"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.
Case Studies of Large-Scale Community Health Worker Programs was derived from the Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, edited by Henry Perry, Lauren Crigler, and Steve Hodgins.
Originally published in May 2014 by USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), it was created in response to the rapid increase in and expansion of CHW programs in low- and middle-income countries over the past decade. In January 2017, a companion document was prepared to provide guidance on 13 case studies, including Afghanistan, Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe. CHW Central is serializing the case studies over time.
India has three cadres of CHWs. The first created is the Auxiliary Nurse-Midwife (ANM), who is based at a sub-center and visits villages in addition to providing care at the subcenter. The second is the Anganwadi Worker (AWW), who works solely in her village and focuses on provision of food supplements to young children, adolescent girls, and lactating women. The most recently created cadre is the Accredited Social Health Activist (ASHA), who also works solely in her village. ASHA workers focus on promotion of MCH, including immunizations and institutional-based deliveries, for which they receive a performance-related fee.
There are at present 208,000 ANMs, 1.2 million AWWs, and 857,000 ASHA workers. They each have their own supervisory systems and payment systems.
ANMs receive 18 months of training while AWWs and ASHA workers each receive 3–4 weeks with additional trainings from time to time.
ANMs are now officially Multipurpose Workers (MPWs) with a broad set of responsibilities, including the support of AWWs and ASHA workers. Some obtain additional training to manage birth complications and refer women with complications to higher levels of care, and some obtain additional training for insertion of intrauterine devices. AWWs manage nutritional supplementation at anganwadi centers for young children, adolescent girls, and lactating women. They also help with promotion of healthy behaviors and mobilization of the community for improved water and sanitation, participation in immunization activities and other special health activities. ASHA workers are given performance-based incentives that focus around facilitating institutional deliveries, immunizations, provision of basic medicines (including oral contraceptives), and referral of patients to the sub-center.
ANMs are paid a government salary. AWWs are considered to volunteers but are paid an “honorarium” of about $27–$29 per month. ASHA workers receive performance-based incentives, such as $10 for facilitation of an institutional delivery and $2.50 for facilitation of a child’s completion of immunizations. They also now receive $16 per month for completing their day-to-day routine tasks independent of the specific tasks for which they receive performance- based incentives.
Supervision of each of these three cadres is carried out independently. For all cases, there is a widespread consensus that the supervision is inadequate.
Evaluations of these programs have produced mixed results. Wide variations exist in the quality of training and in the competency and effectiveness of these CHWs, but strong efforts are under way (particularly for the ASHA Program) to improve training, supervision, remuneration, and logistical support.
What is the historical context of India’s CHW programs?
The network of primary health centers currently forms the foundation of the Indian rural health care system and also the main link to India’s CHW programs. These primary health centers were established in the late 1940s, shortly after India’s Independence in 1947. When sub-centers were created below the primary health center level in the 1960s, lower-level temporary health workers were required to staff them.1 In response to this demand, the Indian MOHFW created the ANM cadre.2 This was followed by the establishment of AWWs for child development through the Integrated Child Development Service (ICDS). The newest addition to the CHW family has been ASHA workers, established by the MOHFW.
Background of Auxiliary Nurse Midwives
At the time the ANM program was launched, ANMs received two years of training focused primarily on MCH, with midwifery being the focus of nine out of the 24 months of training.3,4 ANMs were envisioned to be village-level midwives with “less than full qualifications.”3 Within a decade, in the early 1970s, the role of ANMs was expanded to include a wide range of preventive and curative work at the village level, particularly around FP and immunization.2 With the expansion of their role, ANMs transitioned from temporary to permanent staff within the health system.1 At the same time, ANMs were also reclassified in the health system, from a nurse-midwife to a female MPW.5 In response to the Srivastava Committee’s call for improved ANM training to reflect their multipurpose role,6 in 1977 the Indian Council of Nurses approved a syllabus for ANM training that focused on an expanded set of responsibilities and reduced the midwifery component of the training from 9 to 6 months.4 At the same time the number of subjects included in the training increased, the duration of training was reduced from 24 to 18 months because, as MPWs, ANMs were no longer considered to require extensive and specialized training.3,7
The National Rural Health Mission (NRHM), launched in 2005, is the latest broad vision for improving comprehensive primary health services for the rural poor in India. ANMs are positioned as a key health worker within the NRHM human resources framework.3 The NRHM doubled the number of ANMs at sub-centers from one to two full-time staff.8
Background of Anganwadi Workers
In 1972, the central government released an interministerial survey suggesting that existing social welfare and nutrition programs in India were not improving the nutritional status of children.9 The government attributed these program failures to resource constraints, inadequate coverage, and fragmentation.9 To address some of these shortcomings, the Government of India initiated the ICDS scheme in 1975. Anganwadi Centers, staffed by AWWs, are the central implantation mechanism of the ICDS. The term anganwadi comes from the word angan, meaning courtyard. The angan is traditionally an open space at the center of the house where families can gather and where food is often prepared.
The ICDS program began with a two-year pilot phase involving 4,981 Anganwadi Centers in 33 blocksi throughout India.10 An evaluation found that the program increased BCG and DPT immunization rates, improved the distribution of vitamin A and supplementary food provisions, and improved child nutrition status.11 Subsequent evaluations in 1978 and 1982 found further positive outcomes, and the scheme was scaled up throughout the 1980s. Program coverage expanded rapidly, from 33 blocks in 1975, to 4,200 around the year 2000, and over 5,500 in 2003.12-14 During the 1990s, the program’s budget and number of beneficiaries almost doubled.13
ICDS initially focused on the health issues of children from birth to six years of age.15 However, over the decades, ICDS has expanded to include nutritional support and health education for adolescent girls (under the Kishori Shakti Yojana scheme) and lactating women. In some states the AWW has been envisioned as a curative health care provider and equipped with drug kits to address common illnesses among young children.16,17 However, more recent ICDS reports have indicated that this component of responsibility for drug provision has been eliminated from AWW’s work.
Village Health Guides
Beginning in 1977, inspired by the first successful CHW program in India—the Jamkhed Comprehensive Rural Health Project—the government of India embarked on a national scale-up of the Jamkhed CHW model.18-22 At this time, the newly-elected Janata Party was under pressure to regain the confidence of rural populations after the sterilization campaigns of the 1970s. For this reason, the scale-up was rapid, and perhaps hasty. The program drew heavily on a 40-year-old scheme of the National Planning Committee that had never been set into motion.19-21, 23 Over the course of five years, some 500,000 Village Health Guides were trained in rural India with the goal of having one Village Health Guide for every 1,000–2,000 people.19, 23 Although the program recommended that the Village Health Guides be female, almost all the guides selected were male. These CHWs had three months of formal training to treat minor ailments and first aid, and they were paid a small stipend.18 They had no supervision. Some major problems that were documented during program scale-up included lack of a functioning supply chain for the Village Health Guides, lack of supervision, and lack of community engagement. Selection of trainees was based more on political considerations (and connections to local leaders) than on motivation to serve and competence (R Arole, personal communication, 1997).25
In 1979, two years after the program had been deployed, an evaluation of the program found that 40% of Village Health Guides reported not receiving their drug kits, and over 60% had not received the supplementary materials for community health and counseling.26 In addition, about 50% of the Village Health Guides reported not receiving the CHW manual that was supposed to be used as a reference guide for village activities.26
Some of the challenges that the Village Health Guide Program faced were lack of government buy-in and support following program implementation.18 Moreover, community engagement in program design and deployment inhibited the program’s acceptability and sustainability at the rural community level.18 The stipend provided to the Village Health guides caused workers to think of themselves not as community agents, but instead as simply another level of government employees. Remuneration also became a large burden for the Central government. In 1981, State governments were asked to cover half the cost of the scheme, causing many to terminate their programs entirely.27 Community members that the Village Health Guides were intended to serve reported feeling that the PHC provided by the government lacked responsive and caring health care workers, and did not address the communities’ health needs.18 By 1983, the program had clearly failed. It sputtered throughout the 1980s and 1990s until it was formally terminated in April 2002 when the government severed all funding.27
The Village Health Guide Program failed to provide the funds required to assure that supervision and the needed materials and supplies were available. The government’s financing of the program was heavily dependent on external aid, and the program was poorly managed. Furthermore, the government failed to integrate the community health efforts of the Village Health Guides with responses to other public health problems, such as water supply, and with economic growth opportunities like agricultural inputs and land reclamation. The Village Health Guides’ remuneration became not only a burden to the government, but also caused the Guides to consider themselves as mere extension workers rather than agents of community change. The choice to not require Village Health Guides to be female also stunted the program’s effectiveness. Finally, the Village Health Guide scheme failed to provide supportive supervision to the Village Health Guides, which affected their accountability, job satisfaction, and motivation.18
Background of the ASHA program
In the early 2000s the Government of India was in the final stages of developing the NRHM, which was seen as an “architectural correction” for the rural PHC system.28 Since then, the NRHM has guided an increase in public health care expenditure from 0.9% of GDP to 2%–3% along with expanded state-level efforts to improve accountability and community engagement in the public health care sector.28 The initial draft proposal for the NRHM included a provision for a national CHW cadre focused only on mobilizing FP and promoting institutional delivery. Civil society actors argued that such a narrowly defined role for CHWs would be a lost opportunity and was “not in conformity with the spirit and experience of CHW programmes”.29 The MOHFW responded by creating a stakeholder task force to design the ASHA Program. This task force, together with the MOHFW, developed the ASHA Guidelines that became central to defining the program’s scope.29 When designing the ASHA Program, the task force drew lessons not only from earlier, relatively unsuccessful, state-run CHW programs, but also from several successful civil society-run programs.29 These civil society programs included the Comprehensive Rural Health Project in Jamkhed, Maharashtra (1970–present) and SEARCH in Gadchiroli, Maharashtra (1980–present). Both of these programs showed that female CHWs with minimal formal education can bring about significant improvements in rural health conditions, provided they have strong training and support.
In 2005, when the NRHM was launched, one ASHA worker for every 1,000 people was a key feature.28 In many states, the ASHA program built upon preexisting CHW programs. For instance, in Rajasthan, Anganwadi Center Helpers were nominated to become ASHAs. Andhra Pradesh’s Women Health Volunteers were renamed ASHAs. The Chhattisgarh Mitanin CHW program, launched in 2003 as a precursor to the ASHA Program, has retained the name “Mitanin” for their health workers, but has otherwise been absorbed by the ASHA Program.30 Initially (2005–2008) the ASHA Program was a component of the NRHM only in 18 high-focus states and in the tribal districts of other states. In 2009 the program was extended to cover the entire country of 31 States and Union Territories, although Tamil Nadu opted to continue limiting the ASHA Program to tribal areas only.
Now there are 1,203,300 Anganwadi Centers across India, each one staffed by one AWW,31 207,868 ANMs,32 and 857,000 ASHAs.29
What are India’s health needs?
In the past 60 years, the health status of Indians has improved markedly. The IMR has declined from 120 per 1,000 live births in the 1970s to 42 in 2010.33 Life expectancy at birth has risen from 36 years in 1951 to 65 years in 2010. In 1951, women had an average fertility rate of 6.0, while in 2010 it was 2.4. The MMR has also declined from 400 maternal deaths per 100,000 live births in 1998 to 178 in 2010.33.34
However, despite rapid growth in GDP over the last 20 years,35 India has consistently failed to meet national and international health targets, and it has improved its health status more slowly than most other Asian countries.36 India continues to have high rates of maternal and child mortality from communicable diseases along with poor management of chronic diseases of adulthood.37-40 India’s rank in the human development index among 177 countries rose only two positions between 1999 and 2004—from 128th to 126th.36 One-fourth of all child deaths and 20% of all maternal deaths in the world occur in India.40-41 Rural people, lower-caste people, religious minorities, women, and the poor all suffer from the marked health inequalities that exist in India and from a lack of access to good quality care because of social, geographic, and economic barriers.36,42-44
India is facing a “double burden” of disease, meaning that large proportions of mortality in the population can now be attributed to communicable disease on one hand and chronic conditions on the other. Communicable diseases, such as respiratory infections and diarrhea, are often considered diseases of poverty and disproportionately affect children and the poor. Chronic conditions such as mental health disorders, diabetes, and cardiovascular disease are often considered diseases of more affluent populations and typically cause death among adults later in life. Chronic diseases now account for more than one-half of deaths in India,45,46 and communicable diseases account for 29%.46 The remaining mortality is from injuries (10%), perinatal conditions (7%), and maternal conditions (1%). In 2008, one-third of all deaths in India were among people younger than 14 years of age, and 86% of these deaths were due to communicable diseases or perinatal conditions.47 Among adult deaths, approximately one-fourth can be attributed to communicable disease and 65% to chronic diseases.47
What is the existing health infrastructure?
The rural PHC system includes CHWs at the village level. Each village is supposed to have one AWW and one ASHA worker. AWWs provide information about basic child health and nutritional supplementation for children younger than six years of age, to adolescent girls, and to lactating women.48 The AWW is based out of an Anganwadi Center and is the key functionary of India’s ICDS.49
MPWs, generally a male MPW and an ANM, who is female, conduct outreach to the villages on a monthly basis. They focus on infectious disease and on MCH. MPWs work out of the primary health sub-center, a clinic that serves several villages. This sub-center is open around the clock and normally has a doctor on staff. Referrals can be made from there to the primary health centers and from there to the district hospital. Primary health centers form the second level of the health system, and they are based in larger villages or small towns. In terms of accountability, currently the state’s Minister of Health and Family Welfare oversees the system, delegating responsibility to district medical officers (DMOs), who in turn oversee the block medical officers (BMOs).
India also has a prominent private health care sector. In fact, the majority of Indians seek care at private facilities rather than at free government health centers because of convenience, ease of accessibility, and perceived superior service. Even the poorest quintile of the population seek private care for 76% of their outpatient medical care and 58% of their inpatient care.50 Health care spending composes 4.1% of India’s GDP, which is a fairly average percentage for a developing country.51 Households pay out of pocket for over 70% of health care expenditures in the country.51
What type of program has been implemented?
The ANM cadre is the most well-educated and oldest cadre among the village-level health workers, having been established in the 1960s. The AWW is also well-established in the domain of childcare and nutrition, having been part of the health care system since the mid-1970s. The ASHA is an entirely new cadre, launched in 2005 by the NRHM.28 As the new and often younger addition, ASHAs are monitored and supported by the ANM and AWW. The ASHA is seen by some policymakers as a means of reducing the labor burden on the ANM52 and is often seen as the ANM’s assistant or helper.53
ANMs are women with 18 months of training who manage FP, immunization, and MCH programs. They are based out of sub-centers, the lowest facility in the rural public health care system.
AWWs are female nutrition and child development workers who receive one month of training. They run preschool centers and provide nutritional supplementation for children, lactating and pregnant women, and adolescent girls. They are based out of Anganwadi Centers, which serve as preschools and spaces for the storage and preparation of supplementary foods.54 The AWW is supported by a part-time assistant, called an Anganwadi Helper (AWH) or sometimes also called a Sahayika.
ASHAs are female CHWs who receive 23 days of training and who encourage women to seek ANC and give birth in health centers, assist the ANM with health events such as immunization days, and provide basic first aid and medical supplies such as ORS, contraceptive pills and iron folic acid tablets.28 ASHA workers are to be based in their villages, and they refer people to their local primary health center and community health center. Village Health and Sanitation Committees, composed of village residents and the ASHA worker, also provide support for the ASHA’s activities (see also the section on the community’s role below). Although the precise manner of ASHA functioning varies by state, in general ASHAs are expected to attend weekly meetings at their local primary health center and make home visits to people in the community as needed. They are supposed to work approximately 2.3 hours a day and 4 days per week, except during training and mobilization events (such as health education or immunization promotion), when they are expected to put in more time.55
The Government of India describes the ASHA’s role as having three key components. First, ASHAs are to play a central role in achieving national health and population policy goals.56 Second, they are to act as a bridge between the rural people and the government health system. Third, they are to serve as social change agents, described as follows:
ASHA will be a health activist in the community who will create awareness on health and its social determinants and mobilize the community towards local health planning and increased utilization and accountability of the existing health services.55
This third component of the ASHA’s role is ambitious. Early programmatic evaluations have found limited scope for this type of awareness raising, with many ASHAs working primarily on tasks such as immunization and promoting institutional delivery.53
The ASHA’s formal tasks are as follows:30,57
- Create awareness and provide information to the community on determinants of health such as nutrition, basic sanitation and hygienic practices, healthy living, and work conditions.
- Provide information on existing health services and the need for timely utilization of health and family welfare services.
- Counsel women on birth preparedness, safe delivery, care of the young, breastfeeding and complementary feeding, immunizations, contraception, and prevention of common infections, including sexually transmitted infections.
- Mobilize the community and facilitate access to health services.
- Work with the Village Health and Sanitation Committee to develop a comprehensive village health plan.
- Facilitate health-care seeking for pregnant women and children requiring treatment/admission to the nearest health facility.
- Provide primary medical care for minor ailments such as diarrhea and fevers, and provide first aid for minor injuries.
- Provide DOT for patients with TB.
- Carry essential provisions (ORS packets, TB medicines, iron and folic tablets, chloroquine [in malaria-endemic areas], disposable delivery kits, oral contraceptive pills, and condoms) for use in the community.
- Inform the health system of births, deaths, disease outbreaks, and unusual health problems.
- Promote construction of toilets under the Total Sanitation Campaign.
- Provide home-based newborn care (a new role added in 2011).
ASHA drug kits are refilled through a state-to-village distribution system. Drug kit supplies are procured at the state level by the Office of the Chief Medical Officer of Health. They are then distributed to the block-level health facilities and then on to each primary health center in the block. At monthly ASHA meetings, drug kits are restocked when only 25% of the needed contents are present. ASHA facilitators maintain Drug Kit Stock Registers and send drug supply requests to the block-level medical officer.58 In some cases, AWWs act as depot holders for drug kits and help resupply the ASHA workers.49
LHVs are ANMs who have been promoted to oversee six sub-centers. To be eligible for this promotion, an ANM must have five years of work experience and complete a six-month training program.1
MPW-Ms are male health workers who receive six months of training and are linked to a sub- center (along with an ANM).59 They generally focus on malaria prevention and treatment as well as on encouraging male sterilization. They are considered the “most neglected cadre” as there is no scope for in-service training and over 60% of the positions are vacant.59 These different groups of CHWs work together as a team. ASHAs are to be supported and monitored by both ANMs and AWWs. ANMs are responsible for the following tasks in relation to the ASHA:
- Have a weekly or fortnightly meeting with ASHAs
- Act as a resource person, along with the AWW, for the training of ASHAs
- Inform ASHAs about the date and time of the outreach sessions
- Help ASHAs maintain a register of couples eligible for FP, motivate pregnant women to come for ANC, and ensure that pregnant women receive iron pills and tetanus toxoid injections
- Orient ASHAs on the dose schedule and side effects of oral contraceptive pills
- Educate ASHAs on the danger signs of pregnancy and labor so that they can identify and help pregnant women get further treatment when needed
- Inform ASHAs about the date, time, and place for initial and periodic training
- Ensure that ASHAs receive compensation for their performance and for attending trainings
- Participate in and guide ASHAs in the organization of Health Days at the Anganwadi Center54
AWWs are responsible for the following tasks in relation to the ASHA:
- Guide the ASHA in organizing a Health Day once or twice per week
- Guide the ASHA in undertaking education activities on health issues during Health Days
What about the community’s role?
ASHAs and AWWs are both to be recruited and chosen by the community, while the ANM is hired and put into position by the district-level health administration.60 ASHAs are selected by and accountable to the local village-level government, called the Gram Panchayat, through a participatory process involving the community. After selection, ASHAs work closely with the Village Health and Sanitation Committee. The NRHM envisions the ASHA worker to “act as a bridge between the ANM and the village and be accountable to the Panchayat [local democratic government].”32
The AWW serves as a member of the village Self-Help Group. The ANM, ASHA, and AWW together are to be members of the Village Health and Sanitation Committee (VHSC).61 Self- Help Groups are government-supported voluntary microcredit groups for women. VHSCs are village-level voluntary health groups supported by the local level of the elected government (the Gram Panchayat) under the NRHM.62 The VHSC is to lead the development of a Village Health Plan, which is prepared and implemented by the ASHA, AWW, ANM, functionaries of other departments, and Self-Help Groups.63
CHWs are envisioned by the MOHFW to work together on village-level health activities to integrate health facility service provision with village-level health needs. The Program Implementation Plan for the NRHM states that:
The relationship between the Anganwadi Worker and the ANM at the village level and their respective working methods is critical to the improvement of child health services in rural areas.64
How does India select, train, and retain its CHWs?
AWWs must be female, aged 21–45 years and middle-school educated. Meanwhile, ANMs must have finished 12 years of school, must be female, and must be between 17 and 35 years of age to apply to ANM training programs in nursing schools across India.65 ASHAs are to have a class eight education or higher and preferably be between the ages of 25 and 45. An ASHA is to be a “daughter-in-law” of the village52 who is married, widowed, or divorced and who is likely to live in the village for the foreseeable future since unmarried women generally move to their husband’s village upon marriage. States were afforded the flexibility to select ASHAs with lower literacy levels in order to ensure local residence and community representation.
AWWs: According to official documentation,66 AWWs receive 26 days of training over the course of one month; 22 days are for classroom education with mock sessions and four days are for supervised practice at the Anganwadi Center. However, a more recent review states that AWWs receive three months of training.9 The Ministry of Women and Child Development states that the training should employ participatory learning techniques, whereby classroom teaching is to be supported by role play, demonstration, exercises, hands-on experience, and case studies.66 However, in 2011–2012 only 47% of the AWWs targeted to receive initial training and 51% of the AWWs targeted to receive refresher training actually received it.15 AWWs are also supposed to receive a seven-day refresher training at various points throughout their careers, but it is not clearly stated how often these trainings are to occur.64
ASHA workers: During their first year, ASHA workers receive 23 days of training. Then they are supposed to receive 12 additional days of training each year thereafter. The training manuals (Modules 1–4) have been found to be broadly simplistic, insufficient, and inconsistent.29 In addition, the first four manuals did not have an accompanying training manual and trainers often just read through the manual with the ASHAs without any structured skill development process.29 In contrast, Module 5, developed in consultation with the National ASHA Mentoring Group, includes reading material and a facilitator’s guide to train ASHAs in social mobilization. Two additional training modules have just been added to the training regimen.30 ASHA training has in some states been outsourced to NGOs, while in other states it is being conducted by health staff within the public system.
ANMs: ANMs complete 18 months of training. There are 1,284 ANM training institutions in India that are recognized by the Indian Nursing Council. Funding for an additional 132 ANM schools (focused in geographic areas that lack an ANM training school) was made available in the NRHM 2011 funding cycle.67 The curricula for all ANM training are provided by the Indian Nursing Council. Upon completing their 18 months of training, ANMs are considered to be female MPWs but not skilled birth attendants. The MOHFW is now offering an additional three- to six-week skilled birth attendant training program to ANMs whereby they can learn to better identify danger signs for referral as well as how to actively manage the third stage of labor (particularly with oxytocin or misoprostol) and conduct other emergency measures.68
ANMs can also obtain training in the insertion of intrauterine devices (IUDs) and gain permission to insert IUDs. Once an ANM has five or more years of experience, she can seek six months of promotional training to become a Lady Health Visitor (LHV)/HA (Female). It is helpful to position the ANM within the six levels of nursing training in India today: (1) Multipurpose Health Worker-Female training (ANM or MPHW-F), (2) Female Health Supervisor training (HV or MPHS-F), (3) General Nursing and Midwifery training (GNM), (4) BSc. Nursing training, (5) MSc. Nursing training, and (6) MPhil and PhD Nursing training. The ANM, HV, and GNM trainings are conducted in schools of nursing. The last three are university-level courses, and the universities where these programs are located are responsible.65
AWWs: AWWs are considered “honorary workers” who receive a monthly honorarium, but in fact, this honorarium serves as a salary. The payment is composed of a core honorarium from the central government that is often supplemented by additional payments from the state-level government to compensate AWWs for additional work on schemes beyond ICDS. The core monthly payment from the central government ranges from US$27–$29 (1,438–1,563 rupees) depending on the AWW’s educational qualifications and experience. Anganwadi Helpers (AWHs) receive $9 (500 rupees) per month.49
ANMs: Salaries for ANMs are paid through national health budgets, while the MPW is paid through the state-level health budget.63
ASHAs: The ANM serves as the gatekeeper to the ASHA’s receipt of reimbursement. ANMs check the ASHA’s register to see how many services the ASHA has facilitated for which she can receive payment, such as the number of pregnant women she facilitated in getting an institutional delivery. After approving the register, the ANM sends the register on to the Sarpanch (head of village-level government) for approval. On receiving the Sarpanch’s approval, the ANM is responsible for seeking the ASHA’s payment through the closest primary health center. Payments are usually dispatched once every three months. Once the check is prepared for the ASHA, the ANM picks the check up from the primary health center and delivers it to the ASHA.52 This process is quite convoluted and there have been reports of ANMs keeping portions of the ASHA’s payments as a bribe or of ANMs understating the ASHA’s earnings.
Although ASHAs are considered volunteers, they receive performance-based remuneration for a range of interventions. Initially limited to facilitating institutional deliveries and immunizations, the range has been expanded considerably to 31 activities. They include provision of home-based newborn care, promoting birth-spacing and birth-limiting FP, provision of DOT for TB treatment, making malaria slides, toilet construction, and follow-up of children with severe acute malnutrition after discharge from a nutritional rehabilitation center. For example, an incentive of 250 rupees (approximately $4.10) is given for providing home-based newborn care. Facilitating institutional deliveries is the most common activity for which ASHAs receive payments. Under the Janani Suraksha Yojana (Pregnant Woman Safety Scheme) Program, if an ASHA worker facilitates an institutional delivery, she receives 600 rupees (approximately $10) and the mother receives 1,400 rupees ($23).68 ASHAs also receive 150 rupees (approximately $2.50) for each child completing an immunization session and each individual who begins to use FP.70 ASHAs are compensated for training days, meetings, and additional health-related activities on a state-by-state basis.
The ASHA payment system fails to reflect the amount and type of work expected. Although ASHA workers are tasked with a wide range of activities, including developing and implementing Village Health Plans, they receive remuneration for only a very few highly specific activities (such as bringing in women for institutional deliveries). Understandably, ASHA workers tend to focus on the tasks they are paid for. Moreover, many ASHAs are dissatisfied with the current level of remuneration, reporting that they work far more hours than is sustainable for a volunteer position.71 In response to this, a recent decision has been made to provide an “incentive” (not a salary since ASHAs are still considered to be volunteers) for completion of a set of routine activities regardless of population covered. Now, ASHAs receive 1,000 rupees (about $16) for completing a set of routine and recurrent tasks each month (R. Ved, personal communication).
How does India supervise its CHWs?
Each group of CHWs has a different supervision system. ASHAs, ANMs, and AWWs each have their own separate and different supervisors.
AWWs: AWWs are supervised by an ICDS Anganwadi supervisor and the Child Development Project Officer (CDPO). The CDPO is responsible for ICDS at the block level. The ICDS Anganwadi supervisor oversees 25 AWWs. The CDPO is supported by a statistical assistant at the block level. The AWW is also supported by the ASHA and ANM on MOHFW programs (for immunization, health checkups, and health-related referrals).
ANMs: There is one LHV or HA (Female) assigned to supervise every six sub-centers. This person is tasked with supervising and providing technical guidance to the ANMs at the sub- centers and reporting to the Medical Officer.1
ASHA workers: According to national guidelines, there is to be one ASHA facilitator for every 20 ASHAs. The facilitator is to help with the selection of the ASHA, provide on-the-job mentoring to ASHAs, conduct cluster meetings, maintain records of ASHA activities, attend Village Health and Nutrition Days with the ASHAs, and attend monthly block primary health center meetings.58 The ASHA facilitator is supervised at the block level by the Block Community Mobiliser, who is in turn supervised by the District Mobilization/Coordination Unit, which liaises with the state-level ASHA resource center. In their 2011 evaluation, the National Health Services Research Center found that some states had supervision only at the block level or delegated ASHA supervision to ANMs and other primary health center staff instead of hiring separate facilitators. In other states, the facilitator was hired only to help with ASHA selection and ceased functioning after selection.
At the national level, the ASHA Mentoring Group meets biannually and advises the MOHFW on ASHA policy and programming. The National Health Systems Resource Centre is the technical support unit under the MOHFW and serves as the secretariat for the ASHA Mentoring Group.30
Several states have introduced ASHA motivation and recognition initiatives such as cash awards for the best-performing ASHAs (in Bihar), newsletter and radio programs (in several states), bicycles for all ASHAs (in Assam), and career development opportunities through scholarships to study nursing (in Chhattisgarh).30
An ASHA monitoring system has been developed by the MOHFW. The main source of performance monitoring arises from monthly meetings of the ASHA facilitator with the 20 or so ASHA workers she or he oversees. The reports on ASHA functionality involve recording whether ASHAs are completing 10 tasks, including visiting newborns within the first day (for home deliveries), attending immunization camps, visiting households to discuss nutrition, and acting as DOT providers for TB treatment.58 These reports are then submitted to the block community mobiliser on a monthly basis and assessed quarterly to determine what percentage of ASHA workers are functional. These results are then submitted to the district coordinator, who grades each block in the district based on ASHA functionality. Finally, the monitoring data is consolidated at the state level and each district is graded.
How is the program financed?
AWWs: $8 billion (444 billion rupees) was allocated to the ICDS overall in the 11th Five Year Plan Period (2007–2012).j Financing for AWW payments and the upkeep of Anganwadi Centers comes from both the central and state governments, with the central government contributing 90% and the states contributing 10%. The cost of the food provided by AWWs through ICDS is shared 50-50 by the central and state governments.49 In 2008, ICDS spent $0.07 (4 rupees) on supplementary food per child beneficiary (aged 6–72 months) per day and $0.09 (5 rupees) on supplementary food per pregnant or nursing woman per day.49
ASHA workers: In 2006, the MOHFW stipulated that the ASHA program would cost 10,000 Indian rupees (approximately $163) per ASHA worker per year across 18 high-focus states. This included the cost of the selection process, social mobilization, training, drug kits, identity cards, and support for ASHA workers by the primary health center and the ASHA supervisor (facilitator). This amount did not, however, include the cost of ASHA worker remuneration, which was supposed to come from the budgets of various other MOHFW initiatives such as the Janani Suraksha Yojana Program to support institutional delivery in rural areas.30
The program has consistently absorbed less than 50% of its allocated budget because of lack of support structures and other support activities, limited internal capacity, and reluctance to provide support for entities outside of the public sectors, such as NGOs.30 Absorption varies across states, ranging from 20% in Delhi to 96% in Chhattisgarh, depending on the status of the support structure and the state’s commitment to the program (R. Ved, personal communication). From 2005 to 2011, the program spent only 48% of the total funds available, amounting to 5,400 rupees (approximately $88) per ASHA worker.
What are the program’s demonstrated impact and continuing challenges?
AWWs: Although early evaluations of ICDS were promising, more recent assessments have been less encouraging. In Lokshin et al.’s study,72 anthropometric measures of children obtained from the National Family Health Survey were compared in villages covered by ICDS and in matched villages not covered by ICDS. Their analysis found little overall effect of ICDS on nutritional outcomes. Deolalikar found that the presence of an ICDS Centre is associated with a 5% reduction in the probability of being underweight for boys, but not for girls.73 Another study by Bredenkamp and Akin found that the presence of an ICDS Centre has no significant effect on the nutritional status of children.74
Since its inception, ICDS has been implemented with uniform norms, giving rise to critiques of inflexibility and incapacity to adjust to address pockets of more severe malnutrition.75 The top- down implementation of the program has left very little space for community involvement and has resulted in many ICDS workers (including AWWs) having very little accountability to the communities in which they operate.12 Many studies have identified implementation problems with ICDS in general, and have specifically identified insufficient AWW training and support as a major barrier to program success.12,74,76-78 AWW duties require detailed understanding of child nutrition, maternal health and preschool education. “Supply leakage,” particularly related to pilfering and resale of food grains from ICDS program stocks, has severely undermined nutrition supplementation efforts. What food does get distributed has been found to focus on children between the ages of four and six years, which is actually too late to optimally influence growth.76 Greiner and Pyle identified low community involvement in ICDS as a central barrier to program success.12 Although community selection and support of the AWW are featured in government documents, communities often have little to do with the AWW; similarly, ICDS employees may feel low affinity for the communities in which ICDS operates.
ANMs: There is surprisingly little published evidence of ANM effectiveness. In a placebo- controlled trial from 2002 to 2005, Derman et al. found that ANMs could effectively administer oral misoprostol to reduce rates of acute postpartum hemorrhage and acute severe postpartum hemorrhage.79 Agrawal et al. found that coverage of antenatal home visits and newborn care practices were positively correlated with the knowledge level of AWWs and ANMs.80 Specifically, when comparing women visited by AWWs or ANMs who had better knowledge compared with those with poor knowledge, initiation of breastfeeding in the first hour of life, clean cord care, and thermal care were significantly higher among women visited by ANMs or AWWs with better knowledge.
Challenges within the ANM program include a lack of meaningful supervision and mentoring.81 Mavalankar and Vora also note that an ANM can become an LHV after five years of experience and a six-month training course; however, this six months of training does not include any focus on supervision or human resource management.1 Medical officers in particular are often serving a population of over 15,000 people—and more than 30,000 people in the frequent cases where posts are vacant, leaving them very little time to support ANMs.5 ANMs are thus often left to manage the sub-centers largely on their own. Security is another primary concern to ANMs.
Iyer and Jesani report how stories of ANMs being called out to homes on false pretenses and sexually assaulted circulated among ANMs in their case study areas.5 ANMs may be placed at remote subcenters and are often unmarried. Many refuse to go out at night to medical emergencies; some even choose to live away from the sub-center so they are not available for night calls. Unmarried ANMs have reported being verbally harassed by young men in the village and having had stones thrown at them.82 Furthermore, ANMs are transferred every four years on average, which can often place strain on their family and social lives.82 Many ANMs end up living away from their husbands and children at some points in their careers.82
Mavalankar and Vora highlight the problem of “nonresident” ANMs, citing a 2007k study that found less than one-quarter of all ANMs actually living at the subcenter.1 If ANMs do not make the sub-center their primary residence, they are unable to provide 24-hour medical assistance and are more likely to be absent due to commutes or extended leave times to visit family. It is not surprising that ANMs choose to live away from the sub-center. Beyond the security concerns mentioned above, living at sub-centers places ANMs “on call” at all times. Moreover, subcenters are often little more than concrete rooms and often lack electricity and water.
ASHA workers: The National Health Services Research Centre released ASHA updates in 2009, 2010, and 2011, detailing finances and the status of ASHA training and selection. It is still somewhat early to assess the impact of the program on health indicators. In many states, ASHA selection has only recently been completed. The evaluation report entitled Improving the Performance of Accredited Social Health Activists in India, prepared for the International Advisory Panel by the Earth Institute of Columbia University and the Indian Institute of Management, focuses on ASHA functionality rather than impact.81 The evaluation carried out by the NHSRC entitled ASHA: Which Way Forward? found a wide range of functionality for all ASHA tasks.29 For example, the percentage of all women with children younger than 6 months of age who had received a service from their ASHA ranged from 50% to 70%. Considering that ASHAs are supposed to provide postnatal counseling and encourage breastfeeding after all births, this finding indicates limited functionality. The study also found that it was not the ASHA’s educational level (whether or not an ASHA has passed 8th grade) but the number of days of training and the quality of this training that had an impact on the ASHA’s knowledge and skills. The report cited evidence that ASHAs increased institutional deliveries, although the rollout of the ASHA program coincided with the introduction of financial incentives for institutional birth for both the ASHA and mother, making it hard to disentangle the actual effect of ASHAs. The report cited no evidence that ASHAs had influenced immunization levels, but also pointed out that the main limiting factor was the availability of vaccines, over which ASHAs had no control. Although at least 70% of ASHAs were found to have been consulted about sick children, few were able to provide appropriate care because they lacked drugs, skills, or support. For example, ASHAs were able to supply ORS in only 27% of diarrhea cases in Bihar for which they were consulted. There have been concerns expressed about a lack of clarity on roles and responsibilities. Many ASHAs are unable to specify their job responsibilities.71
The ASHA payment system fails to reflect the amount and type of work expected; although ASHAs are tasked with a wide range of activities, including developing and implementing Village Health Plans, they receive remuneration for only a few activities (primarily bringing in women for institutional deliveries). Understandably, ASHAs tend to focus on the tasks they are paid for. Moreover, many ASHAs are dissatisfied with the current level of remuneration, reporting that they work far more hours than is sustainable for a volunteer position.71 There are also major concerns about the adequacy and quality of training.29,71 The training process and manuals have been criticized as dense, knowledge based rather than skills based, and irrelevant to many day-to-day ASHA activities. The ASHA training period is very short (and few ASHAs even receive the requisite 23 days) and assessments of ASHA knowledge and retention have indicated that the training is highly insufficient.29
A central challenge at the heart of the ASHA program is supervision and feedback. Despite detailed national guidelines on ASHA supervision, in most states, support structures are weak and were set up several years after ASHAs were to have been selected and trained, almost as an afterthought rather than as a priority activity.29 However, at the end of 2013, all but three states had at least two levels of support structures and intact payment systems (R. Ved, personal communication).
Although ASHAs are supposed to be representatives of and accountable to the people, they receive their payments through the ANM at the primary health center and are often treated as extensions of the health system. ANMs consider ASHAs their assistants, which diminishes the ASHA’s her “social health activist role”.53 In addition, ANMs provide mentoring and support for the ASHAs linked to their primary health centers, yet have no official supervisory position.71
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i Blocks are rural jurisdictions ranging in population from fewer than 100,000 to more than three million; several blocks (approximately 10) make up a district and several districts (from two in Goa to 75 in Uttar Pradesh) make up a state.
j The Planning Commission of India allocates resources to the states based on planning sessions for the upcoming five years; these plans are written up into official Five Year Plans and have been released every five years since 1951.
k The URL to access this data was no longer operational when the authors sought to check it, on 8 April 2013. The reference given was: Key Indicators, India, Facility Survey. 2003. http://www.rchindia.org/sr/ki_india.pdf. Accessed September 5, 2007.