital management.
¨ Provision of training to members of PRIs.
¨ Making available health related database to all stakeholders, including Panchayats at all levels.
Specific action plans at district level would include the following:
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Constitution of District Health Mission led by Zilla Parishad to lead the activities under NRHM and Total Sanitation Campaign (TSC) in the district.
- Preparation of integrated District Action Plan as per the NRHM mandate.
- Constitution of Hospital Management Society for district hospital, Community Health Centres (CHCs) and Primary Health Centres (PHCs), after which maintenance grant of Rs. 1 lakh shall be released by the Government of India.
- Opening a Joint Account of ANM and Sarpanch to manage Untied Fund of Rs. 10,000 per Sub-Centre, to address the unmet gaps reflected in Village Health Plan.
- Facilitation of village health planning under the guidance of village Health and Sanitation Committee of the Gram Panchayat.
- Upgradation of CHCs to Indian Public Health Standards (IPHS) in a time bound manner.
- Addressing issues of availability of manpower, equipment and drugs in public health facilities.
- Exploring models of Public-Private Partnership to supplement with services in the district, like contractual engagement of district paramedics, hiring services of district specialists on payment of remuneration, and contracting out services to NGOs/accredited private health facilities in the district.
- Operationalising services of mobile medical unit in every district.
- Ensuring supply and replenishment of generic drugs for common ailments supplied under NRHM at CHC/PHC/sub-centre/village level.
- Organizing selection and training of ASHAs.
- Strengthening Universal Immunisation through Micro-planning, including availability of Auto Disabled Syringes and alternate vaccine delivery.
- Ensuring maintenance of cold chain and plan for waste plastics and sharp disposal.
- Implementation of Janani Suraksha Yojana (JSY) to improve levels of institutional delivery by dissemination of the scheme to ensure fund flow, identification of pubic and private hospitals for providing services, and ensuring compliance to Citizen’s Charter displayed at CHCs.
- Ensuring simple procedure for BPL certification and introduction of voucher system wherever possible for JSY, immunization, contraception etc.
- Conducting verbal autopsy of maternal deaths.
- Promoting breast-feeding and Integrated Management of Neonatal Childhood Illness(IMNCI) in the district.
Each State shall develop its own strategy for National Rural Health Mission (NRHM) under the overarching guidelines of the Government of India. Some specific State level actions envisaged under the NRHM include the following:
- Organizing State and Divisional/District level stakeholder workshops involving Department of Health, Family Welfare, AYUSH, Women and Child Development, Panchayati Raj, Rural development, Finance, Drinking Water Supply, Finance, District Administration including District Magistrate, chief Medical Associations like IMA and FOGSI, and Corporate Sector.
- Constitution of State Health Mission chaired by the Chief Minister and co-chaired by the State Health Minister.
- Merging different societies of Health and Family Programmes into an integrated Society at State and district level.
- Preparation of integrated State Action Plan for RCH-II, National Disease Control Programmes, and Intergrated Disease Surveillance Programmes and related Sectors of Nutrition, Sanitation and Hygiene. The Sate Action Plan to also reflect available funds under State Health Budget, and funds received from Planning Commission, Bilateral Agencies and major NGOs.
- State government would identify core performance indicators and time frames for achieving the same.
- Preparing a distinct strategy for addressing vulnerable population groups and underserved areas to be specified in the State Action Plan.
- Ensuring key role of Panchayati Raj Institutions at all levels under the Mission to plan, control and monitor the health programme.
- Integrating the Institutional Framework of health & Total Sanitation campaign at District and Sub-district levels, to ensure provision of household toilets under the Mission.
- Guidelines for constitution of Hospital Management Committees at district, CHC an PHC level, fully empowered to levy and utilize user charges.
- The finalise State Model of ASHA and Training Modules for the same.
- Issue Government Order to facilitate a fixed Health Day at Aanganwadi level every month for comprehensive mother and child healthcare activities.
- Strengthening Programme Management Unit at State and district level through induction of skilled professionals, and their integration into the mainstream organization.
- Organizing trainings for staff, finalizing new organogram, providing office equipment to the new recruits.
- GIS mapping of public and private health facilities.
- Identifying atleast two CHCs per districts for upgradation to Indian Public Health Standards (IPHS) in the first year.