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 GramSabha.
·
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 programmers
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.
Womens committees (like self-help groups or womens 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.
SUPPORT MECHANISM FOR ASHA
1. 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-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 sets of guidelines are issued to enable the States
to develop and put in place a proper support mechanism for ASHA.
ASHA Mentoring Group:
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.
Selection of ASHA
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 GramSabha.
Training of ASHA
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.
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
desired goal.
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 is 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 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.
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.
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.
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.
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-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 those guidelines.
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.
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 support mechanism.
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.
In order to provide adequate support to the ASHAs, the following
has been provided:
At State Level
In 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 Office Attendant.
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 Office Attendant.
These 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, 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,
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 guidelines.
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 separately.
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