ASSESSMENT OF PERFORMANCE BASED INCENTIVE SYSTEMFOR ASHA SAHYOGINI IN UDAIPUR DISTRICT , RAJASTHAN

2008-09

R.N.T. Medical College, Udaipur

Sponsored by: NIHFW, New Delhi

UNFPA, New Delhi

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ASSESSMENT OF PERFORMANCE BASED INCENTIVE SYSTEM

FOR ASHA SAHYOGINI IN UDAIPUR DISTRICT , RAJASTHAN

Chief Investigator

Prof. Deoki NandanDirector

National Institute of Health and Family Welfare

Study Team

R.N.T. Medical College, Udaipur (Rajasthan)

Dr. Rekha BhatnagarDr.Keeri Singh

National Institute of Health and Family Welfare

Dr.T.BirDr.U. Datta

Mr. Sherin Raj T.P

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CONTENTS

Preface

Acknowledgements

List of Abbreviations

List of Tables

List of Graphs

Executive Summary

Chapter 1 Introduction

Chapter 2 Methodology

Chapter 3 Findings and Discussion

Chapter 4 Conclusion and Recommendations

References

Annexures

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PREFACE

The National Rural Health Mission (NRHM) was launched by the Government of Indiaon 12th April 2005 to carry out necessary architectural correction in the basic health caredelivery system, with a plan of action that includes a commitment to increase publicexpenditure on health. The Mission envisages an additionality of 30% over existingannual budgetary outlays every year to fulfil the mandate to raise the outlays for publichealth from 0.9% of GDP to 2 -3% of GDP. Under the Mission, multifarious activities havebeen initiated to strengthen the rural health care delivery system for the improvement ofhealth of the rural population.

NRHM implementation framework does not envisage significant engagemnent of medicalcolleges in delivery of mission interventions. The role of medical colleges in RCH -II islargely limited to conduction of clinical skill based trainings. In the absence of anysystematic engagement of medical colleges, faculty members of departments are cluelessabout the evidence-based technical strategies being pursued in the implementa tion ofvarious National Health Programmes. There is a huge potential available in medicalcolleges of the country for undertaking innovations, facilitating programme interventionsand conducting health systems research, which largely remains untapped.

The Rapid Assessment of Health Interventions (RAHI), a collaborative activity with theUnited Nations Population Fund (UNFPA), is a unique initiative taken under the widerumbrella of the Public Health Education and Research Consortium (PHERC) of theNational Institute of Health and Family Welfare (NIHFW) for developing partnershipswith different organisations working in the field of health and family welfare. Theobjective of the project is to accelerate NRHM delivery in identified states by organisingtimely, quality and appropriate inputs through rapid assessments/reviews to addresspriority implementation problems. During the first phase of the RAHI project, theUNFPA supported 12 health systems research projects in five low performing states viz.Madhya Pradesh, Jharkhand, Chhattisgarh, Uttar Pradesh and Orissa. During the secondphase, another 12 health system s research projects from 6 low performing states viz. UttarPradesh, Uttarakhand, Madhya Pradesh, Jharkhand, Bihar and Rajasthan were take n up.

The rationale for supporting such rapid assessments stems from the discussions during theperiodic Joint Review Missions and Common Review Missions. An impressive number ofinnovations have been supported by the states to improve access and enhanc e servicequality. Many innovations are currently underway in the states and districts to deliverhealth care services in an effective manner. The state and district programme managerswish to know how well these innovations are performing so that in case of gapscorrective measures can be taken to achieve the stated objectives. There has been anincreasing recognition for incremental improvements in the programme delivery byundertaking quick and rapid health systems research and engineering the feedback i nto

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the processes. As an institutional response to such demand an attempt has been made todevelop a network of institutions and strengthen their capacities on rapid appraisalmethodologies for generating programme -relevant information at local and reg ionallevels.

The rapid appraisal of some of the interventions taken up in the second phase of RAHI -project covered the issues of contribution of indigenous system s of medicine inoperationalisation of 24x7 services, interface of ASHAs with the community and serviceproviders, logistics and supply management system of drugs at different levels,functioning of mobile medical units, birth preparedness and complication readiness as atools to reduce MMR, quality assessment of institutional deliveries, perfo rmance basedincentives to ASHA Sahyogini, referal transport systems, functioning of programmemanagement units, functioning of RKS, utilisation of untied funds at various levels andutilisation and client satisfaction of RCH service. The present study report entitledAssessment of Performance Based Incentive System for ASHA Sahyogini in UdaipurDistrict, Rajasthan by the R.N.T. Medical College, Udaipur (Rajasthan), was finalized byNIHFW in consultation with UNFPA.

The findings and recommendations of the se studies will trigger of a series of follow -upmeasures by programme managers in the state. We strongly feel availability of such aresource to the programme managers wi ll provide necessary evidence -based inputsenabling them to make any mid course corre ctions and also scaling up. An added benefitwill be incorporation of information about newer programmatic interventions in themedical curriculum.

Dr. Dinesh Agarwal Prof. Deoki NandanNational Programme Officer, UNFPA Director, NIHFW

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ACKNOWLEDGEMENTS

The Study Team wishes to acknowledge the contributions of the following persons whoprovided extensive support in carrying out this study:

Prof. (Dr.) Deoki Nandan, Director, National Institute of Health and Family Welfare, NewDelhi, for providing us opportunity to conduct this study and his valuable support and inputs.

We are thankful to Dr. M.L.Jain, Director , RCH, Government of Rajasthan for his supportand cooperation.

We extend our sincere thanks to Prof. S. K. Kaushik, Principal, R.N.T. Medical CollegeUdaipur. He was always supportive and co -operative in pursuit of research and studiesundertaken by this department. We are thankful to Dr.G.L. Bunkar for his support andcooperation.

Dr. V.K. Tiwari, Dr. T. Bir, Dr. U. Datta and other senior faculties of NIHFW deserve specialthanks for their technical guidance, support and co-operation at every stage of the study.Weextend our heartful thanks to Dr. Suparna and Dr. Ramesh for their support and activeinvolvement.

We are thankful to Mrs.Anshu Bhatnagar, Dy. Director ICDS and Supervisors of three blockfor their support and cooperations. A special thanks to our post-graduate students. Dr.Ashutosh Sharma, Dr. Hemlata and interns who have been actively involved in datacollection.We extend our thanks to Sh. Kishan Mali for his constant support in data entry.

We are thankful to Dr. Deora , Sb. Joint Director, Dr. Aahari CMHO and Kumaril AgarwalDPM of Udaipur.

We also sincerely extend our thanks to ASHA workers of the blocks, and the women of thecommunity for their generous participation and cooperation during the conduction of in-depthinterviews and FGDS.

Dr. Rekha Bhatnagar(Principal Investigator)

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ABBREVIATIONS

ANC ................................ ............Antenatal Care

ANM ................................ ............Auxiliary Nurse Midwife

ASHA................................ ...........Accredited Social Health Activist

AWW ................................ ...........Anganwadi Worker

ARC ................................ .............ASHA Resource Centre

BMO ................................ ............Block Medical Officer

BPM ................................ .............Block Programme Manager

CHC ................................ .............Community Health Centre

CMHO................................ ..........Chief Health and Medical Officer

CDPO................................ ...........Child Development Project Officer

DHIO................................ ............District Health Information Officer

DPM................................ .............District Programme Manager

DWCD ................................ .........Department of Women and Child Development

DHS................................ ..............District Health Society

FGD................................ ..............Focus Group Discussion

FRU................................ ..............First Referral Unit

HW(F) ................................ ..........Heath Worker Female

IFA ................................ ...............Iron Folic Acid Tablets

JSY................................ ...............Janani Suraksha Yojana

LS................................ .................Lady Supervisor

M/O ................................ ..............Medical Officer

MPW ................................ ............Muti Purpose Worker

MCHN Day................................ ..Monthly Child Health Nutrition Day

NRHM................................ ..........National Rural Health Mission

PHC................................ ..............Primary Health Centre

PNC................................ ..............Post Natal Care

PRI ................................ ...............Panchayti Raj Institution

SBA................................ ..............Skill Birth Attendant

TBA................................ ..............Traditional Birth Attendant

TT................................ .................Tetanus Toxoid

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LIST OF TABLES

TableNo

Details Page

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

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Operational Status in Selected Block s

Coverage of the Study (Udaipur district)

General Demographic Profile of ASHA

Trainings Imparted to ASHAs

Knowledge of ASHA

Comparison of Expected and Actual Work Done by ASHAper month in Udaipur District

Work Done by ASHA in Last One Year

Comparison of Expected and Actual Work Done by ASHAper month in Udaipur District

Timeliness of Incentives for ASHA

Payment Agencies of Incentives for ASHA

Expenditure of ASHA for Transport and other Expenses perInstitutional Delivery

Average Incentive by ASHA per Month in Last 6 Months

Satisfaction of ASHA with Incentives

Causes of Dissatisfaction of ASHA

Suggestions for Better Performance by ASHA

Expectations of ASHA Regarding Incentives

Suggestions to Solve the Problems Faced by ASHA

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LIST OF GRAPHS

1. Work done by ASHA in last one year .

2. Expenditure of ASHA for Transport and other Expenses per Institutional Delivery

3. Average Compensation to ASHA per Month Including Honorarium Rs.500/- by

dept. by DWCD

4. Causes of Dissatisfaction of ASHA

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EXECUTIVE SUMMARY

Introduction

Government of India in 2005 announced a National Rural Health Mission with a clear goal ofaddressing the health needs of rural population specially vulnerable section of the societyand to improve the access of beneficiaries to health services. It is proposed to have villagelevel functionaries who will be named as accredited social health activist. ASHA is the firstpart of call for any health related demand of poor people specially women and children. Sheis supposed to be an escort, motivator and guide for village community on health issu e.NRHM was launched in state of Rajasthan with a aim to provide accessible , affordable andquality health services to rural and under served urban area.

National Institute of Health and Family Welfare (NIHFW), with financial assistance fromUNFPA initiated RAHI projects. (Rapid Appraisal of Heal th Intervention) under NRHM incollaboration with its academic partners (Medical Colleges). This report is based on RapidAppraisal of Performance Based Incentive System for ASHA Sahyogini in Udaipur Districtof Rajasthan.

General Objective

To assess the performance-based incentive system for ASHA as it is one of the mostimportant factor in successful working of ASHA.

Specific Objectives

To measure the norm-wise and timeliness of the incentives to ASHA for JSY andother NRHM activities.

To measure the level of satisfaction of ASHA with this performance -based incentivesystem,

To assess the utilization of services and satisfaction of beneficiaries of ASHA for JSYand other NRHM activities, and

To give feedback to programme managers.

Methodology

Three blocks (one urban, one rural and one tribal) were randomly selected . The study wastypically cross-sectional design with a mix of both in -depth interviews and FGDs.

The study respondents included the following:

ASHAs of all the three blocks: A total of 180 ASHAs were randomly selected for in-depth interviews.

Beneficiaries and non-beneficiaries of ASHA at village level : 6 FGDs were conducted 2in each block.

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Salient Findings

1. Majority of ASHAs caters to popul ation between 1000-1500 in urban area and 500 to1000 in rural and tribal area.

2. Majority of ASHAs in three blocks received 2 trainings i.e one initial on first modulefor 10 days and second training on II module for four days.

3. Tribal ASHAs have to travel l arge distance at work (>33% have to travel > 2.5km s)4. Overall knowledge of ASHA regarding environmental sanitation was low.5. Mobilization of ANC and immunization, motivation for sterilization and accompany

for institutional deliver were the commonest service s provided by ASHA in threeblocks. None of the ASHA in all the three blocks has worked for m otivation forconstruction of sanitary latrin and mobilization for cataract surgery. No ASHA inurban area ever completed DOTS.

6. No monthly meeting was held and a ttended by urban ASHAs and even in rural andtribal attendance was around 50% only.

7. Maximum delay was observed in getting incentive for MCHN days by ASHA.Around 75% of the ASHA in all the three blocks area getting incentive for MCHNdays in more than 30 days and even latest by 5-6 months are also noted.

8. The average compensation package for ASHAs in all the three blocks in our studywas found to be Rs.756/- per month which is only 48.24% of the expected guideline sof state average which is Rs.1567/-[1067+500 honorarium (Annexure 3)] per month.

9. Most of the ASHAs in all three block s voice dissatisfaction with the incentive. Themain reason that came out of the study were they have to work hard, their expensesare more and incentive are delayed. According to DPM Udaipur delay was at the levelof district and block because of backlog of payment and vacant position of BPMduring July 08 - December 08. The dissatisfaction was observed more in the tribalASHAs. More expenses is the commonest cause of dissatisfact ion in tribal ASHA.Mean expenditure of 34% tribal ASHA has to spend more than Rs 400 perinstitutional delivery.

10. As in Rajasthan ASHA are getting honorarium of Rs. 500 per month DWCD hencethey are regularly working at AWC and badly neglecting some of assigned tasks like:Mobilization for cataract surgery, completion of DOTS, construction of sanitarylatrines.

11. The problems faced by ASHAs in the field are as follows: The pregnant women and the relatives are reluctant to take assistance of

ASHAs as escort for hospital delivery. They have the misconception that ifASHA comes with them she will get a cut from their rightful JSY incentive. SoASHAs are not entitled to JSY money.

Although ASHAs are mobilizing pregnant women for ANC but getting noincentive, if cannot accompany woman for institutional delivery.

Tribal ASHAs suffered this lack of timeline ss more as compared to urban andrural ASHAs.

When they take delivery cases to hospi tal they are given harsh and un -cooperative treatment by hosp ital staff.

12. In FGDs it was found that most of the participants were utilizing JSY, ANC, PNC andimmunization and were satisfied but none of participants were befitted and evenaware for construction of sanitary latrines, mobilization of cataract surgery andcompletion of DOTS by ASHA.

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Key Recommendations

1. Refresher training with latest update should be conducted for ASHA at regularinterval.

2. Mostly ASHAs are working for RCH services. During refresher training stress mustbe given on tasks like DOTS completion, mobilization for cataract surgeries providingprimary health care and construction of latrine, so that with improvement in ASHAsperformance ASHA can earn more incentives.

3. Drug kit supply must be regular.4. Monthly meeting should be regularly hel d, attendance of ASHA must be ensured for

proper feedback.5. Timely fund flow must be ensured from DPM to BPM and from BPM to MO/Ic as

these are the levels of delay.6. Fund audits should be done at regular interval.7. Extra incentive should be given in tribal a nd difficult areas.8. Awareness generation and education with the help of local leaders is of prime

importance for proper utilization of services of ASHA and bridging gape betweenASHA and community.

9. Monitoring system should be improved from top to bottom.

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CHAPTER 1

INTRODUCTION

Background

Government of India in 2005 launched the National Rural Health Mission with a sole aim toprotect and promote the health and wellbeing of its citizens in general and mother andchildren in specific. It aims at reducing maternal and childhood morbidity and mortalitythrough intervention like engagement of ASHA at village level.

The National Rural Health Mission (2005-12) seeks to provide effective health care to ruralpopulation throughout the country with special focus on 18 states, which have weak publichealth indicators and/or weak infrastructure. It aims to undertake architectural correction ofthe health system to enable it to effectively handle increased allocations as promised underthe National Common Minimum Programme and promote policies that strengthen publichealth management and service delivery system in the country.

It has as its key components provision of a female health activist in each village; a villagehealth plan prepared through a local team headed by the Health and Sanitation Committee ofthe Panchayat; strengthening of the rural hospital for effective curative care and mademeasurable and accountable to the community through Indian Public Health Standards(IPHS); and integration of vertica l Health and Family Welfare Programmes and funds foroptimal utilization of funds and infrastructure and strengthening delivery of primary healthcare. It seeks to revitalize local health traditions and mainstream AYUSH into the publichealth system. It aims at effective integration of health concerns with determinants of healthlike sanitation and hygiene, nutrition, and safe drinking water through a District Plan forHealth. It seeks decentralization of programmes for district management of health. It seeks toaddress the inter-state and inter-district disparities, especially among the 18 high focus states,including unmet needs for public health infrastructure. It shall define time-bound goals andreport publicly on their progress. It seeks to improve access of rural people, especially poorwomen and children to equitable, affordable, accountable and effective primary.

Goals Reduction in Infant Mortality Rate (IMR) and materials mortality. Universal access to public services for food and nutrition, sanitation and hygiene

and universal access to public health care se rvices with emphasis on servicesaddressing women’s and children’s health and universal immunization .

Prevention and control of communicable and non -communicable diseases,including locally endemic disease s.

Access to integrated comprehensive primary health care. Population stabilization, gender and demographic balance. Revitalize local health traditions and mainstream AYUSH. Promotion of healthy lifestyles.

Rationale

One of the key components of the National Rural Health Mission is to provide every villagewith a trained female community health activist – ASHA or Accredited Social Health

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Activist. Selected from the village itself and accountable to it. The ASHA will be trained towork as an interface between the community and the public health system.

ASHA will be a health activist in the community who will create awareness on health and itssocial determinants and mobilize the community towards l ocal health planning and increasedutilization of the existing health services.

GUIDELINES ON ASHA APPROVED BY GOVERNMENT OF RAJASTHAN( www.nrhmrajasthan.nic.in )

Criteria for Selections of ASHA (As per norms)

ASHA must be primarily a woman resident of the village – ‘Married/Widow/Divorced’and preferably in the age group of 25 to 45 y ears.

ASHA should have effective communication skills, leadership qualities and be able toreach out to the community. She should be a literate woman with formal education upto Eighth Class. This may be relaxed only if no suitable person with this qualification isavailable.

Adequate representation from disadvantaged population groups should be ensured toserve such group better.

Roles and Responsibilities of ASHA Sahayogini

1. Create Awareness

Health, nutrition, basic sanitation, hygienic practices, healthy living and workingconditions, information on existing health services and need for timely utilization ofhealth, nutrition and family welfare services.

2. Counseling

Birth preparedness, importance of safe and i nstitutional delivery, breast -feeding,complementary feeding, immunization, contraception, prevention of RTI / STI,nutrition and other health issues.

3. Mobilization

Facilitate the community to access and avail the health services available in the publichealth system at Anganwadi Centres, Sub -Center, PHC, CHC and district hospitals.

4. Village Health Plan

Work with Village Health and Sanitation Committee of the Gram Panchayat t o developthe village health plan.

5. Escorts/Accompany

Arrange escort/accompany pregnant women and children requiring treatment/admissionto the nearest pre-identified health facility i.e. Primary Health Centre/CommunityHealth Centre/First Referral Unit.

6. Provision of Primary Medical Health Care

- Provide primary medical care for minor ailments such as diarrh oea, fevers and firstaid for minor injuries.

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- She will be a provider of Directly Observed Treatment Short -course (DOTS) underRNTCP.

- Depot Holder for ORS, IFA, DDK, Chloroquine, oral pills and condoms.

7. Inform about the births, deaths and any unusual health problem/disease outbreaks in thecommunity to the sub-centers/Primary Health Centre.

Promote construction of household toilets under Total Sanitation Cam paign.

COMPENSATION PACKAGE TO ASHA

ASHA would be an honorary volunteer and would not receive any salary or honorarium. Butin Rajasthan ASHA is called as ASHA Sahyogini and getting Rs.500/ month as anhonorarium from DWCD in Rajasthan. Her work would be so tailored that it does notinterfere with her normal livelihood.

However ASHA could be compensated for her time in the following situations:

a. For the duration of her training both in terms of TA and DA. (so that her loss oflivelihood for those days is partly compensated)

b. For participating in the monthly/bi -monthly meeting, as the case may be. (Forsituations (a) and (b), payment will be made at the venue of the training /meetingwhen ASHAs come for regular training sessions and meetings).

c. Wherever compensation has been provided for under different national programmesfor undertaking specific health or other social sector programmes with measurableoutputs, such tasks should be assigned to ASHAs on priority (i.e. before it is offeredto other village volunteers) wherever they are in position.

(For situation I disbursement of compensation to ASHAs will be made as per thespecific payment mechanism built into individual programmes).

d. Other than the above specific programmes, a number of key health related activitiesand service outcomes are aimed within a village (For example all eligible childrenimmunized, all newborns weighed, all pregnant women attended an antenatal clinicetc). The Untied Fund of Rs.10,000/ - at the sub-centre level (to be jointly operatedby the ANM and the Sarpanch) could be used as monetary compensation to ASHAfor achieving these key processes. (For situation (d) the payment to ASHAs will bemade at Panchayats).

Group recognition/awards may also be considered. Non-monetary incentive e.g. exposure visits, annual conventions etc can be

considered. A drug kit containing basic drugs should be given.

A suggestive/indicative compensation package for ASHA for training and various servicesprovided by her is enclosed at Annexure I. This would be finalized subsequently inconsultation with the States and various other stakeholders in due course .

Operational Status in Rajasthan

ASHA Sahyogini is a joint initiative of HFW and DWCD in Rajasthan. Presently 30000ASHA Sahyogini are in place in Rajasthan. ASHA Sahyogini is getting fixed honorarium ofRs. 500/month from DWCD. She is also getting performance based incentives worked out fordifferent schemes. If she works as per expectation she will get a minimum compensationpackage of approximately Rs.1067 per month.

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Operational Status in Udaipur District

Selection and Training

1. In Udaipur district 1983 ASHA Sahyogini have been selected by due process.2. Two round of training has been completed in Udaipur District

I round – 10 days training on module 1 No of ASHA Sahyogini trained 1971

II round – 4 days training on module 2 No of ASHA Sahyogini trained 1628

Operational Status of ASHA scheme in Selected Blocks

Name of Block No. of ASHAreported

No. of ASHAtrained in First

round

No. of ASHAtrained in Second

roundSarada (Tribal) 201 201 193Bhinder (Rural) 198 194 136Udaipur (Urban) 136 136 136

FUND- FLOW MECHANISM FOR ASHA IN UDAIPUR DISTRICT

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SUPPORT SYSTEM

REPORTING SYSTEMASHA is reporting monthly in MPR format (Annexure 2) to ANM

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Performance and Incentive

Timeliness (as per norms) and satisfaction of ASHA Sahyogini with this performance basedincentive system is one of the most important critical factor for the success of ASHASahyogini and NRHM. So there is a need for mid -term rapid assessment of this performancebased incentive system to give feed back to health managers to improve the situation andfacilitate the ASHA Sahyogini in their work.

General Objective

Main objective of the study is to assess the performance -based incentive system for ASHA asit is one of the most important factor in successful working of ASHA.

Specific Objectives

To measure the norm wise and timeliness of the incentives to ASHA for JSY andother NRHM activities.

To measure the level of satisfaction of ASHA with this performance based incentivesystem.

To assesses utilization of services and level of satisfaction of beneficiaries of ASHAfor JSY and other NRHM activities.

To give feedback to programme managers.

During the study we can also get the work performance and average compensation to ASHAin the district.

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CHAPTER 2

METHODOLOGY

Study Design

The study was a cross-sectional descriptive study.

Study Area

We have assessed the performance b ased incentive system for ASHAs working in urban,rural and tribal areas of Udaipur district. For this one block from each urban, rural and tribalarea was selected randomly.The sampling of blocks was based on simple random method (Lottery method).

Map of Udaipur District (Showing Selected Blocks)

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Table 1 : Coverage of the Study (Udaipur District)

Area Blocks Population

Distancefrom

DistrictHeadquarter

No. ofsanctioned

post forASHA

No. ofASHA

Workingin area

No. ofRespondents

In-depthinterview

FGDwomen

Rural Bhinder 2,76,240 55-km 242 201 60 2Urban Udaipur

UrbanBlock

4,60,142 - 136 136 60 2

Tribal Sarada 2,60,454 65-km 224 198 60 2

Study Units

Primarily our study unit was ASHA. Its beneficiaries and non-beneficiaries for JSY were alsoincluded in the study for FGDs as a source of information for utilization and satisfaction ofservices of ASHA.

Sampling

There are around 200 ASHAs presently working in rural and tribal block. There are 136ASHAs working in Udaipur city. We enlisted all the ASHA separately for tribal /rural andurban* block. 30% (60 from each block). ASHA selected randomly after allotting number tothem.(* In urban area we have taken more than 30% ASHA for in-depth interview to give equalrepresentation of all three areas)

Study Period

12 weeks, with data collection- 8 weeks approximately

Data Collection Techniques

Primary data were collected through in-depth interview. Primary data were also collectedfrom beneficiaries and non-beneficiaries of ASHA for JSY and other NRHM activitiesthrough FGD.

Qualitative

In-depth interview: Primary data were collected from ASHA through personalinterview with semi structured questionnaire about individual ’s personal data,regarding training, knowledge, incentive and level of satisfaction (Annexure 1).

Focus Group Discussion: Focus group discussion at community level wereconducted. FGD included women who were either pregnant or delivered in last oneyear and potential beneficiaries of ASHA. Each FGD included 8-10 participants.

FGDs in rural and tribal area were conducted at PHCs (randomly selected) of selectedCHCs. In urban area an FGD was conducted at UHTC and other at MB HosptialUdaipur. Participants were identified by supervisors of our team. Before conductingfocus group discussion, guide was prepared including questions on MCH servicesutilization and ASHA functioning . The process of FGD started with initial round of

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introduction and participants had made aware about various entitlements that NRHMhas promised especially in the context of the maternal and child heath services, JSYand other NRHM activities.

After describing the purpose of discussion, the process of FGD has explained to theparticipants.

The discussion during FGDs were document ed and simultaneously recorded andaudio cassettes were prepared .

Data Analysis

Unit of analysis was ASHA. Collected data were entered and analyzed with the EPI6 andExcel.

Team Composition and Participation

1. Principal Investigator - 12. Co-Investigator - 13. Supervisors - 34. Computer operator - 15. Field Staff - 36. Local ANMs - 37. Local LS (DWCD) - 38. Class IV - 3

Selection of the Team

We have not appointed any new team member, we have utilized already existing relevantpersons.

Quality Assurance

Field investigators were post-graduate students in community medicine. A two daysOrientation training on Project methodology, art of interviewing, focus group discussion andfindings was imparted to team members. The tools were pretested in the field and set ofguidelines was developed and provided to each team member . Principal Investigator and Co-investigator stayed in the field throughout duration of data collection and focus groupdiscussion and regularly monitored field staff and supervisors.

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CHAPTER 3

FINDINGS AND DISCUSSION

This chapter deals with the demographic and socio-economic status of ASHAs, trainingreceived, workload and their level of satisfaction with the incentives and timeliness ofincentives.

Table 2 : General Demographic Profile of ASHA

Characteristics Urban Rural Tribal TotalAge group N=60 N=60 N=60 N=180

<21 1(1.67%) 3(5%) 2(3.33%) 6(3.33%)21-25 10(16.67%) 24(40%) 25(41.67%) 59(32.78%)26-30 24(40%) 19(31.67%) 23(38.33%) 66(36.67%)31-35 17(28.33%) 8(13.33%) 10(16.67%) 35(19.44%)36-40 7(11.67%) 6(10%) NA 13(7.22%)41-45 1(1.67%) NA NA 1(0.56%)Caste N=60 N=60 N=60 N=180

SC 9(15%) 4(6.67%) 13(21.67%) 26(14.44%)ST 5(8.33%) 7(11.67%) 38(63.33%) 50(27.78%)

OBC 25(41.67%) 22(36.67%) 4(6.67%) 51(28.33%)GEN 19(31.67%) 26(43.33%) 5(8.33%) 50(27.78%)

OTHERS 2(3.33%) 1(1.67%) NA 3(1.67%)Education Urban Rural Tribal Total

N=60 N=60 N=60 N=180Middle (8th std) 22(36.67%) 29(48.33%) 42(70%) 93(51.67%)

Secondary 24(40%) 23(38.33%) 14(23.33%) 61(33.89%)Senior

Secondary10(16.67%) 4(6.67%) 1(1.67%) 15(8.33%)

Graduate 4(6.67%) 4(6.67%) 3(5%) 11(6.11%)Marital Status Urban Rural Tribal Total

Married 54(90%) 56(93.33%) 57(95%) 167(92.78%)Unmarried 3(5%) 1(1.67%) NA 4(2.22%)

Widow 1(1.67%) 3(5%) 2(3.33%) 6(3.33%)Divorce 1(1.67%) NA 1(1.67%) 2(1.11%)Others 1(1.67%) NA NA 1(0.56%)

Distance (inKm)

Urban Rural Tribal Total

<0.5 41(68.33%) 27(45%) 6(10%) 74(41.11%)Upto 1 12(20%) 11(18.33%) 12(20%) 35(19.44%)1-1.5 2(3.33%) 2(3.33%) 4(6.67%) 8(4.44%)1.5-2 4(6.67%) 5(8.33%) 13(21.67%) 22(12.22%)2-2.5 1(1.67%) 2(3.33%) 5(8.33%) 8(4.44%)2.5-3 NA 8(13.33%) 11(18.33%) 19(10.56%)

>3 NA 5(8.33%) 9(15%) 14(7.78%)Population Urban Rural Tribal Total

<500 1(1.67%) 2(3.33%) 12(20%) 15(8.33%)

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500-1000 9(15%) 26(43.33%) 27(45%) 62(34.44%)1000-1500 45(75%) 22(36.67%) 19(31.67%) 86(47.78%)1500-2000 1(1.67%) 7(11.67%) 1(1.67%) 9(5%)2000-2500 1(1.67%) 0 1(1.67%) 2(1.11%)2500-3000 1(1.67%) 1(1.67%) NA 2(1.11%)

>3000 2(3.33%) 1(1.67%) NA 3(1.67%)Not Known NA 1(1.67%) NA 1(0.56%)

Age and Caste

Most of the ASHAs in the urban block were in the age group of 26-30 (40%), followed by theage group of 31-35(28%). In rural (40%) and tribal (41%) block most of them belonged toage group of 21-25 followed by age group of 26-30.

When distributed according to caste 41% of ASHAs in urban block belonged to OBCfollowed by general category (31%). In rural block 43% belonged to general categoryfollowed by OBC (36%), ST (11%) and SC (6%) while in tribal block majority (63%)belonged to ST followed by SC (21%) .

Literacy

Among the ASHAs belonging to urban block 40 per cent had studied upto secondary,followed by 36 per cent ASHAs who had completed middle level (8th std) . Forty eight percent ASHAs in the rural block had completed middle level and 38 per cent had completedsecondary. In the tribal block almost 50 percent studied upto middle level.

Interestingly around 6 per cent of the ASHAs in all three blocks were graduates.

Marital Status

Most of the ASHAs in all the three blocks were married 90 per cent in urban, 93 per cent inrural and 95 per cent in tribal block.

Most of the ASHAs in the urban block (88 per cent) and rural block (63 per cent) had totravel less than a kilometer from their residence for work while in the tr ibal block 70 per centhad to travel more than a kilometer for work every day. 15% ASHA in tribal block has totravel > 3 kms for work every day.

The average population catered by almost 50% of the ASHAs in all the three blocks rangedbetween 1000-1500 followed by 34% catering a population between 500-1000.

Table 3: Trainings Imparted to ASHA

Number ofASHAstrained

Urban Rural Tribal Total

I module only 9(15%) 12(20%) 16(26.66%) 37(20.55%)I and II module

both51(85%) 48(80%) 37(61.66%) 136(75.55%)

Untrained 0 0 7(11.66%) 7(3.88%)Total 60 60 60 180

24

Majority of the ASHAs in the urban block (83%) had received two trainings . In the ruralblock 50% of the ASHAs had received two trainings and 20% had received one training. Inthe tribal block one-third had received three trainings followed by 18% who received twotrainings.

Table 4 : Knowledge of ASHA

Urban Rural Tribal TOTAL- Task of ASHA 60(100%) 59(98.33%) 58(96.67%) 177(98.33%)- Environmental Sanitation 24(40%) 18(30%) 45(75%) 87(48.33%)- Transmission of HIV/AIDS 57(95%) 57(95%) 56(93.33%) 170(94.44%)- BCG Vaccination 59(98.33%) 59(98.33%) 59(98.33%) 177(98.33%)- DPT Vaccination 59(98.33%) 59(98.33%) 60(100%) 178(98.897%)- Diaerhoeal Diseases 58(96.67%) 57(95%) 54(90%) 169(93.89%)- Use of Paracetamol 55(91.67%) 48(80%) 57(95%) 160(88.89%)- Sign and Symptoms of T.B. 59(98.336%) 52(86.67%) 57(95%) 168(93.33%)- Snake bite 60(100%) 59(98.33%) 59(98.33%) 178(98.89%)Average Marks Obtained 8.18 7.8 8.31 8.09Percentage Scored 90.92% 86.66% 92.40% 80.9%

P value 0.5 Non-Significant

No significant difference was observed regarding knowledge of ASHA in all the threeblocks

There were 9 questions in the questionnaire to access the knowledge of the ASHA. Eachquestion carried equal marks i.e. every correct answer carry '1' mark and every wrong answercarry '0' mark. Average marks scored by urban ASHA were 8.18, rural ASHA 7.8 and tribalASHA 8.31.

On the basis of average marks scored, ASHA from all the 3 blocks fall in knowledgecategory good.

Most of the ASHAs from all the three blocks gave incorrect answers for questions related tosanitation. Question no. 19, Part IV (Annexure 1)

Table 5 : Work Done by ASHA in Last One Year

Sr.No.

Ever work done byASHA

Urban Rural Tribal TOTAL

1. Mobilization for ANC 47(78.33%) 47(78.33%) 45(75%) 139(77.22%)2. Accompany for

Institutional delivery53(88.33%) 46(76.67%) 27(45%) 126(70%)

3. Mobilization forImmunization on MCHNday

51(85%) 37(61.67%) 27(45%) 115(63.89%)

4. Motivation for sterilization 42(70%) 25(41.67%) 31(51.67%) 98(54.44%)5. Completion of DOTS 0(0%) 10(16.67%) 14(23.33%) 24(13.33%)6. Mobilization for cataract

surgery0 0 0 0

25

7. Motivation forconstruction of sanitarylatrine

0 0 0 0

8. Monthly meeting attended 0 40(66.660%) 26(43.33%) 66(36.66%)

In all the three block mobilization for ANC and accompanying pregnant woman forinstitutional delivery were found to be the commonest services provided by ASHAs but lessnumber of tribal ASHA provide ANC (75%) as compared to urban and rural ASHA s(78.33%). This is a highly significant difference (P<0.0002).

Similarly only 45% of tribal AHSAs as compared to 88% urban and 76% rural accompanieddelivery cases to hospitals (P<0.03).

85% of Urban ASHA, 61.67% of rural ASHA and 45% of tribal ASHA had worked onMCHN days for vaccination.

DOTS implementation and other services studied such as motivation for cataract surgery andconstruction of sanitary latrines were neglected by most of the ASHAs in the three blocks.

In this study none of ASHA reported about mobilization for cataract surgery in the threeblocks but in the report obtained form DPM there were 179 cases of cataract referred byASHA (Annexure 5).

On the whole significantly less number of tribal ASHAs were providing services under JSY,ANC and MCHN days. As tribal blocks around Udaipur are hilly and population is scatteredover large areas so these ASHAs have to cover more distance on feet while working .

As compared to urban population tribal people need more efforts for motivation. These factlead to more time consumption and less work out put particularly by tribal ASHAs.

Fig 1: Work Done by ASHA in Last One Year

-

20.00

40.00

60.00

80.00

100.00

120.00

140.00

160.00

Mobilizationfor ANC

Accompanyfor

Institutionaldelivery

Mobilizationfor

Immunizationon MCHN day

Motivation forsterlization

Completionof DOTS

Mobilizationfor cataract

surgery

Motivation forconstructionof sanitary

latrine

Monthlymeeting

attended

WORK

PERCENTAGEUrbanRuralTribalTOTAL

26

Table 6 : Comparison of Expected and Actual Work Done by ASHA per Month inUdaipur District

Work Mobilizationforinstitutionaldelivery

No. ofMCHNsessionsattended

No. offemalesmotivatedforsterilization

No. ofmalesmotivatedforsterilization

No. ofANCsregistered

No. ofPNCsattended

Monthlymeetingsattendedat CHC/PHC

No. ofDOTScases

No. ofcataractcases

*Expected 1 1 1 0.25 2.5 2.5 1 0.25 0.5

**Actual 0.49 0.85 0.03 0.01 1.75 1.15 0.71 0.0272 0.02

* As data obtained from Annexure 3**As reported by DPM Jan 08-Nov 08 (Annexure 5)

Overall comparison of expected and actual work done by ASHA/months in Udaipurdistrict shows. Low work out put than expected. ASHA are doing the work less than 10%of the expected work in number of components.

Table 7 : Timeliness of Incentives for ASHA

Sr.No.

Task Same day ≤ 7 days 7 to 30 days > 30 days

Urban Rural Tribal Urban Rural Tribal Urban Rural Tribal Urban Rural Tribal

1. Sterlization(n=97)U=36R=35T=26

20(55.55%)

30(85.71%)

24(92.30%)

15(41.66%)

5(14.28%)

2 (7.69) 1(2.77%)

- - - - -

2. JSYN=(130)U=54R=33T=43

3(5.55%)

4(12.12%)

8(18.60%)

48(88.88%)

28(84.84%)

30(69.76%)

2(3.73%)

1(3.03%)

3(6.97%)

1(1.85%)

- 2(4.65%)

3. Vaccinationn=136[180-44=136]U=34R=53T=49

1(2.94%)

4(7.54%)

2(4.08%)

1(2.94%)

5(9.43%)

4(8.16%)

2(5.88%)

11(20.75%)

4(8.16%)

30(88.23%)

33(62.26%)

39(79.59%)

All 97 ASHA received incentives for sterilization cases. 55.5 % urban, 85.7 rural and82.7% tribal ASHAs received incentives on the same day when sterilization was done.Most of the rest got payment with in 7 days and 1 urban ASHA got it after from 15 days.

Out of 130 ASHA who accompanied cases for institutional delivery majority in all thethree blocks got money within 7 days after delivery of women (Generally the cheque isgiven at the time of discharge of the mother).

All ASHA in all the three blocks have been taking children for immunization at healthcentres or Anganwadi on MCH days but 34 (24.4%) did not get any incentives for thisservice. 30 out of 34 (88.2% ) urban 33.53 (i.e.62.3%) rural and 39 out of 48 (79.5%) of

27

tribal ASHA got payment after more than one month. Only a small number in all thethree blocks got payment within 7 days.

For sterilization: Out of 180 ASHA that were interviewed 97 (53.9 %) had accompaniedcases of sterilization majority of them got incentive from hospital on the same day.

Hence timeliness in payment of incentive was observed for services like sterilization andinstitutional delivery but it was poor for immunization.

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Table 8 : Payment of Incentives for ASHA by AgenciesSr.No. Task Hosp/HC ANM OTHER*

Urban Rural Tribal TOTAL Urban Rural Tribal TOTAL Urban Rural Tribal TOTAL

1.

Sterilization(n=97)U=36R=35T=26

32(88.88%)

30(85.71%)

17(65.38%)

79(81.44%)

3(8.33%)

2(5.71%)

7(26.92%)

12(12.37%)

1(2.77%)

3(8.57%)

2(7.69%)

6(6.18%)

2.

JSYN=(130)

U=54R=33T=43

48(88.88%)

18(54.54%)

34(79.06%)

100(76.92%)

6(11.11%)

15(45.45%)

9(20.90%)

30(23.07%)

- - - -

3.

Vaccinationn=136U=34R=53T=49

-28

(52.83%)37

(75.51%)65

(47.79%)37

(91.89%)22

(41.50%)10

(20.40%)69

(50.73%)1

(2.94%)3

(5.66%)2

(4.08%)6

(4.41%)

Most of the ASHAs in urban and rural block got incentive for sterilization cases from the hospital or health centre where sterilization was done. Whereas in tribalblock 17out of 26 (i.e. 65.4%) ASHA got incentive at health centre and 7 out of 26 (i.e. 27%) got it from ANM.

Incentives under JSY is given at the hospital after delivery in the form of cheque. 15 out of 33 (45.5%) ASHAs in rural block got payment from ANM and 9 outof 45 (i.e. 21 %) ASHA in tribal block got incentives from ANM.

Vaccination incentives are given as cash. 28 out of 53 (i.e. 52.83%) of rural and 37 out of 49 (i.e. 75.51%) of tribal ASHAs got money from health centre and 22out of 53 (i.e. 41.50%) of rural and 10 out of 49 (i.e. 20.4%) of tribal ASHAs got it from ANM. All except one urban ASHA got incentive for vaccination fromANM.

* Other means: Person from village health committee or LS/AWW of DWCDIn some cases specially in interior villages cheque or cash of the incentive is delivered by person from village health committee or LS/AWW of DWCD tothe ASHA.

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Table 9 : Expenditure of ASHA for Transport and Other Expenses per InstitutionalDelivery

Urban(n=54)

Rural(n=33)

Tribal(n=43)

Total(n=130)

<100 13(24.07%) 1(3.03%) 3(6.97%) 17(13.07%)100-200 38(70.37%) 15(45.45%) 17(39.53%) 70(54.84%)200-300 1(1.85%) 7(21.21%) 4(9.30%) 12(9.23%)300-400 - 4(12.12%) 4(9.30%) 8(6.15%)>400 - 4(12.12%) 15(34.88%) 19(14.61%)Not known 2(3.70%) 2(6.06%) - 4(3.07%)Mean 115 268.75 348.86 244.20Range 25-250 50-900 50-1000

Mean expenditure of ASHA per institutional d elivery for transportation and otherexpenses is highest (Rs.348.86 per institutional delivery) in tribal block . Around 35% ofthe ASHA has to spend more than Rs. 400 Per institutional delivery. This over amount isher out of pocket expenditure.

Hence transport and other expenses per institutional delivery was more for ASHAworking in tribal blocks as compare to rural and urban blocks. It was least for urbanASHA.

Fig 2: Expenditure of ASHA for transport and other expenses perinstitutional delivery

0

10

20

30

40

50

60

70

80

<100 100-200 200-300 300-400 >400 Not Known

Urban (n=54)Rural (n=33)Tribal (n=43)TOTAL (n=130)

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Table 10 : Average incentive by ASHA per Month in last 6 Months (Rs.500/-Honorarium by DWCD not included)

Urban Rural Tribal Total<250 30(50%) 21(35%) 34(56.67%) 85(47.22%)250-500 10(16.67%) 22(36.67%) 15(25%) 47(26.11%)500-750 2(3.33%) 6(10%) 5(8.33%) 13(7.22%)750-1000 2(3.33%) 8(13%) 2(3.33%) 12(6.67%)>1000 9(15%) 1(1.67%) 2(3.33%) 12(6.67%)Not Known 7(11.67%) 2(3.33%) 2(3.33%) 11(6.11%)

Urban Rural Tribal Total Benchmark

Average compensationpackage (includinghonorarium Rs.500/-)

671 890 707 7561567

(1067+500)

“In urban area people are already aware and well a cquainted with health facility. Theyare self-motivated for institutional delivery and immunization services so the incentivesare less to ASHA. In tribal area majority of the ASHA has to travel more distances ascompare to rural and urban ASHAs”. So work done by tribal ASHAs is less and expens esare more.

When we calculated the composition package received by ASHAs in all the three blocks.It came out to Rs. 756/- per month which is only 48.24% of expected state average i.e.Rs. 1567/-.

The average compensation package received by urban ASHAs was least among all thethree blocks (Rs. 671/-).

This was followed by tribal (Rs.707/ -) and rural (Rs.890/-).

Only a small number of ASHAs in all the 3 blocks getting more than Rs. 500 per month(in addition to Rs.500 by DWCD) as incentive for services which is more than the stateaverage.

1. The causes for low incentive are :

All the ASHAs in all the 3 blocks said that they take children for immunization tohealth centre or Anganwadis on MCHA days but 24.4% i.e. one fourth ASHAsdid not receive incentive for this service and most of the rest who got incentive,got it after one month.

For unexplained reasons the families of pregnant women do not take ASHAs withthem to hospital at the time of delivery so although ASHAs follow and take careof the pregnant women throughout her pregnancy but she is not entitled to theJSY incentive.

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None of the ASHA has worked for mobilization for cataract surgery, constructionof sanitary latrine and a very few ASHA has worked for completion of DOTS.

None of the ASHA was aware about incentive of Rs.5/- per person for providingprimary health care.

Table 11.a : Satisfaction of ASHA with Incentives

ASHA satisfiedwith incentives

Urban Rural Tribal Total P value

Yes 4(6.67%) 9(15%) 1(1.67%) 14(7.78%) 0.183 NSNo 53(88.33%) 49(81.67%) 59(98.33%) 161(89.44%) 0.002 SNot Known 3(5%) 2(3.33%) 5(2.78%) 0.199 NS

Level of satisfaction: Only 6.6% urban, 15% rural and 1.6% of tribal ASHA are satisfiedwith incentives.

Dissatisfaction with incentives was observed more in tribal (98.33%) than urban(88.33%) and rural (81.67%) ASHAs. This difference was statistically significant(P.002).

Fig 3: Average compensation to ASHA per month includinghonorarium of Rs.500/- by dept. by DWCD

0

200

400

600

800

1000

1200

1400

1600

1800

URBAN RURAL TRIBAL Benchmark

Block

Rs. Average compensationpackage (IncludingHonorarioum of Rs.500/- )

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Table 11.b : Causes of Dissatisfaction of ASHA

Sr.No.

Causes Urban Rural Tribal TOTAL

1. Incentive not on time 17(28.33%) 19(31.67%) 47(78.33%) 83(46.11%)2. Expenses more than

incentive32(53.33%) 32(53.33%) 51(85%) 115(63.89%)

3. Others 7(11.67%) 4(6.67%) 6(10%) 17(9.44%)

Figure 4

Common causes identified for dissatisfaction of ASHA are delayed payment of incentiveand expenses are more than incentive.

As per discussion with DPM Udaipur no delay was observed at the level of State NRHMcell. But there was a delay at level of district and block major reasons as communicatedby DPM for this delay are:

There was a backlog in the payment for last one year in Udaipur district. During thatperiod fund flow was through RCHO. It takes lot of time to clear that backlog byDPM.

At the block level BPM came into force in the month of July 08 at Bhinder and in themonth of October 2008 at Sarada block and we have conduct ed study during the

33

period of October 2008 and November 2008 till that time lot of ASHAs were gettingincentives once in every 3-4 months for MCHN days.

When we look for the work done by ASHA , major work done by ASHAs was antenatalcare, contraceptive awareness, health awareness and taking children for immunization butno incentives are guidelined for first three works and as for immunization of childrenincentives are mostly delayed beyond one month and sometime even upto 5 to 6 months.

One common factor that emerged from the interview was that although ASHA giveantenatal care to pregnant women but the family is reluctant to take ASHA with them tothe Hospital at the time of delivery. Hence ASHA do not get the incentive guidelinedunder JSY.

Incentives for DOTS and cataract surgery services are good but none of the urban ASHAand a few from rural or tribal ASHA have participated in providing these services.

“Expenses more than incentives ” emerged as second most common cause ofdissatisfaction and here also tribal ASHAs voiced this complaint more as compared tourban and rural ASHAs.

The tribal ASHAs have to work in hilly and difficulty terrain. They have to travel moreas compared to rural and urban ASHAs, 33% of the tribal ASHAs have to travel morethan 2.5kms every day (Table IV). The tribes are mostly illiterate and unaware. It needmore efforts to motivate them. So tribal ASHAs have to put more time and efforts toperform these assigned tasks than urban and rural ASHAs.

When tribal ASHAs accompany a delivery case for institutional delivery they have totravel long distance, the transport fare most of the time e xceeds the sanctioned transportmoney, because of the distance of the tribal area from hospital . ASHA has to spend moreon traveling and her duration of s tay with the case is also prolonged and hence there is aproportional increase in other expenses also.

This two prominent cause of dissatisfaction studied ultimately bring down the actualearned incentive of tribal ASHAs . This tallys with our observation a nd Table 16 whereaverage compensation package per month to tribal ASHAs is only Rs.707/ - as comparedto the average of all the three blocks which is Rs.756/ -.

Table 12 : Suggestions for Better Performance by ASHA

Suggestion Urban Rural Tribal TotalRefresher training 26(43.33%) 20(33.33%) 14(23.33%) 60(33.33%)Encouragement for work 3(5%) 10(16.67%) 29(48.33%) 42(23.33%)Public awareness about ASHA 9(15%) 9(15%) 28(46.67%) 46(25.56%)Others 36(60%) 12(20%) 16(26.67%) 64(35.56%)

Most of the ASHA in all the 3 blocks gave more than one suggestion for strengthening ofASHA. Majority felt need for refresher trainings 26 out of 60 (43.3%) in urban, 20 out of60 (33.3%) in rural and 14 out of 60 (23.3%) in tribal.

34

5% urban, 16.7% rural and 48% tribal ASHA felt that more encouragement was neededfor better performance.

28 out of 60 (46.7%) tribal and 15% each in urban and rural said that public should bemade more aware about ASHA and their benefits . That way people will listen to andfollow and cooperate with them.

Table 13: Expectations of ASHA Regarding Incentives

Expectations Urban Rural Tribal TotalIncrease in honorarium 52(86.67%) 45(75%) 46(76.67%) 143(79.44%)Incentive should be in time 13(21.67%) 20(33.33%) 37(61.67%) 70(38.89%)Others 10(16.67%) 6(10%) 8(13.33%) 24(13.33%)

Most of the ASHA in all the 3 blocks voiced for increase in honorarium which at presentis Rs. 500/- per month. Dissatisfaction was more in urban block 54 out of 60 (86.6%)as compared to rural 45 out of 60 (75%) and tribal 46 out of 60 (76.7%) blocks.

13 out of 16 (21.7%) urban, 20 out of 60 (33.3%) rural and 37 out of 60 (61.7%) tribalASHAs expect timely payment of incentives. This reflects the delay in payment ofincentives discussed earlier (Table 12).The delay is more in tribal block (61.7%)

Incentives are given to ASHA by MOI/C of the PHC and by ANMs. Since Tribal areasare difficult to approach so it may be a cause of delay.

Table 14: Suggestions to Solve the Problems Faced by the ASHAs

Suggestions Urban Rural Tribal TotalTraining 2(3.33%) 5(8.33%) 7(11.67%) 14(7.78%)Cooperation of staff 44(73.33%) 19(31.67%) 38(63.33%) 101(56.11%)Incentive in time 6(10%) 5(8.33%) 16(26.67%) 27(15%)Public awareness about ASHA 24(40%) 19(31.67%) 43(71.67%) 86(47.78%)Others 29(48.33%) 13(21.67%) 11(18.33%) 53(29.44%)

44 out of 60 (61.7%) urban, 19 out of 60 (31.7%) rural and 38 out of 60 (63.3%) tribalASHAs suggested that quality of work will be improved if they get adequate cooperationfrom other staff such as ANMs, AWW and hospital staff where deliveries are conducted.They suggest cooperation in the form of good behaviour by hospital staff, propersupervision and guidance by ANM s and AWW should not accept ASHA to do theirchores like cooking and washing utensils.

24 out of 60 (40%) urban, 19 out of 60 (31.7%) rural and 43 out of 60 (71.7%) tribalASHAs suggested that public should be made more aware of the role of ASHA s andbenefits to them from the services given by ASHA. Lack of public awareness i s

35

highlighted more by ASHA in tribal block this may be due to illiteracy, cultural taboosand biased attitude of the tribes.

40% urban ASHA too feel same and this may be due to lower educational status andpoverty in urban slums.

Due to lack of awareness people do not listen to ASHA and pregnant women do not takethem to the hospital at the time of delivery. They believe that part of their JSY paymentwill go to ASHA if she accompanies them.

61.7% tribal ASHA as compared to 9 to 10 per cent of the urban and rural ASHA felt thatincentives were not paid on time and it was a big cause behind problems faced by theASHA.

It is first draft report for RAHI Phase II. For satisfactory interpretation of study findings ,suggestions and recommendations . Statistical test of significance and triangulation ofdata with other sources are needed. We will send you soon second draft report with thesame.

FGDs and Their Outcomes

Beneficiaries and non-beneficiaries of the ASHAs were the second group of this studypopulation. They were interrogated through focus group discussions (FGDs).

Two FGDs were conducted in each urban, rural and tribal blocks. 8-10 such women whowere either pregnant or had delivered in last one year were included in the FGDsirrespective of whether they had utilized the services of ASHAs or not .

The scientific technique of FGDs was followed . All women in each group came out withtheir experiences and views.

Focus Group Discussion-I (Vallabhnagar)

FGD conducted at Vallabhnagar included 9 women who had delivered in last one yearand were utilizing services of the ASHA. Most of them were knowing that ASHA isworking in their area. When asked about services given by the ASHA they answered-mobilization for ANC, mobilization for immunization, accompanying them forinstitutional delivery, counseling for contraception, breast-feeding. All the females exceptone were satisfied by work done by the ASHA and favoured continuation of JSY scheme.

One lady complained about improper behavio ur of the ASHA. In her words Hum ASHAbehanji ki salah nahin lete kynki, weh kehti hain - bhangi ke ghar nahin aate .

36

FGD (Vallabhnagar)–II

FGD-II conducted at Vallabhnagar included 9 females belonging to villages Gumanpuraand Udakhera who were either pregnant or had delive red in last one year. The servicesgiven by the ASHA included mobilization for ANC, accompanying for institution aldelivery, mobilization for immunization, counseling for contraception and treatment ofminor ailments. Most of them had institutional delivery and were accompanied by theASHA who also arranged the transport and stayed with them in the hospital.

No one in their families has received treatment for TB (DOTS) or had undergone cataractoperation. Also they were not told about construction of hou sehold toilet. It seems thatASHA Sahayogini have been linked with providers of MCH services.

They were asked few questions like: Kya aapke ghar mein koi T.B. ka mareez h ain- Nahi Baccha beemar hone par kya gharelu upchar karte ho - Nahi, phone karke behanji ko

bulate hain- saadharan beemari mein dawai deti hein, paisa nahi leti Kya bacche ke janm ke bad pehla doodh pilaya - Haan, ASHA behanji ne salah di

thi.

FGD Palodara-III

The FGD included 8 females belonging to village Palodara who were either pregna nt orhad delivered in last one year. When asked about the ASHA, most of them were knowingher except one. The services rendered by the ASHA in their village included mobilizationfor ANC, mobilization for immunization, accompanying for institutional d elivery,counseling for contraception and treatment for minor ailments.

One lady (Varju) had come to Udaipur for institutional delivery. The amount spent ontransport was Rs. 900/- which was arranged by her family members. The ASHAaccompanied her and stayed in the hospital for 3 days. She got the JSY money (Rs.1400/-) after delivery before discharge from the hospital in cash.

Another pregnant lady (Kaani) in the group had undergone two antenatal check -ups, hadtaken TT injections and was planning for de livery in the hospital. Only one lady in thegroup had home delivery.

When asked about the money given under JSY scheme they replied "Is paise se maddadmilti hai, hamare kharch mein kaam aata hai, ghee kharidte hain" .

No one in the group had a toilet in the household and were neither told by the ASHA forconstruction of one in their house.

37

FGD (Dhanmandi)-IV

FGD conducted at Dhanmandi included 10 females residing in the area who had recentlydelivered and were utilizing services of the ASHA. When asked about the ASHASahayogini working in their area, there was a mixed response. Some of them had notheard of ASHA.

Most of them had institutional delivery in the Government hospital, since they wereliving nearby. When asked about money given under JSY scheme all of them hadreceived Rs. 1000/- immediately through either cash or cheque. Only one lady (Shahnaz)had got Rs.600/- after two months.

When asked “Prasav se pehle ASHA kya maddad karti hai - janch ke liye saath aanyee”,teeke ke liye anganwadi le jaati hain, saath me sahayata milti hai, line main nahi lagnapadta”. When asked whether they all were accompanied by the ASHA to the hospital fordelivery, a few of them answered “nau mahine dekh bhaal ki par delivery ke waqt hamnenahin bulaya”.

FGD- (Devpura )–V

FGD conducted at Devpura included 9 females belonging to villages .

Most of them were knowing ASHA b ehanji but were not familiar with her name. Whenasked about services of the ASHA they replied:

Delivery main saath aati hain . Teekakaran karwaati hain. Zukaam, khaansi main dawa deti hain . Aanganwadi main khaana banati hain, bacchon ko padhati hain .

Out of 9 females, 4 had home delivery and 5 females had institutional delivery. Only 3 ofthem were accompanied by the ASHA for delivery.

One lady (Lakshmi) had come to Udaipur for delivery alongwith her hus band, mother-in-law and brother-in-law. When she was asked, “Kya delivery ke waqt aapke saath ASHAnahin aanyee- she replied, jaanch ke liye to aati thee par delivery ke waqt raat mainhumne nahin bulaya”.

FGD (M.B.Hospital) –VI

FGD conducted at M.B.Hospital, Udaipur included 10 females who had delivered in lastone year and had come for immunization of their child ren.When asked about services rendered by the ASHA they answered:

Tikakaran mein sayhog Delivery wali mahila ke saath aati hain Ghar aati hain-bacchon ko tolti hain, garbh nirodhak goliyan deti h ain

Most of the ladies in the group had institutional delivery. Two of them had undergonecaesarian operation and received Rs.1600/ -.

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The FGD results and the observations that were drawn from the interviews of the ASHAswere supporting each other .

FGD Findings

1. Most of the beneficiaries were utilizing services given by the ASHA and weresatisfied with them.

2. The services rendered by the ASHA included mobilization for ANC, arrangingtransport and accompanying for institutional delivery, mobilization forimmunization, counseling for contraception and treatment for minor ailments.

3. None of the beneficiaries had received services like treatment for DOTS,mobilization for cataract operation, construction of household toilets.

4. Some of the beneficiaries had utilized services of the ASHA during pregnancy butdid not inform her at the time of delivery.

5. In one of the FGD a lady complained about caste discrimination practiced byASHA

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CHAPTER 4

CONCLUSION AND RECOMMENDATIONS

Though there is a presence of good performance of incentives plus Rs 500/month ashonorarium from DWCD to ASHA/month in sta te of Rajasthan. If ASHA worksaccording to expectation she can get Rs. 1567/month (1067+500) but averagecompensation received by the ASHA in all the three study blocks in Udaipur district wasonly 48.24% of the benchmark.

In every component ASHA’s work output is less than expected work output in Udaipurdistrict and it is very low (less than 10% expected) in number of components likemobilization for cataract surgery , completions of DOTS and construction of sanitarylatrine. None of the ASHA get compensation for providing primary health care in all thethree blocks as none of them were aware for this incentive and drug kit was also suppliedonce in last one year. Around 75% of the ASHAs are regularly attending MCHN sessionsbut 75% of these ASHAs are getting incentives in more than 30 days . Delayed incentiveis identified as most common cause for dissatisfaction of the ASHA in Udaipur district.Thus there are two major problems: 1. low work performance of the ASHA than expectedand 2 delay in incentives . Efforts are needed by both the side i.e. ASHA herself andsupports system (administration).

Important Findings

Majority of the ASHAs caters to population between 1000 -1500 in urban area and

500 to 1000 in rural and tribal area.

Majority of the ASHAs in the three blocks received 2 trainings i.e one initial on

first module for 10 days and second training on II module for four days.

Tribal ASHAs have to travel large distance at work (>33% have to travel > 2.5

kms)

Overall knowledge of the ASHA regarding environmental sanitation was low.

Mobilization of ANC and immunization, motivation for sterilization and

accompany for institutional deliver y were the commonest services provided by

the ASHA in the three blocks. None of the ASHA in all the three blocks has

worked for motivation for construction of sanitary latrine and mobilization for

cataract surgery. No ASHA in urban area ever completed DOTS.

No monthly meeting was held and attended by urban ASHAs and even in rural

and tribal attendance was around 50% only.

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Maximum delay was observed in getting incentive for MCHN days by the ASHA.

Around 75% of the ASHA in all the three blocks area getting incentive for

MCHN days in more than 30 days and even latest by 5 -6 months are also noted.

The average compensation package for the ASHAs and all the three blocks in this

study was found to be Rs.756/- per month which is only 48.24% of the expected

guidelined state average which is Rs.1567/-[1067+500 Honorarium (Annexure 3)]

per month.

Most of the ASHAs in all the three blocks voice dissatisfaction with the incentive.

The main reason that came out of the study w as they have to work hard, their

expenses are more and incentive are delayed. According to DPM Udaipur delay

was at the level of district and block be cause of backlog of payment and vacant

position of BPM during July 08 -Dec 08. The dissatisfaction was observed more in

the tribal ASHAs. More expenses is the commonest cause of dissatisfaction in

tribal ASHAs. Mean expenditure of 34% of the tribal ASHA is to spend more

than Rs. 400 per institutional delivery.

As in Rajasthan ASHAs are getting honorarium of Rs. 500 per month DWCD

hence they are regularly working at AWC and badly neglecting some of assigned

tasks like: mobilization for cataract surgery, completion of DOTS, construction of

sanitary latrine.

The problems faced by the ASHAs in the field are as follows:

The pregnant women and the relatives are reluctant to take assistance of the

ASHAs as escort for hospital delivery. They have t he misconception that if

ASHA comes with them she will get a cut from their rightful JSY incentive.

So ASHAs are not entitled to JSY money.

Although ASHAs are mobilizing pregnant women for ANC but getting no

incentive, if cannot accompany woman for institu tional delivery.

Tribal ASHAs suffered this lack of timelines more as compared to urban and

rural ASHAs.

When they take delivery cases to hospital they are given harsh and un

cooperative treatment by hospital staff.

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In FGDs it was found that most of the pa rticipants were utilizing JSY, ANC,

PNC and immunization and were satisfied but none of the participants were

befitted and even aware for construction of sanitary latrine, mobilization of

cataract surgery and completion of DOTS by the ASHA.

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KEY RECOMMENDATIONS

Refresher training with latest update should be conducted for ASHA at regular

interval.

Mostly ASHAs are working for RCH services. During refresher training stress

must be given on tasks like DOTS completion, mobilization for cataract surger ies

providing primary health care and construction of latrine, so that with

improvement in ASHA’s performances ASHA can earn more incentives.

Drug kit supply must be regular.

Monthly meeting should be held regularly and attendance of ASHA must be

ensured for proper feedback.

Timely fund flow must be ensured from DPM to BPM and from BPM to MO/Ic

as these are the levels of delay.

Fund audits should be done at regular interval.

Extra incentive should be given in tribal and difficult area.

Awareness generation and education with the help of local leaders is of prime

importance for proper utilization of services of the ASHA and bridging the gape

between ASHA and community.

Monitoring system should be improved from top to bottom.

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References

1. Government of India (2005), National Rural Health Mission (2005-2012),

Mission Document, Ministry of Health and Family Welfare, New Delhi.

2. Government of India (2005), National Rural Health Mission, Accredited Social

Health Activist (ASHA), Guidelines Ministry of Health and F amily Welfare, New

Delhi.

3. Government of India (2006), Annual Report 2005-06, Ministry of Health and

Family Welfare, New Delhi .

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Annexure 1Compensation Package to ASHA Norms for Adequacy, Timeliness and

Mechanism of Flow

Sr.No.

Work Incentive/Compensation

When Where Who isresponsible

1. Incentive forfemalesterilization

Rs. 150 After twodays

HSC ANM

2. Male sterlization Rs. 200 After twodays

HSC ANM

3. JSY(Rural area) Rs. 600 in twoinstallments (Firstinstallments ofRs. 400- 500 forreferral transport andRs. 100 incentive andRs 100 as incentive forPNC

Afterinstitutionaldelivery

Wheredelivery held

First installment –by Medical OfficerIncharge andSecondinstallment byA.N.M.

4. JSY urban area Rs. 200/- twoinstallments

Afterinstitutionaldelivery

Wheredelivery held

First installment –by Medical OfficerIncharge andSecondinstallment byA.N.M.

5. SocialmobilizationMCHN days

Rs.150/- per session Same day AnganwadiKendra

ANM

6. Cataractoperation ingovernment orprivate hospital

Rs. 175/-(not appliedfor eye campsorganized by NGOs)

Afteroperation

Same hospitalwhereoperation held

Medical Officer

7. DOTS treatment Rs. 250/- Afterfinishing oftreatment

ConcernedPHC duringmonthlymeeting

Medical Officer Incharge

8. Complication forattendingtrainings

Rs. 100/- per day Last day oftraining

Trainingvenues

Training Organizer

9. Attendingmonthly meeting

Rs. 100/- After meeting Meeting place Medical Officer in-charge

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10. Sanitary toilets 1. Rs. 30/- toilet forAPL families

2. Rs. 20/- toilet forBPL families

3. Rs. 10/- per monthfor regular usage ofthat toilet by thefamily

Completion oftoiletconstruction

Totalsanitationcampaign

Concerned District/block TSC in-charge officer

11. Primarytreatment forcommunity

Rs. 5/- person After givingmedicines

Benefitedfamily

Benefited

12. Monthlyhonorarium

Rs. 500/- Per month DWCD DWCD

Source: www.nrhmrajasthan.nic.in

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Annexure 2

Benchmark Compensation (ASHA Module – I NRHM Rajasthan)

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48

Annexure 3MPR

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50

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Annexure 4Physical Progress – DPM Udaipur AVERGARE PER ASHA PER

MONTH/11