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Assessing and Supporting NIPI* Interventions
Technical report
November 2011
PUBLIC HEALTH FOUNDATION OF INDIA Beena Varghese (PI) Sanghita Bhattacharya Reetabrata Roy Aradhana Srivastava Somen Saha Rajmohan Panda Sudha Ramani Priya Chitkara
UNIVERSITY OF OSLO Sidsel Roalkvam
Jagrati Jani-Bølstad Cecilie Nordfeldt Dagrun Kyte Gjøstein Synnøve Knivestøen
*Norway India Partnership Initiative
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Content
EXECUTIVE SUMMARY .................................................................................................................................. 6
2. INTRODUCTION ....................................................................................................................................... 12
2.1 Literature review ............................................................................................................................... 12
2.2 NIPI Interventions ............................................................................................................................. 14
2.3 ASNI -- Goals and Objectives ............................................................................................................. 16
3. METHODOLOGY ...................................................................................................................................... 17
3.1 Study Design ...................................................................................................................................... 17
3.2 Data collection and analysis .............................................................................................................. 21
3.3 Limitations ......................................................................................................................................... 23
4. UNDERSTANDING DEMAND FOR HEALTH SERVICES .......................................................................... 24
5. THE YASHODA PROGRAM ................................................................................................................... 34
5.1 The Yashoda Program – Operational Aspects ................................................................................... 34
5.2 The Yashoda program – Health provider & community perspectives .............................................. 40
5.3 Summary ........................................................................................................................................... 54
5.4 Recommendations ............................................................................................................................ 55
6. HOME BASED NEWBORN CARE -- EFFECT OF ASHA TRAINING .......................................................... 56
6.1 NRHM & NIPI training modules for ASHAs: Comparative Review .................................................... 56
6.2 Assessment of NIPI training .............................................................................................................. 61
6.3 Community Survey -- Outcome for HBNC Indicators ........................................................................ 62
6.4 Summary ........................................................................................................................................... 66
6.5 Recommendations ............................................................................................................................ 67
7. COMBINED BENEFITS OF YASHODA & HBNC PROGRAM .................................................................... 68
8. TECHNO-MANAGERIAL SUPPORT & .................................................................................................... 70
FINANCIAL RESOURCE ANALYSIS OF NIPI ................................................................................................... 70
8.1 Techno Managerial support .............................................................................................................. 70
8.2 Financial resource analysis ................................................................................................................ 72
8.3 Summary ........................................................................................................................................... 75
8.4 Recommendation .............................................................................................................................. 76
9. CONCLUSION AND RECOMMENDATIONS` ......................................................................................... 77
ANNEXES ..................................................................................................................................................... 80
REFERENCES ................................................................................................................................................ 85
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List of figures
Figure 3.1: Research design of the ASNI project ......................................................................................... 17
Figure 5.1: Occupational structure of sample population .......................................................................... 44
Figure 5.2: Time allocation of Yashoda ....................................................................................................... 48
Figure 6.1: Counseling on HBNC by ASHA, Rajasthan ................................................................................. 64
Figure 6.2: Counseling on HBNC by ASHA, Orissa ....................................................................................... 64
Figure 7.1: Combined Effect of Yashoda and ASHA .................................................................................... 68
Figure 8.1: Year-wise fund utilization in Anugul ......................................................................................... 72
Figure 8.2: Year-wise fund utilization in Alwar ........................................................................................... 73
List of tables
Table 3.1: ASNI methodological tool box: strengths and weaknesses ....................................................... 18
Table 3.2: Sample size of community survey .............................................................................................. 20
Table 5.1: Profile of Yashoda – Alwar and Anugul District ......................................................................... 35
Table 5.2: Operational guidelines for Yashoda and their implementation in Rajasthan and Orissa .......... 39
Table 5.3: Key indicators of socio-economic characteristics of respondents ............................................. 43
Table 5.4: Key Indicators on pregnancy history of respondents ................................................................ 46
Table 5.5: Median household expenditure towards maternal and neonatal care ..................................... 47
Table 5.6: Pre delivery care (Sharing of ANC card and physical examination) ........................................... 49
Table 5.7: Post natal counseling, checkup and practice, Rajasthan ........................................................... 51
Table 5.8: Post natal counseling, checkup and practice, Orissa (DH) ......................................................... 52
Table 5.9: Key post natal indicators for mothers who had a C-section delivery ........................................ 53
Table 5.10: Reason for coming back to facility for next delivery ................................................................ 54
Table 6.1: Comparative summary of NRHM and NIPI state training modules for ASHAs .......................... 59
Table 6.2: Frequency of home visits by ASHA ............................................................................................. 62
Table 6.3: Counseling on HBNC by ASHA .................................................................................................... 63
Table 6.4: HBNC- Health outcomes for Newborn ....................................................................................... 65
Table 6.5: Information related to Referral .................................................................................................. 66
Table 7.1: Incremental benefit of Yashoda and HBNC program ................................................................. 68
Table 8.1: Key Budget head fund utilization Anugul (2010-11) .................................................................. 73
Table 8.2: Key budget head fund utilization Alwar (2010-11) .................................................................... 74
Table 8.3: NIPI Financial Management in Orissa and Rajasthan ................................................................. 74
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Abbreviations
ANC- Ante Natal Care
ANM- Auxiliary Nurse Midwives
ASHA- Accredited Social Health Activists
ASNI- Assessing and Supporting NIPI Interventions
AWW- Anganwadi Workers
BPL- Below the poverty line
BPMU- Block Project Management Unit
CHC- Community Health Centers
CHS- Child Health Supervisor
DCHS- Deputy Child Health Supervisors
DH- District Hospitals
DLHs- District Level Household Survey
DPMU- District Project Management Unit
FGD- Focus Group Discussions
FMR- Financial Management Review
GoI- Government of India’s
HBNC- Home Based Newborn Care
HBPNC- Home Based Postnatal Care
HMIS- Heath Management Information Systems
IASAM, University of Oslo - International Health, Faculty of Medicine
IBF1- Initiation of breastfeeding within 1 hour
IDIs- In-depth Interviews
IMNCI- Integrated Management of Neonatal and Childhood Illness
JSY- Janani Suraksha Yojana
MDG- Millennium Development Goal
NIPI- Norway - India Partnership Initiative
NRHM- National Rural Health Mission
PHFI- Public Health Foundation of India
PIP- Program Implementation Plan
PNC card- Postnatal Checkup card
RCH-II Reproductive and Child Health Programme phase II
RKS- Rogi Kalyan Samiti
SNCU - Sick Newborn Care Unit
SIHFW- State Institute of Health and Family Welfare
SUM- Centre for Development and the Environment
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ACKNOWLEDGEMENT
The study team for ‘Assessing and Supporting NIPI Interventions’ (ASNI) acknowledges the valuable
support and inputs provided by the various cadres of staff at the Department of Health and Family
Welfare and the National Rural Health Mission in Orissa and Rajasthan. Their views and experiences
helped us understand the complexity of the issues being faced by the larger health system and the
catalytic support provided by the NIPI interventions. Similarly, the NIPI secretariat and the state NIPI
teams have provided excellent inputs and support for our work. Their perspective on the successes,
challenges and learning from the NIPI interventions has helped the team gain comprehensive insight
into the program and enabled us to provide recommendations to address some of gaps identified by our
study.
The ASNI team would like to make a special mention and express our gratitude to the various health
care providers at the facilities and the community, especially the ASHAs and Yashodas who were willing
to talk to us and provide us insights about all aspects of their work. Our special thanks to mothers who
welcomed us into their lives and shared their personal experience with our team. Without their support
it would not have been possible to present this report.
We are grateful to Dr. R. M Pandey for his generous support and extensive statistical guidance in
developing and reviewing the methods of the study. Thanks to GfK MODE (survey agency) and our field
teams who did an excellent job collecting all required information and meeting our deadlines. The
support provided by the PHFI administrative and finance staff has been valuable and appreciated.
We would like to conclude with our sincere gratitude to the Royal Norwegian Embassy which provided
us the funds and support to make ASNI possible.
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EXECUTIVE SUMMARY
The Norway - India Partnership Initiative (NIPI) is an outcome of a commitment by the Prime Ministers
of Norway and India to reduce child mortality and improve child health in attaining Millennium
Development Goal 4(MDG 4) by 2015. Assessing and Supporting NIPI Interventions (ASNI) is an
operations research project, taken up by the Public Health Foundation of India (PHFI), the Centre for
International Health, Faculty of Medicine (IASAM), and Centre for Development & the Environment
(SUM, University of Oslo). This research aims to assess NIPI activities within a continuum of care
approach, focusing on both demand and supply side issues, and to strengthen NIPI to achieve MDG 4
and National Rural Health Mission (NRHM) goals.
Objectives
The main objectives of the study were to:
Understand perspectives of communities reached by NIPI interventions on childcare and birthing
practices.
Assess the facility based Yashoda program—a cadre of lay workers who assist mothers during delivery
and help with newborn care.
Assess Home Based Newborn Care (HBNC) provided by Accredited Social Health Activists (ASHAs)
trained by NIPI.
Assess the roles, responsibilities and the value addition of NIPI techno-managerial personnel who
provide support to NRHM.
Provide recommendations to scale up NIPI interventions.
Methods
The study was conducted between November 2009 to September 2011 in Rajasthan and Orissa, two
NIPI focus states in India. This was a quasi experimental design study with an intervention and control
district in each of the states. The intervention districts were Alwar in Rajasthan and Anugul in Orissa;
non NIPI control districts were Sawai Madhopur, Rajasthan and Bargarh, Orissa. Mixed methods of data
collection—ethnographic, qualitative, and quantitative (survey) --were used to collect relevant data
from both the supply side (health care providers and administrators) and the demand side (community).
In addition, a resource analysis was conducted to understand the fund flow mechanisms and integration
with NRHM funding mechanisms.
A community survey of women who had delivered in the two months preceding the survey was
conducted between March and May 2011. The sample size required to show a minimum of 25 percent
difference in newborn care indicators (60 percent prevalence, 80 percent power and α =0.05) was a
total of 1728 mothers. Univariate, bivariate and logistic regression analyses were done to assess the
benefits of the Yashoda and HBNC interventions. Further analysis to estimate the combined effects of
Yashoda and HBNC programs were also done by comparing relevant indicators for mothers who were
exposed to both Yashoda and ASHA with those who were exposed to just ASHAs and those who had no
exposure to either the Yashoda or NIPI trained ASHAs.
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Strengths and limitation of the study: The strength of the study is its multi-method approaches with
ethnography, qualitative (IDIs, FGDs) and quantitative (survey) methods. One of the main limitations of
this study was lack of baseline information on the selected indicators; however, this was partially
addressed through the selection of control districts that most matched the intervention district.
Interpretation of the findings from this study should be limited to the effect on counseling and practice
indicators and not on maternal and neonatal mortality outcomes.
Results
Community demand
The ethnographic study explored the meaning health seekers attach to acceptance and refusals of
governmental health services. From a community and family perspective, the delivery of a child in a
formal medical institution involves the movement of the birthing mother to an unfamiliar environment,
where strangers attend woman in the absence of the physical, symbolic and social support of the family.
In the communities’ studied, childbearing, birth and post-partum work are “natural” social processes
that do not need the interference from medical doctors and trained personnel. The demand for facility
births is voiced in cases where something appears to go wrong.
In government health facilities women express that they feel vulnerable and exposed. They are not only
exposed to male doctors, nurses, sweepers and ward boys, but also to evil eye ('nazar'). Government
institutions are thus thought of as dangerous and potentially harmful to mother and child. These
facilities are judged as intolerant to the important cultural and ritual practices surrounding childbirth.
Women have minimal expectations of being treated well at health facilities and lack trust on the
provider.
The ethnographic study thus highlights the need to distinguish between active demand and passive
acceptance in understanding health seeking behaviors. Young mothers are taken to facility for birthing
motivated by the Janani Suraksha Yojana (JSY) incentives, who easily accept this because they are not
the ones who set the rules. With the introduction of JSY, the incentive has become the main driver. The
important questions then are: how and why does acceptance and demand for skilled and facility based
births become a prevailing social condition? How flexible is the demand if the service is not up to
standard, if services deteriorate or if incentives are withdrawn? It is in this context that an enabled
Yashoda could provide support.
Yashoda Program
This study showed that the Yashoda program is functional at the district hospital (DH) and at community
health centers (CHC) in Alwar and at the DH in Anugul. The profile of Yashodas (in terms of age and
educational status) at the two study districts matched NIPI guidelines. In terms of remuneration,
Yashodas reported preference for a mixed system of remuneration (fixed amount plus incentive).
Supervision systems in Rajasthan were found to be weak compared to Orissa, especially at the CHC level
where no supervisors were available. Yashodas also highlighted the need for more frequent training.
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Yashodas were positioned in the health facilities to be mother's aides. However, there seemed a
constant push for her to be a technical aide rather than a mother’s aide. Yashodas spent majority of
their time in the postnatal care (PNC) ward providing support to the mother and newborn with limited
interactions with ASHAs. This was supported by the survey findings - 81 percent of mothers in Alwar DH;
41 percent in Alwar CHCs; and 93 percent in Anugul DH reported being attended by Yashoda in the PNC
ward. A significantly higher proportion of mothers in the intervention districts (55 percent to 97 percent
in Alwar; 87 percent to 94 percent in Anugul) received counseling on immunization, breastfeeding,
family planning and nutrition compared to those in control districts (34 percent to 66 percent in Sawai
Madhopur; 49 percent to 94 percent in Bargarh). Yashodas had an impact on receipt of postnatal checks
at the intervention facilities—mothers in Alwar DH (Anugul DH) were four to five times (1.4 to 1.5 times)
more likely to receive temperature and blood pressure check than mothers in Sawai Madhopur
(Bargarh). However, the absolute proportion who received basic postnatal checks was still low.
Some of the neonatal care indicators (keeping the newborn warm, initiation of breast feeding and
immunization), were reported by more than 90 percent of mothers in both intervention and control
districts. This perhaps reflects the positive impact of the NRHM program. However, the benefit of the
Yashoda program was most evident for initiation of breastfeeding among women who had a caesarian
section- 76 percent of these respondents in the intervention districts reported that they initiated
breastfeeding within five hours compared to 44 percent in the control districts.
At the CHC level too, the Yashoda intervention showed significant benefits, however the proportion of
mothers reporting benefits was lower than mothers at the district hospitals. This may be attributed to
lack of supervision of Yashodas at the CHCs and other factors like lesser length of stay and fewer
number of Yashodas at these facilities.
The objective of the program was to enhance a joint ownership for care coordination at the facility with
'Yashoda’ as part of the larger system. A pregnant woman is expected to feel welcome as she enters the
facility and leaves with her newborn baby with a feeling of being cared for and looked after. The study
found that Yashodas both at the DH and CHC levels in Rajasthan and at the DH level in Orissa provided
significant support to mothers and newborns during the postnatal period at the facilities--
mothers/families felt that the presence of Yashodas was beneficial to them and were more comfortable
within the hospital environment in the presence of a Yashoda than without her support. The additional
value of Yashoda program thus could contribute to the generation of demand for good maternity
services and proper care for newborns. However, if the supply-chain within the health system remains
weak it is indeed difficult to sustain the demand, even with the Yashoda in place. The challenge is to
create a space for the Yashoda within the health system that allows her to perform her duties as a
mother’s aide and protect her from the technical push.
NIPI supported HBNC Program
The NIPI supported HBNC program is functional in both the study districts. During the study period,
ASHAs had received two-day training on HBNC; the five-day skill based training had only begun in the
first quarter of 2011.
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The data from the community survey clearly showed improvement in key areas of new born care
outcomes in the intervention districts: mothers in Alwar (Anugul) were twice (four times)as likely to
register their newborn compared to mothers in Sawai Madhopur (Bargarh); and twice (16 times) as
likely to have their babies weighed at home. Rates of zero dose immunization were above 90 percent in
both the intervention and control districts. The proportion of mothers who reported receipt of
counseling messages specific to newborn care (breastfeeding, birth registration, immunization) from
ASHAs during their postnatal home visits were significantly higher in the intervention districts in
Rajasthan and Orissa compared to control districts. The identification of danger signs and subsequent
referrals including use of referral funds were higher in intervention districts than in the control, but the
actual proportions reporting these were still low and have potential for significant improvement.
The training methods, content, and supportive supervision including field level follow-up were perhaps
the main reasons for the differences in new born outcomes observed between the intervention and
control districts. The structure of the training program of NIPI with emphasis on field visits and a skill
based approach thus holds promise and can play a critical role in making HBNC trainings more
consistent, effective and result oriented.
Yashoda and ASHA: combined benefits
The analysis done to assess the incremental and combined benefits of Yashoda and ASHA on newborn
care showed that the dual exposure of mothers to both Yashoda and NIPI trained ASHA had an
incremental effect on newborn care indicators (both counseling and practice). For example, mothers in
Alwar (Anugul) were almost four (three) times (Alwar OR 3.79, CI 2.57, 5.57; Anugul 2.96, CI 1.77, 4.96)
more likely to have received counseling on keeping the baby warm compared to mothers in the control
district. Similarly, birth registration was 2.5 (1.37) times higher among mothers who had dual exposure
to Yashoda and ASHA in Alwar (Anugul) compared to mothers in control districts. These suggest that
NIPI interventions on the whole have resulted in improved information among mothers and better
outcomes for the newborn. Further studies may be undertaken to understand the impact of these two
program components on neonatal mortality.
Combined Effect of Yashoda and ASHA (Odds ratios with 95 percent confidence intervals)
Rajasthan Orissa
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Techno managerial support
The techno managerial support of coordinating and providing technical support for maternal and child
health issues in the districts needs strengthening. Recruitment through government channels and
retention of staff remained challenging. However, support provided in managing the Yashoda and HBNC
programs has been significant. Another important achievement has been the on-ground post-training
support provided by child health managers to ASHAs on HBNC.
Fund utilization
NIPI funds contributed to about six percent of total NRHM district allocation for 2010-11. The utilization
of these funds has been around 40 percent in both Anugul and Alwar, a significant improvement from
utilization in the first year of the program. Across Rajasthan and Orissa, maximum fund utilization was
for Yashoda and HBNC components. Frequent revisions of financial guidelines, financial monitoring,
follow-up, and lack of coordination were some of the reasons for low fund utilization especially for the
ASHA referral and untied funds. .
NIPI should be acknowledged and appreciated for integrating its programs under the NRHM. This is a
significant contribution to secure sustainability of the program. However, some of the biggest challenges
faced in the implementation of NIPI programs were also intrinsically linked to procedures in the NRHM
such as recruitment, fund-flow, retention of staff, and procedures in procurement.
Conclusion
The assessment thus showed that the Yashoda and HBNC programs supported by NIPI in Rajasthan and
Orissa have resulted in significant improvements in the knowledge and practice of important maternal
and new born indicators. These interventions could be scaled up in rest of the districts in the state and
perhaps in the country in a phased manner with due considerations to the various recommendations
provided below. These could have an impact on both maternal and neonatal outcomes. However, it is
important to have active participation of communities as a non-negotiable precondition for such
programs to be sustainable and have long lasting impact.
Recommendations
Active demand for institutional births supported by Yashoda should be promoted by building in
strategies for community participation and involvement of local communities (through increased
awareness).
Branding of the Yashoda through her clothing and work as a mothers aide perhaps with supply of
newborn kits to support the mother and new born would be important. Yashoda’s role as a mother’s
aide to be made specific and clear during recruitment (keep education level below tenth grade) and
training and to keep her identity distinct from that of nurses or other staff.
Increase focus on normative behavior (dignity, ethical norms, human rights, protection) in the
training modules for both ASHA and Yashoda.
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Weak supervision of Yashodas has serious implications on discharge of duties by them, and
therefore supervision needs to be strengthened, especially at the CHC levels. Supportive supervision
through appropriate support at the facility and encouraging their role as mother’s aide is important.
To improve continuum of care, the presence of ASHAs at registration provides an excellent
opportunity for Yashodas to interact with them and take over the mother’s care (through sharing of
the ANC card information) at the facility. Similarly, at discharge, Yashodas could provide similar
information about the mother to the ASHAs to continue care through postnatal visits at home.
Counseling on danger signs, facilitation of postnatal checks, and use of supplementary feed could
receive further focus and attention. Customized, field based, and frequent training that emphasizes
on these topics should be considered.
HBNC training should be customized further in terms of local content, imparted through more field
level demonstrations. Continued focus on supportive supervision, regular refresher training,
performance monitoring and feedback are integral and should be emphasized.
ASHAs should be provided more information and training on the identification of danger signs for
the mother and new born and appropriate referral along with availability of referral funds for
transport should be strengthened.
Guidelines for utilizing untied funds should suggest a list of possible and permissible activities.
Program managers should be adequately sensitized about the guidelines.
NIPI program should attempt to implement uniform system of financial reporting based on activity-
wise resource allocation and expenditure and reporting of efficiency in incurring of expenses by
blocks.
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2. INTRODUCTION
2.1 Literature review
In contemporary debate concerning maternal and child health care, provisions of health care services
are increasingly understood as a dynamic system of entitlement and obligations between people,
communities, providers and governments. Community participation, health promotion, social support
and empowerment of individuals (especially of women) are seen as critical to achieving sustainable
improvements in maternal and child health care. While governments should make quality reproductive
services and information accessible, women and families should be encouraged to articulate what they
need and expect in terms of services. In the report on Macroeconomics and Health the substantial
barriers to access that exists for the poorest members of society became abundantly clear1. Although
the reasons for why the poor do not make use of services is driven by both supply and demand factors
related to health care services, the focus of much health interventions has been on reducing supply side
barriers2. Yet, whether and where to utilize health services starts well before arrival at the clinic and
requires myriad and often conflicting choices on behalf of the health seeker.
In 2004, the government of India launched the National Rural health Mission (NRHM) to address both
the supply and demand side issues in public health care services in rural India. The government
introduced a conditional cash transfer program, a demand side financial incentive --Janani Suraksha
Yojana (JSY) to increase the level of institutional births in the country. This central government
sponsored scheme links cash assistance with delivery and post-delivery care, taking into account the
pregnant woman’s need for escort, transport, and in case of complications, referral services. JSY has
succeeded in increasing the number of institutional deliveries in the country3,4. However these have not
adequately addressed the quality of care and counseling needs of mother and infants within the facility.
This dramatic increase in facility births and has now put tremendous pressure on the institutions.
Maternity wards at the DHs and sometimes at the CHCs are overcrowded and staff overstretched. The
doctors and nurses -- routine caregivers in a facility, are often unable and not equipped to provide
emotional support to mothers and non-medical support for newborns. Besides, vacancies in the health
sector necessitate the optimal use of specialized skills of the workforce like doctors and nurses. Raising
expectations at the demand side was not met adequately by supply side factors and this could result in
both cynicism and despair among both providers and users leading to a serious setback for what the
Government of India intended to achieve. Global policies encourage rational re-allocation of less
specialized but important tasks to less-trained cadres of health workforce.5
International evidence points towards the usefulness of birth companions who provide support to
women during childbirth, ranging from psychosocial support to assistance with information and
procedures.6,7 Birth companions were traditionally community women or family members who
comforted and supported a woman emotionally as she went through the extremely stressful experience
of childbirth. However, with technical advancements in modern medicine and the stress on facility-
based births with skilled birth assistance, the role of traditional birth companions was gradually
sidelined. But research since the 1970s has proven the presence of a birth companion as being
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extremely beneficial in easing the trauma of childbirth for the mother and in helping her cope with her
experience.8 The lack of emotional support or empathy by birth attendants can in fact make the whole
process of childbirth a dissatisfying and painful experience for the mother.9,10 Birth companionship is
now accepted as a low-cost intervention beneficial to labor outcomes, giving birth companions a
renewed acceptance in the modern scenario as well.6 The professional birth companion or ‘Doula’
emerged consequently in the Americas. They are paid companions who accompany mothers during
delivery and provide her the necessary support, guidance, information and encouragement.
Besides providing emotional support, birth companions help improve patient-provider communication,
assist the mother in getting the requisite delivery care, advice regarding coping techniques, comfort
measures (comforting touch, massages, promoting adequate fluid intake and output) and advocacy.6
There is a possibility of the role of birth companions clashing with those of obstetric nurses, but this
could be minimized by ensuring that their roles are complementary and not conflicting.11,12 Birth
companionship was found to be positively associated with reduced length of labor and improved
maternal-infant interaction.13 A Cochrane review of sixteen trials involving female birth companions
found that women who had continuous intra-partum support were likely to have a slightly shorter labor,
were more likely to have a spontaneous vaginal birth and less likely to have intra-partum analgesia or to
report dissatisfaction with their childbirth experiences.14 Birth companions’ presence is also likely to lead
to fewer newborn complications.15
In India, the Government of Tamil Nadu initiated a “birth companion” scheme in 2004 in all public
hospitals in the state, under which women getting admitted to facilities could nominate a female family
member to be their birth companion. The companion should be aware of the labor process and should
stay with the mother without interfering in the medical procedures.6 One of the positive effects of the
intervention was observed in a study on maternal care in Tamil Nadu which showed that the presence of
a birth companion in the labor room may have reduced the likelihood of abuse by providers of women
in labor.16 Most women agreed that a birth companion would not only support the woman in labor but
could also act as her advocate and demand better quality of services on her behalf.
Another critical concern relates to ensuring the survival of newborns and infants. HBNC has been
recognized as an effective low-cost strategy for reduction of newborn and infant mortality and
morbidity in resource-poor countries where there is lack of availability of facilities and preference for
home births, and where hospital-based interventions are often not practical, appropriate or
affordable.17 It has been observed by various studies on newborn care that the knowledge and practice
of simple newborn care (such as the identification of danger signs in the newborn, and care-seeking) is
generally poor.18,19,20 In order to ensure care at home, there should be a continuum of care between the
hospital and the community. Many studies in the past have proved the efficacy of the role of community
health workers in continuum of care.21 The Gadchiroli study demonstrated that neonatal and infant
mortality can be reduced by 50 percent22 through counseling and management of some basic newborn
complications, provided by trained village health workers during home visits. Similar improvements in
newborn and peri-natal outcomes have been observed in other studies on home-based care in countries
like Pakistan and Bangladesh.23,24
14
Owing to its critical role in complementing institutional care, HBNC as a key element of the continuum of
care approach, and has become an integral part of Government of India’s (GoI) neonatal care strategy
under the Integrated Management of Neonatal and Childhood Illness (IMNCI) approach, introduced in
the Reproductive and Child Health Program phase II (RCH-II). Home visits by health workers (Auxiliary
Nurse Midwives (ANMs), Anganwadi Workers (AWWs), Accredited Social Health Activists (ASHAs) and
other link volunteers) help mothers and families to understand and provide essential newborn care at
home and detect and manage newborns with special needs due to low birth weight or sickness.25
According to GoI guidelines five home visits are to be provided to every newborn starting with the first
visit on the day of birth followed by visits on days 3, 7, 14 and 28. Services to be provided include advice
on keeping the child warm, covered, skin and eye care, initiation of breastfeeding immediately after
birth and counseling for exclusive breastfeeding. The training includes recognition of illness in newborn
and management and/or referral and immunization.
A recent evaluation of HBNC conducted by National Health Systems Resource Center (NHSRC) in eight
states of India reported that 73 percent of the respondents received advice on early initiation of
breastfeeding, 65 percent consulted ASHA during illness of a sick child. But at the same time the study
reported that ASHAs are not as effective in influencing critical health behaviors such as breastfeeding,
adequacy in complementary feeding with the same intensity, which undermines her effectiveness in
bringing about changes in health outcomes. This has been identified as a core area for improvement by
the fourth common review of the NRHM, which stresses on the need for all ASHAs to imbibe skills in
home-based newborn care including inter-personal behavior change.26
2.2 NIPI Interventions
NIPI was designed to provide three main areas of catalytic support to NRHM, first in terms on providing
support to mothers and infants in select health facilities through voluntary birth companions called
Yashodas; support for the HBNC program to address the post natal needs of mothers and newborn; and
provide techno managerial support at district and sub-district levels to improve the functioning of the
health system. These activities are expected to reduce child mortality, improve child health and help
attain MDG 4 by 2015.
The Yashoda program: This program is designed so that local volunteers from the community assist
mothers with their post-natal requirements and provide support for newborn care in the maternity and
post-natal wards of DHs and select CHCs. NIPI envisages Yashodas to provide the following support:
1. Receiving and supporting pregnant women at the facility.
2. Counseling the mother on immediate and exclusive breast feeding, nutrition for self and newborn,
immunization and family planning choices and informing them about accessing child health services
after leaving the hospital.
3. Ensuring overall cleanliness of the beds and ward including toilets; ensuring dignity and privacy of
mother by avoiding crowding around the bed.
4. Drawing the attention of the doctor or nurse if the baby is found sick.
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5. Keeping records of all mothers and children born.
HBNC component: To establish the continuum of care by strengthening the HBNC component, NIPI
builds on the presence and competency of the ASHA to create a structured follow-up system for both
the mother and the newborn in the community. The three pronged approach that NIPI employs to
achieve this are:
1. A special training module (2+5 days) on HBNC
2. An incentive of Rs. 100 to ASHAs for completing five to six PNC checkups
3. A referral fund to ensure that sick newborns and mothers can be referred to a facility where proper
care is available.
Newborn care includes the provision of warmth, umbilical cord care, cleaning of mucous, proper airway
resuscitation, feeding, basic hygiene, identification of danger signs, and seeking help from health
personnel when required. ASHAs under the HBNC program are supposed to provide:
A. PNC visits: The ASHA does five to six post natal visits per mother, generally visiting three or four
households a day. The first post natal visit is on the day of discharge after coming from hospital.
Subsequent visits are on 3rd, 7th, 14th and 28th day. A visit on the 42nd day is also made in Rajasthan. The
activities focus on checking the health of baby and mother, nutrition of mother, counseling on breast
feeding, family planning and immunization, and examining the baby for danger signs. The ASHAs are
required to fill a Postnatal Checkup card (PNC-card) during the visit, and submit it for validation and
payment after the requisite visits have been completed.
B. Referrals: ASHAs are trained to identify danger signs in mothers and newborns during their home
visits. On identification of danger signs that require referral, the woman and/or newborn must be sent
to the referral hospital in the locality, the block hospital (CHC) or the DH. There are a total of nine
danger signs for newborns and four for mothers in the post delivery period, which require urgent
attention. Proper and timely identification skills for such danger signs and referrals are given to the
ASHAs during their training. ASHAs must tell the woman and family member about the hospital where to
go and how to go. They should assist the family in finding a suitable transport facility. The referral card
should be filled up appropriately and given to the family.
NIPI’s Techno-managerial support to NRHM: This contributes towards enhancing the overall quality and
effectiveness of the program and strengthening of systems. The overall framework for this is:
1. National, state, district and block level planning and implementation of child health activities. The
new techno-managerial support takes into account existing support mechanisms at various levels and
extends them to current initiatives under NRHM as well as new innovations.
2. Technical support at all levels for development, adaptation, sharing and dissemination of tools,
including those for ASHAs and all child health activities.
3. Catalytic action to galvanize and motivate teams, and support training activities, including those for
ASHAs and all child health activities
16
4. Gap management and problem-solving related to technical solutions, planning, budgeting,
management, and financial issues.
5. Innovative solutions, action research, identification of best practices, and refinement of approaches.
6. Streamlining communication and referrals in the ASHA chain.
2.3 ASNI -- Goals and Objectives
The current study--Assessing and Supporting NIPI Interventions (ASNI) is an operations research project,
taken up by the Public Health Foundation of India (PHFI) and the Centre for International Health, Faculty
of Medicine (IASAM, University of Oslo) and Centre for Development and the Environment (SUM). The
aims of the study are two-fold:
1) To understand the functioning of three thematic areas under NIPI activities: facility based Yashoda
initiatives; HBNC provided by ASHAs; techno managerial support and their convergence with NRHM.
2) To identify key obstacles/problems if any in the effective implementation of these initiatives so as to
provide recommendations to improve the program. It also aims to assess NIPI activities within a
continuum of care approach focusing on both the demand as well as the supply side, and to strengthen
NIPI to achieve MDG 4 and NRHM goals.
The main objectives of the study were to:
Understand perspectives of communities reached by NIPI interventions on childcare and
birthing practices.
Assess the facility based Yashoda program—a cadre of lay workers who assist mothers during
delivery and help with newborn care.
Assess Home Based Newborn Care (HBNC) provided by Accredited Social Health Activists
(ASHAs) trained by NIPI.
Assess the roles, responsibilities and the value addition of NIPI techno-managerial personnel
who provide support to NRHM.
Provide recommendations to scale up NIPI interventions.
Currently, evidence from India on establishing a facility based health worker system for maternal and
child health care is limited. Hence, the innovative Yashoda program under NIPI provides an opportunity
to assess their additional value. Similarly, the improved HBNC program through NIPI and the techno-
managerial support to NRHM are innovative additions to the existing system and an assessment of the
same would provide valuable information to NIPI and to the state governments.
17
3. METHODOLOGY
3.1 Study Design
Research design and selection of study area
To assess and document the additional benefits of NIPI interventions, the study used a quasi-
experimental design, wherein the intervention district (where NIPI is functional) was compared to a non-
NIPI district (control district). The differences between the intervention district and control district in
processes and in intermediate outcomes related to maternal and child health are assessed at the facility
level and the community level. Figure 3.1 depicts the research design of the project.
Figure 3.1: Research design of the ASNI project
At the start of the ASNI study, NIPI interventions were operational in three districts each of Rajasthan
and Orissa -- Alwar, Dausa and Bharatpur districts of Rajasthan and Anugul, Sambalpur and Jharsaguda
districts of Orissa. Thus, for this study, one intervention district out of the three was chosen in each of
the study states. The choice of the intervention districts for this study was done on the basis of inputs
from NIPI program personnel and program data provided by the NIPI teams. In Rajasthan, Alwar was
chosen since NIPI interventions such as the Yashoda program, training of ASHAs for HBNC and Sick
Newborn Care Unit (SNCU) were fully functional. A similar rationale was used in Orissa where Anugul
was chosen as the NIPI intervention district.
The choice of the control district was done based on a comparison of various socioeconomic and
epidemiological indicators across districts within a state. The main indicators that were used for
comparison included population density, economic profile, literacy rates and health indicators relevant
to maternal and child health such as Ante Natal Care (ANC), immunization rates, rates of institutional
delivery. These were obtained from the District Level Household Survey (DLHS) III, census data, and
supplemented using state-level Heath Management Information Systems (HMIS) data (See Annexure
1).The control districts were Sawai Madhopur in Rajasthan and Bargarh in Orissa.
The assessment study looked at the Yashoda program’s norms of appointment, operational issues in
implementing the model viz., recruitment, training, supervision, integration of Yashodas into the existing
NRHM model and the benefits of having such a cadre of workers from a provider and mother’s
perspective.
Control District
(Non NIPI Focus)
Observe, Assess and
identify barriers
Formulate
recommendation
Intervention district
(NIPI focus)
18
It also assessed the training received by ASHAs on HBNC, the usefulness of this training, their workload
and implication for HBNC. It also reviewed the referral mechanisms and linkages with Yashodas and the
techno-managerial component of the program.
The study methods were a combination of both qualitative and quantitative techniques. Implementation
research and other forms of research in health have moved increasingly from single method to multi-
method approaches27. Although cross sectional sample surveys are still common, they are now often
combined with qualitative methods. As each key method has its own strengths and weaknesses (see
Table 3.1) they are increasingly selected for use together. As a result, multi-method combine studies are
now able to benefit from the advantages of sample surveys and statistical methods (quantification,
representativeness and attribution) and the advantages of the qualitative and participatory approaches
(ability to uncover approaches, capture the diversity of opinions and perceptions, unexpected impacts
etc.). Qualitative tools, used in the first phase of this study, focused on largely programmatic and
implementation perspectives, while the quantitative survey in Phase II aimed to measure benefits of the
two NIPI interventions through a community survey of recently delivered women. Review of various
government and NIPI documents combined with a literature review of birth companions and HBNC
programs was carried out, which facilitated the development of quantitative survey and qualitative tools
(In-depth Interviews (IDIs) and Focus Group Discussions (FGDs)) for data collection.
Table 3.1: ASNI methodological tool box: strengths and weaknesses
Criteria/ Method Survey Qualitative studies/Rapid appraisal
Ethnographic studies/ participant observation
Scale of applicability High Medium Low Representativeness High Medium Low Ability of isolate and measure non-intervention causes of change
High Low Low
Ability to capture qualitative information on maternal-child health
Low Medium High
Ability to capture non-causal processes of utilization and vulnerability
Low Medium High
Ability to elicit views of women Low Medium High Ability to capture unexpected impacts
Low High Very high
Time scale High Medium Very high Human resource requirement Large with special
supervision Skilled practitioners Long-time
commitment, good supervision
Study Timeline: The study began in December 2009 with the literature review. This was followed by
development of the qualitative data collection tools. The qualitative data collection was done from
March to May 2010, and the report writing was completed between June and September 2010.
19
Subsequently for the community survey in Phase II of the study, the questionnaire development,
selection of survey agency and formalization of data collection plan spanned from November 2010 to
March 2011. The field data collection was conducted between March and May 2011, followed by data
analysis from May to August 2011.
The study obtained ethical clearance from PHFI’s institutional ethics committee. Informed consents
were obtained from study participants and to ensure confidentially during data collection identification
of respondents were not recorded. The access to data was limited to the study team.
Qualitative research design (Phase I):
In-depth interviews with various health care providers and health administrators helped collect
information regarding the additional benefits of NIPI interventions. In addition, they also focused on
identifying road blocks and issues related to the successful implementation of the NIPI program.
Interviews and group discussions with mothers were also conducted to understand the community level
perspective. A total of 100 IDIs, 20 FGDs, and 26 days of observation were undertaken. Additionally, 532
structured interviews were conducted among mothers, Yashodas and ASHAs. (See Annexure 2)
An observation study of the hospital wards focused on documenting the tasks done by Yashodas and
other staff at the DH during the pre-delivery, delivery and post-delivery periods. Facility surveys among
mothers focused on their delivery experiences at the facility. The surveys done among Yashodas and
ASHAs collected information related to their knowledge, training, and tasks performed by them.
Ethnographic studies: The ethnographic team embarked on their fieldwork in January 2010 and lived in
two communities in the following 6 months. Unrecognized in most health research that is designated
qualitative but which relies mainly on interview based methods, is the difference between what people
do say and what people do. This method of participation and observation helped distinguish between
normative statements (what people say should be the case) and actual practices (what really happens).
It follows from the mandate of an ethnographer to see the object of study from as many angles as
possible and a presupposition and experience within the discipline that all people, things, ideas or
events (i.e. all “social facts”) are socially and culturally situated and contingent28. This is an empirical
based grasp of the context specific nature of the NIPI intervention. In documenting complex details of
everyday life an important corrective can be made to misleading generalizations and abstractions.
Therefore, this report also emphasizes the importance of cultural and social specific description of some
detail for the NIPI interventions. Ethnographies achieve generalizability through logical rather than
statistical inferences and seek statistical inferences by feeding issues raised through qualitative and
ethnographic data into a larger survey.
Fund flow analyses: A fund flow analysis was undertaken in one NIPI intervention district each from
Rajasthan and Orissa. It focused on:
Analyzing the fund flow system from center to state and district level
20
Understanding the utilization and absorptive capacity of state and districts to utilize the fund,
through some basic financial performance indicators
Identifying bottlenecks in the financial management of NIPI.
Quantitative research design (Phase II)
For the community survey, study participants were defined as ‘Mothers who have delivered in the last
two months preceding the survey and who reside in a community where ASHA is present and active.’ To
estimate the sample size required for this group, indicators with the least differences expected in the
intervention and the control districts was used. The sample size calculated using this method would
ensure that the differences for all other variables are adequately captured between the intervention
and the control areas.
To calculate the required sample size for the community survey, initiation of breastfeeding within one
hour (IBF1), immunization, receipt of postnatal care within 48 hours and similar newborn care indicators
were considered. The prevalence of these indicators was based on data from DLHS III (2007-08).
Assuming a prevalence rate of 60 percent for IBF1, to demonstrate at least a 25 percent difference
between the intervention and control groups (with 80 percent power and α=0.05); the minimum
sample was estimated to be 216 mothers. A design effect of two was assumed, increasing the sample
size to 432 each in the intervention and control districts of Orissa and Rajasthan, generating a total
sample size of 1728. To ensure a fair distribution of the study sample across facilities and home and to
be able to capture the benefits of the Yashoda program that is most functional at the DH level, the
following distribution of the sample was envisaged:
1. DH: 50 percent
2. CHC: 30 percent
3. Home based and others: 20 percent
The procedure followed for listing and identification of respondents is explained in Annexure 3.
In the second phase, against an estimated sample of 1728, the survey included a total of 1698 mothers;
46 responses were found to be invalid and excluded yielding a total of 1652 valid responses of women
who had delivered in the two months preceding the survey across the four study districts (Table 3.2).
The sample size in Rajasthan was larger because of the requirement to cover the requisite number of
deliveries in CHCs where Yashoda was placed. This was not required in Orissa, where no Yashodas were
available at the CHC level.
Table 3.2: Sample size of community survey
State District Number of respondents (Mothers who delivered in last 2
months preceding the survey, valid responses)
Rajasthan Alwar 451
Sawai Madhopur 489
Orissa Anugul 359
Bargarh 353
Total 1652
21
A detailed questionnaire was developed for the community survey, divided into thematic sections. The
primary indicators for which data was collected for the Yashoda program included initiation of
breastfeeding within one to five hours after delivery, weighing of the baby, immunization (Polio + BCG),
counseling on exclusive breast feeding, family planning, nutrition, danger signs, cleanliness and length of
stay at the facility after delivery. Primary indicators for the HBNC program included five PNC home visits
by ASHAs, counseling during home visits on various important newborn care issues and referrals of
mother and child.
Explanatory variables included in the questionnaire were indicators of demographic and socio- economic
status and maternal and child outcomes. Details of pregnancy history and birth experience were also
collected, including antenatal, intra-natal and postnatal care, quality of care (cleanliness, availability of
toilet & drinking water), trust and emotional support, cost of care and awareness and receipt of Janani
Suraksha Yojana (JSY).
3.2 Data collection and analysis
Phase I
The study team visited the NIPI intervention districts between March and May 2010 in Orissa and
Rajasthan to conduct the qualitative research. They met key district staff including the Yashoda
Coordinator, District and Block Maternal and Child Health (MCH) Officer, District Accounts Manager
responsible for NIPI fund management, State Program Manager (NIPI) and Finance and Accounts
Controller of NRHM. To get an understanding of the financial management systems in place, IDIs with the
block MCH Coordinators and Block Program Managers responsible for NIPI financial management were
conducted in five blocks each from Alwar and Anugul. The topics covered included frequency of fund
transfer, delays in fund transfer, fund utilization, adequacy of financial guidelines, and NIPI review process
at block and district level. Apart from IDIs with the key staff, the team reviewed financial documents to
analyze approved budget, released fund, utilized fund, and performance of the district in utilization of
funds.
To assess the techno managerial support provided by NIPI to NRHM, IDIs were conducted to understand
issues of recruitment, roles, value addition and convergence/integration with NRHM. Interviews were
conducted with NIPI staff at the center, state and district levels and NRHM staff. In addition to the
interviews documents on recruitment processes, job descriptions of NIPI staff at various levels were also
studied.
The data was collected by investigators from the State Institute of Health and Family Welfare (SIHFW),
Orissa, Department of Anthropology, University of Rajasthan and the PHFI team. IDIs and FGDs with the
health care providers especially those at the nurse level and below were conducted in native languages
(Hindi and Oriya). Some of the interviews with medical doctors and administrators were in English. All
those in the native languages were translated into English and then transcribed and coded manually.
Broad thematic analysis of IDIs, FGDs, and the observation studies were done. The themes were initially
22
analyzed in the form of role-ordered matrices, based on qualitative frameworks suggested by Miles and
Huberman.29 Quantitative data from the facility and provider surveys were analyzed using SPSS.
The ethnography study was conducted in two communities in Alwar. The two communities were similar
in that the majority of the population was living below the poverty line and had similar access to health
care services. They differed clearly however in utilization of services. Community 1 was referred to as
“well performing” with a “well performing” ASHA in its midst. Community 2 was, on the other hand
referred to as a” low performing” regards uptake of governmental services. The ethnographic method
implied long-term fieldwork in the two communities (6 months in each community). The fieldworkers
lived, observed, and participated in community life. They participated in numerous childbirths at
facilities and at home. They accompanied ASHA and Yashoda in their daily tasks as well as accompanied
mothers to the facilities. In addition to observational and participatory data, fieldworkers conducted in-
depth interviews with mothers, family members and health workers, held focus group discussions and
examined documents and records. The study design covers the entire referral system as an
ethnographic site with a clear demand side approach.
Phase II
The community survey of recently delivered women was conducted during March-May 2011. A
professional survey agency was identified and contracted for data collection, entry and tabulation. It
was ensured that all investigators and majority of supervisors were women. ASNI team members
prepared the questionnaire and participated in the training of investigators on administering the
questionnaire and monitoring of field data collection. Spot checks of forms on many of the important
questions were carried out to check accuracy of data collection. The team also conducted checks for
data quality on a regular basis for about five percent of the sample answered questionnaires every two
to three days.
Final analysis of the data and report writing was also carried out by ASNI team members. A senior
national level expert on biostatistics was consulted in finalizing the questionnaire and designing the
analysis plan. Data consistency and accuracy was checked through range checks and conditional checks.
For all important indicators frequencies were checked to ensure data consistency. Univariate analyses
was followed by binary logistic regression to check for the effect of Yashodas and NIPI trained ASHAs on
maternal and newborn indicators controlled for possible confounding factors of age, education, income
and type of deliveries, and number of ANC visits. To analyze the specific effect on mothers who had
cesarean sections, only nonparametric tests were used, odds ratios were not calculated as the sample
sizes of these mothers were less than fifty.
To analyze across income groups, the respondents were divided into quartiles based on monthly
incomes and using monthly expenditure data-- quartile one referring to the poorest and four to the least
poor groups in this sample. This classification was used for further analyses of various indicators across
socioeconomic groups. The survey collected information on both medical cost (fees, drugs, supplies,
laboratory diagnostics, total costs) as well as non-medical costs (transportation, stay, food, and informal
payments) related to ANC, delivery and PNC in the intervention and the control districts. The cost
23
information for ANC, delivery and informal payments in facilities were restricted to those mothers who
had delivered at public facilities and cost data for PNC and referral included all mothers in the sample.
Median expenditures along with 25th and 75th percentiles were calculated.
To further understand the incremental and total value of a dual exposure to Yashodas and ASHAs
compared to just NIPI trained ASHAs and the control group, key counseling and practice indicators were
analyzed across three sub-groups of the sample – women who had exposure to both Yashodas and
HBNC (mothers who delivered at DH and CHC in Alwar and DH in Anugul); women who had exposure to
only HBNC (mothers who delivered at home/facilities other than DH/CHCs in Alwar and at
home/facilities other than DH in Anugul) and women with no exposure to the NIPI program (control
districts). The study was, however, not designed to show significant differences between the two groups
(Yashoda + ASHA vs. ASHAs), but only to compare differences between a NIPI intervention and non-
intervention district. To understand the effect of gender on newborn care, four key indicators – length
of stay in facility, initiation of breast feeding, immunization at the facility and referral were analyzed by
sex of the newborn.
For both phases, data on the Yashoda component was collected from both DH and CHCs in Alwar where
the Yashoda program was functional. In Anugul data was collected only from the DH level as the
Yashoda program was not functional at the CHC level. In Sawai Madhopur, women delivering in DH were
not included as Yashodas were introduced there in June 2010; instead data was collected from Sub
District Hospitals (SDH) where Yashodas were not placed.
3.3 Limitations
The following limitations can be identified for the study methodology and field data collection:
Implementation research design does not enable collection of baseline information on the selected
indicators. This affects the selection of a true control sample and thus potentially results in biased
findings. However, this was partially addressed through the use of DLHS data to compare maternal
and newborn care indicators across all districts of the study states and selecting a control that most
matched the intervention district.
Final sample size was slightly less than the estimated required sample size for the study. The analysis
on mothers who had a cesarean section delivery was limited due to small sample size as
unexpectedly, the number of C-section were not very high at district hospitals. Thus benefits of
Yashodas for this subgroup could not be analyzed completely.
There is a possibility of recall bias among women regarding Yashodas, as many times they were not
able to differentiate the Yashoda from the staff nurses.
In Alwar district, the sample was largely from urban areas as the DH in Alwar served the large urban
as well as rural population surrounding it. Exposure and awareness levels of women in urban areas
are quite different from women in rural areas, and could thereby affect their responses.
Certain sections of the questionnaire, such as relating to sexual intercourse or family planning, could
not be spot-checked by male supervisors as respondents were not comfortable answering such
questions in their presence.
24
4. UNDERSTANDING DEMAND FOR HEALTH SERVICES
The term “demand side” appears with increased frequency in pro-poor health planning and policy. The
drivers behind this interest are located both in the economic and institutional crisis of the national
health sectors. The health sector has seen an increased marketization and provider pluralism. Many
countries have experienced a collapse of public sector services alongside a limited success of supply side
demanding health sector reforms to improve health service delivery. The renewed focus on maternal
and child health mortality and morbidity enforced by the MDG 4 & 5 has highlighted the lack of demand
for governmental services. These poverty reduction strategies and related aid instruments have led to
renewed focus on the “voices of the poor” and a greater understanding of the powerlessness of the
poor in relation to responsiveness of service delivery. Poor people tend to underutilize health services.
The determinants of this are complex and encompass not only cost factors but also indifferent
treatment, rude behavior from providers, gender barriers within household and a host of other cultural
and social constrains. The prominence of unorganized markets in health care and the associated
provider pluralism pose major challenges to the reform of health systems. Individuals and household
face an unregulated environment in which the boundaries between public and private become
increasingly blurred. They also face this market from a position of information inequality.
The recent slogans of public health reform availability, quality and access rests on a substantial body of
research showing that supply side factors such as cost of care substantially reduce the health care
utilization by the poor. Demand for care rises significantly with increasing proportion of qualified
medical staff. In addition, the probability of seeking care from any formal provider decreases with the
increase in distance to that provider. Yet ensuring demand is not only a matter of adequate supply side.
An intriguing and very important social phenomenon is women, men and families acceptances of
governmental facilities as the best and safest place to give birth. Within a field of medical pluralism they
need also to accept bio-medicine as the best way to ensure their and their children’s health. Social
scientist has understandably emphasized the social and cultural factors that could explain low
utilization. Now with introduction of JSY and consequently a tremendous increase in facility based birth,
important questions remain to be answered: how and why does acceptance and demand for skilled and
facility based births become a prevailing social condition? How flexible is the demand if the service is
not up to standard, if services deteriorate or if incentives are withdrawn? When and why do some
sections of the community still not utilize government health services?
In this chapter we investigate acceptance of governmental facilities and we discuss variations across
contexts. We explore the meanings health workers and families attach to acceptance and refusals of
governmental services. We need to understand demand in its local situated context. Below we discuss
how social inequalities, such as gender, caste and class shapes people’s experiences of the health
services offered them. Instead of focusing upon characteristics of individuals as being educated,
knowledgeable and modern, to give a few examples of labels frequently used in explaining demand and
health seeking behavior, we highlight a relational and contextualized approach to demand. We close
this chapter by discussing briefly the community foundation for lay-health worker programme like the
25
Yashoda and the ASHA and let this serve as a background for our assessment of the NIPI interventions to
be discussed in the following chapters.
Acceptance for facility based births in contexts
The female disadvantage in less-developed countries with regard to health and well-being has been
documented abundantly30. The health status of both women and children, particularly female children,
suffers in relation to that of males in areas where system of kinship and authority limit women’s
autonomy. Research that explores the relationship between women’s autonomy and health outcomes
shows that women’s status is a general term with many connotations; its definition necessarily changes
from one setting to another. Second, some aspects of women’s status are far more significant than
others with regard to specific outcomes.
Decision making processes and gender empowerment - who decides?
Women’s life in rural north India is rooted in the domestic sphere and family and kinship are key factors
defining the parameters of their experiences. Maternal and child health nests within families and
households. For rural women perspectives on the state, governmental institutions and public health
interventions are first and foremost shaped in the “local moral world” that has daily bearing on women
through their household and farm work and through their own child bearing histories and the stories of
their neighbors and kin31,32.
Women’s utilization of services are heavily dependent upon women’s roles, rights and responsibilities as
defined by household structure and their relationship to in-laws and natal kin. The organization of the
kinship structure around property, ownership and rights ultimately marginalizes daughters in north
Indian societies. In this part of India the kinship system is patrilineal and with few exceptions patrilocal.
A daughter marries and moves in with her husband’s family. She earns her rights in this household by
giving birth to a son that will maintain the family lineage. The flow of resources is also unidirectional,
from the wife’s father to the husband. Anthropologists have observed, however, that the frequency of
contact with natal kin after marriage is a powerful mediator after marriage. Women with close ties to
their parents and brothers have greater ability to realize their needs and desires. After marriage natal
kin provides both material and emotional support to their daughters. Our observations also shows that
women prefer to give birth to their first child in their natal home. Among Hindus the transformation
from daughter to bride is particularly intense since she is arrives as a stranger to her groom’s family. A
Muslim daughter is usually married closer to home and to a family that has known her for years. The
ability to keep up a relation to natal kin thus heavily affects married women’s autonomy and hence also
their ability to utilize the services they feel they need or want.
Whereas women can express a longing for good and safe delivery care she is not the one to decide
where the delivery is to take place. In most cases these are decisions made by the mother-in-law. The
mother-in-law is very often also the one who accompanies the daughter-i- law to the facility or even
may deliver the baby at home. With introduction of the JSY scheme birthing mothers express that they
are brought to the facility because of the money. In theory the JSY incentive should cover the actual
26
cost. In practice, there are ongoing maximizing strategies so that the incentive also should provide some
fresh household cash. There are several strategies to achieve an extra income however meager.
Mothers-in-law bargain with ASHAs and facility personnel (both eager to achieve their targets) on
showing home deliveries as institutional deliveries in the records, or even manipulating the number of
home deliveries. This reflects there is an active demand for the JSY incentive, but not necessarily for
giving birth at the facility. If women themselves had the choice, what would their choice be and why?
Contrasting homebirths and facility births
Pregnancy and childbirth are universally associated with
culturally based ceremonies and rituals33,34. All cultures have
beliefs about appropriate behavior during pregnancy, labor
and the postpartum period. Culturally described rules
concerning foods to eat, activity to avoid and care and
behavior during delivery and the postpartum period guides
choices and behaviors. The cultural contexts in which
childbirth occur provides the norms that influences
attitudes, values and interpretations of personal and
interpersonal experiences of birthing as well as mothering
behavior.
It is a common understanding in the communities studied
that childbearing, birth and post partum work are “natural”
social processes that does not need the interference from
medical doctors and skilled personnel. The demand for
facility births and the interference of skilled personnel is only voiced in cases where something appears
to go wrong. When mother and child is at risk there is indeed an active social demand.
Safety and familiarity of the home environment are important factors in women’s decision to have
home births. The work of bringing a child into the world is delineated between those who assist in
deliveries and those who perform the healing, cleansing and symbolically critically tasks during the most
vulnerable post-partum period when, mother and child is spatially located outside of their normal social
webs. The latter work is often done by Dalit and falls into the scope of Jajmani, (social and economic
arrangements between families of different castes within the community) while labor and delivery are
most often handled by family members. Birth specialist does not do post partum tasks. The delineation
of post-partum work involves the social ordering of polluting bodily substances. On the one hand this is
a stigmatized form of labor, on the other hand it involves tasks aimed at recovery and healing as well as
a range of symbolically vital transitions. The Dai accompanies mother and child through a phase of
vulnerability and seclusion. It is said that a new born baby has no Jati, i.e. no structure of belonging
and identity. In this post partum process healing parallels the re- integration of mother and child.
While all these acts can be understood through the idiom “pollution taboos” to think about the post
partum period solely in these terms would undermine its symbolic, physical and social value. Women
prefer to utilize the services of the Dai not only to keep childbirth in their local environment, but also
“I feel too shy to go the hospital,
so I had my baby her at home”.
“In my village all the deliveries of
children are at home, it is best to
stay home with your family, they
can help you.”
I preferred to stay at home.
Everyone in the village calls the
dai for delivery.”
27
because important rites of cleansing, protection
and social integration are well taken care of. This
is one of the main reasons for why women giving
birth at the facility want to return home as soon as
possible after delivery.
The delivery of a child in a formal medical
institution involves the movement of the birthing
mother to an unfamiliar environment, where
strangers attend the woman in the absence of the
physical, symbolic and social necessities the family
and the Dai offers. In governmental facilities
women express that they feel vulnerable and
exposed. They are not only exposed to male
doctors, nurses, sweepers and ward boys, but also
to nazar (evil eye). New born babies are
particularly vulnerable to nazar. Governmental
institutions are thus thought of as dangerous and
potentially harmful to mother and child.
Governmental facilities are furthermore judged
intolerant to the important cultural and ritual
practices surrounding childbirth. These practices
are crucial as they are seen to protect both mother
and child during the vulnerable stages of birth and
post partum period.
Apart from being ignorant or intolerant of cultural
and social needs and necessities, health facilities
and their personnel are referred to as negligent in
their services when they really need them as well
as rude in attending to birthing women and the
family members accompanying them. Women are
seriously afraid of being subjected to forced
sterilizations as well as being told of and blamed
for stupidity and negligence in full public. Women
have minimal positive expectations of being
treated well at health facilities. Numerous stories
circulate in local communities about mistreatment,
negligence and rude behavior and reinforce the
relation of mistrust existing between
governmental facilities and community members.
A pregnant woman came in to the CHC early in
the morning. She was accompanied by her
ASHA, her mother in law and her husband. She
was wailing in pain. The Nurse on duty checked
her and observed that the umbilical cord had
come out The patient had been told that she
might need to go to the District Hospital due to
possible complications. In the afternoon they
were still waiting and they had not received any
further attention by the medical staff present.
The fieldworker suggested to the ASHA that
they needed to go to the district hospital
immediately. The ASHA explained that the
family was too poor, and that it would be too
costly. What about their PBL card probed the
fieldworker, and told them about the free
ambulance and hospital-medicines that should
be provided to the holder of such cards. On this
information they decided to go but suggested
that they should speak to lady doctor at the
CHC firs. The lady doctor was no were to be
found in the hospital so the ASHA and the
labouring woman went to her home. There
when on the front steps the delivery started.
Nurse and staff were called with equipment and
the delivery was performed there on the porch,
in full view for everyone to see, neighbors as
well as children. The child, a full grown good
looking boy, was stillborn. The medical staff
gave him s injections but with no success. The
boy-child was declared stillborn and handed
over to the father, who carried him around,
crying loudly. The mother was not told that the
child was stillborn. The staff explained that she
would not heal if she were to be told now. Later
in the evening the father passed the stillborn
baby on to some friends or relatives so that they
could bury him somewhere outside the fields in
order that its inauspiciousness would not be
disturbing to life.
28
Shared histories and shares notions
Shared notions emerge when relatives and neighbors exchange accounts of their birthing experiences.
Bad treatment by health workers; a doctor that did not appear when needed, or asked for bribes in
order to attend to them; painful birthing process and stillbirths are stories that travel and stories that
have impact on utilization over a long period of time. The population campaign in the 1970 is still
hampering the Indian health system. There are number of stories about intimidation and coercions that
raises serious human rights issues. Memories of these rigorous procedures have become part of
community understanding of governmental facilities. Sadly, these memories are very much kept real
and alive with present day behaviors. Importantly here is that the ANM and the ASHA are involved in
both curative and preventive care with the most aggressive targets set on family planning. Observational
data and stories told give evidence to a prevailing practice of misinformation, and brute force in order
for health personnel to meet the targets set. When people actively express distrust to the health
system, this is not only because of history it is also because of present day practice.
Issues of social inequality and relation to the nation state
Acceptance and demand behavior needs to be understood in their local situational context. The
ethnographic study in our two different villages shows how inequality in the form of caste and class may
interfere with utilization and demand. Social inequality may coerce people to adhere to rules. Like the
young mothers referred to above that are taken to facility births because of the JSY Incentive. They
easily conform because they are not the ones who set the rules. The ASHA of the well performing village
was chosen from one of the elite families in the community. At community level then the local
governmental structure could operate through the village elite in mobilizing villagers for health
activities. In this she had success. The downside of her elite position was that she refused to enter the
households of the scheduled caste to perform her duties. There was a lot of resentment in these
households about this but they felt unable to protest as the ASHA was an upper caste person with
influential family and in this they were not the ones who complained and set the rules. An interesting
feature with Community 1 was that the Brahmin caste dominated it, with only 10 households belonging
to a scheduled caste Meena and 3 Saini households. Yet both Scheduled castes and the Brahmin
referred to themselves as modern by the fact that they appreciated and utilized governmental services
of immunization and facility based births. For the scheduled castes there was indeed an active demand,
but due to local system of inequalities they had limited access.
In village 2, referred to as low performing community with regards to uptake of governmental services,
this situation was different. Village 2 is a “hard to reach community” in terms of conceptualizations, not
geographical distance. The village had a population of 1553 people predominantly Muslims (Meo) and
Hindu low caste. Several of the elder Meo in the village had parents or family who fled to Pakistan
during the partition. The distrust towards governmental facilities was far more pronounced in
Community 2 than in Community 1. Although here too the JSY scheme had its followers, this was a
community were home births was clearly voiced as preferred. The pronounced mistrust uttered by this
community brings yet another perspective to what influences demand. Public health programs, such as
the JSY can be defined as regulation, surveillance and control of bodies by the state. For communities
29
public health interventions can therefore also have profound political meaning. It can be understood as
the human and benevolent intentions by the state towards its subject. But it can also be seen as a tool
for control and surveillance and hence met with fierce resistance, refusal and mistrust. At a micro level
then refusal of a governmental health program can be an occasion to express political or religious
differences.
Acceptance, social demand and trust
In this chapter we have brought attention to the part of the ASNI project that attempts at understanding
demand. We have argued that demand needs to be understood in its local situational context. We have
focused upon how the complexities of social relations affect demand. There is not one single definition
of what fosters demand. Demand is socially situated and contingent. We have pointed to how the
interactions of various dimensions of social inequalities, such as gender caste, class shapes peoples
experiences of the health services offered them. Instead of focusing upon characteristics of individuals
as being educated, knowledgeable and modern, to give a few examples of labels frequently used in
explaining demand and health seeking behavior, we have highlighted a relational and contextualized
approach to demand and traced the consequences of caste, class and gender for lived experience.
In the field of service provision and utilization, we need to be aware of the seemingly unrelated factors
that can influence a person's life experience and response to services. For instance, national health
policies urging all women or even paying poor women to give birth in governmental facilities does not
take into account how the extraordinary coerciveness of India’s family planning programs targeting the
poor segments of the population has fostered deep mistrust to the public health system. Neither
does it capture the fine distinctions between active demand and acceptance. Passive acceptance
denotes compliance by a public that yields to recommendations and social pressure by community
leaders and health workers. The young wife accepting the rule of the mother in law is an act of passive
compliance. A community referring to themselves as modern by choosing facility births, likewise.
Neither does it take into full account how marginal conducting life below the poverty line can be. There
is indeed a demand for the JSY incentive. But it is not necessarily an active social demand that entails
adherence to governmental health programs by an informed public that perceives the benefits of and
the need for safe facility births with skilled attendance.
We have argued that trust is fostered at the point of service. Attitudes of personnel and quality of
services offered are of crucial importance. The key positions in the health system are thus the
“frontliners”: those dealing directly with the birthing mothers. The role of this new cadre--the Yashoda
at the facility and the ASHA doing the community HBNC program - in fostering trust to the public health
system and raising an active demand is important. We close this chapter with some reflections on the
role of lay health workers as change agents and as builders of trust.
30
Lay-health workers: change agents and a builder of trust?
Interventions aimed at modifying individual, household and community behaviors have been a salient
factor in public health interventions. In the literature of medical anthropology there has been a
counterview that health beliefs and practices have their own integrity and should be understood in their
own right. The truth and falsity of this is beside the point as traditional birthing practices, as illustrated
above, fulfill other potential health promoting as well as sociological, psychological and emotional
needs. JSY is a demand side financing (DSF) scheme transferring purchasing power to particular defined
target groups. It is an attempt to change demand side behaviors by removing costs by giving purchasing
power to the targeted populations. International experience suggests that these schemes have been
most successful in increasing coverage to poorer and vulnerable groups. However, demand side
financing have been less successful in raising the quality of service provision. Schemes work best in
relation to easy defined targets and where the service offered are standard and predictable. Enson 2004
therefore suggests that demand side financing schemes are not a quick fix in an institutional sense.
Most of the detailed examples we have of these financing schemes comes from developed countries
were institutional and informational requirements are already met. This includes population
registration, functioning bureaucracies, strong regulatory frameworks and robust mechanisms for
accountability. Neither of these are recognizable traits of the Indian health system. In contexts where
these are lacking, the political bureaucratic, regulatory and accountability deficits that undermine the
supply side interventions will affect the demand side interventions as well.
In the paragraphs above, we discussed how demand and lack thereof is not a matter of knowledge and
education. We have shown how, bio-medicine beckons with promises of health also for poor women, at
the same time as institutions repel with a range of threats. The choice of seeking care is thus taken
within a delicate balance of longing and mistrust. It is within this complexity that the lay health-workers
as the Yashoda and the ASHA are set to develop and navigate their roles and responsibilities.
The lay worker denominated Yashoda1 is meant to be the caregiver to the mother and respective
newborn at the facility. The Yashoda is conceptualised to be the mothers’ friend at the health
institution, to give comfort, maintain hygiene in the mother’s surroundings, to explain and assist the
mother with basic newborn care, to motivate the mother to early and exclusive breastfeeding and to
encourage the mothers to stay in the facility 24-48h after delivery. The ASHA is a community health
mobilizer situated in the communities in order to mobilize for health and healthcare choices. The ASHA
is responsible for bringing the mother to the facility, the Yashoda is responsible for making her stay
comfortable at the same time as she initiate good child health care. The ASHA under NIPI program is
responsible for the 5 HBNC visits (after delivery) to the mother and newborn in community. NIPI
intervention thus attempts to assure mother and child care within the frame of continuum of care.
Placing the Yashodas in the maternity ward as a mother’s aide and as a support worker for improving
quality of care, addresses some of the gaps that surfaced with the implementation of JSY scheme. A
UNFPA assessment in selected Indian states raised several issues about the benefits of JSY for women
1 Named in respect of the foster-mother to Krishna in Hindu mythology
31
and newborns. In order that JSY should contribute to lower maternal and newborn deaths, increasing
the number of facility-based births was not enough. “Reduction in maternal morbidity will be achieved
when women coming to the facility receive quality delivery and post partum care services” the UNFPA
report concluded35. The quality of care at the facility, the services available there, the safety of mother
and child in the facility and lastly the availability of counseling for newborn care; breastfeeding,
immunization, and diarrhea management, needed also to be addressed and improved35. NIPI designed
the Yashoda intervention in order that
these gaps could be addressed.
Nevertheless the human rights
organizations in India argue that to
persuade women to give birth at facilities
with such a poor quality of care is indeed
a human rights violation.
A study by Singh and Gupta (2004)
addressing quality of care and utilization
of health services in Rajasthan public
facilities, paints a rather bleak picture.
They conclude bluntly that the public
services are abysmal, unregulated and
underutilized. Unqualified private
providers provided in fact the bulk of
healthcare in the area studied.
Interestingly they argue also that
although the quality is appalling, villagers
seems content with what they are
getting, perhaps the authors suggest,
because they have come to expect very
little. There is thus a challenge to build
trust in public facility as well as
strengthen the voice of the poor to
demand good quality of services. A well
trained lay health-worker could if trained
accordingly play a role in giving voice to
the demand for better quality of care.
Decisions women make with respect to
maternity and where to give birth are
neither governed by a purely religious
tradition nor the result of free choice
from a range of traditional and modern
At the maternity ward, a puerperal mother and her
mother-in-law were crying. Family members and
other patients were gathering around them. The
Yashoda intruded gently, and asked the mother if
everything was all right with the child and if she
had breastfed. But the mother was all in tears and
did not respond. The mother-in-law explained that
she had not given breast milk yet, as she was still
tired and crying. The mother had given birth to a
girl. It was her third daughter. They were both very
disappointed. She was also scared of the reaction
of her husband, explained the mother-in-law. The
new mother’s mother stood by the side of her
daughter, listening and nodding. The mother
herself was not paying much attention.
The Yashoda smiled and shook her head, asking
why they were so sad. She told them, to look at
herself and at the female visiting researcher – how
they as women were free to move around, work
and contribute to the society. Patients and their
family members on the other beds gathered to
listen. The mother also turned her head and
listened. The Yashoda continued, and told them
that she herself only had one sister, and that the
two sisters took care of their parents, maybe better
than any sons would have done. She said that girls
take better care of parents than boys, since girls
are more compassionate. At this, other people in
the room agreed, and told the mother not to cry;
others told stories of successful women, and said
that these days, girls can have good educations
and do better than boys.
32
private and public options. The family decisions whether or not seek medical care during pregnancy
and birth are based on a finely tuned appreciation of the ways in which class and case power shape
their experience of medical institutions. Whatever the social class or caste of staff they are not likely to
identify with poor women giving birth. The withering scorn of hospital staff towards birthing women are
frequent observations. The lack of cleanliness in the hospital is explained as due to the lack of
cleanliness of patients. Anguish for women were also the harsh attitudes towards pain-- “why are you
making such big noise now, shut your mouth”. Within the tradition pain incurred in pregnancy and birth
are seen as integral parts of woman- and motherhood. Expressed pain thus also understood as
opportunities for other women to give comfort and care. The village midwife or the dai see their task as
an extension of these virtues and stress that what they offer the birthing woman are the qualities of
patience and endurance. They contrast this with facility based births were hospital staff is seen as
impatient with the mothers. Impatience is also experienced when the baby is overdue, often explained
as resulting in a forced caesarian section or an episiotomy. Another issue to them is the lack of
protection and sheltering of her body and herself. The crowdedness and the degree of exposure of the
female body stand in sharp contrast to the seclusion and protection experienced at home.
To solidify the “friendship” between the mothers and Yashodas, a disposable birthing kit was designed.
The kit was intended to strengthen the bond between the Yashoda and the expectant-mother, and
support principles of cleanliness and hygiene inside maternities. The distribution of such Kits would
create a friendly atmosphere for the mothers to initiate and continue habits of good cleanliness. Such
contributions could help prevent infection and hypothermia of the newborn baby. The birthing kit
includes: a bed sheet for the mother, a flannel blanket for the baby, rubber/oil cloth for the baby, a
sterile baby sheet, cotton diapers, and a maternity pad for the mother & newborn baby. Additionally the
kit contains material for the health provider such as gloves, a cap, a plastic gown, a mask and an
umbilical clam
A well trained Yashoda can help fill the gap of care in institutional deliveries by on the one hand
placing emphasis on the emotional and comfort aspects in the delivery process inside busy maternity
services and slowly change clinical practice towards a more humanized and gender sensitive
approach. Her comforting role, her ability to shelter, protect and give voice to needs is of crucial
importance for her to fulfill community expectations of a mother’s aide.
One of the main challenges however in all lay-health worker programs is while lay-health workers are
set up as change-agents they are often experienced as being an extension of the formal health system.36
Community participation is crucial for the success for of lay-health worker programmes. Although
today’s discourse is more pragmatic and technical compared to the concern in the 1980, it is widely
acknowledged that the sustainability and impact of these programmes require ownership and active
participation of communities as a non negotiable pre condition.
33
To conclude
For the past 20 years lay health workers has been key players in primary health care models because of
their knowledge of the community and its socio-cultural belief system. A well trained lay health-worker
can serve as an important negotiator between traditional practises and facility-based care. She can
negotiate birthing practises, give comfort and care when the birth of a baby girl results in grief, as well
as gently support the change of traditional mother and child health care practises seen as harmful to
mother and child. Likewise she can help pinpoint community resources and practises beneficial to the
health of mother and child.
The ethnographic study highlights however that one of the most important roles of these new cadres is
to be enabled to slowly change the way in which people engage with the health system and perceive
their entitlements to health and health care. There is a clear demand for god quality services. The lay
health workers, the Yashoda and the ASHA, should adapt their role to this present community concern.
34
5. THE YASHODA PROGRAM
5.1 The Yashoda Program – Operational Aspects
Yashoda Profile
NIPI defines Yashodas as “volunteer support workers who are paid a performance-linked incentive,
working in shifts, placed at the DHs and some CHCs”. The objective of the program is to enhance a joint
ownership for care coordination at the facility with ‘Yashoda’ as part of the larger system, where the
pregnant women feels welcome as she enters the facility and leaves with her newborn baby with a
feeling of being cared for and looked after. The value addition that the Yashoda program brings is the
demand generation of services for care of the newborn and improved accountability at the facility level.
The profile of Yashodas at the two study districts matched NIPI guidelines. The study found that in Alwar
the median age of the Yashodas was 35 years with 52 percent of them in the age group of 35 to 40 yrs.
Initially NIPI had specified a minimum age of 25 years for Yashodas; however the acceptability of women
in this younger age group proved to be a hindrance in influencing mothers and their families.
Considering this, the minimum age limit was increased to 35 years. Forty three percent Yashodas in
Alwar were either separated, divorced or widowed. Fifty percent of them took up the position because
of necessity which is further supported by the fact that their earnings contribute to 71 percent of her
average family income. Thus, this engagement has provided the Yashoda’s financial stability especially
for those who did not have spouses to depend upon. Also, close to 60 percent of them expressed the
wish to continue their service as a Yashoda in the future.
The median age of Yashodas was 33 in Anugul DH. Although in Anugul 75 percent of the Yashodas were
currently married yet necessity (58 percent) was cited again as the prime reason for working. Here the
Yashoda’s income contributed to 33 percent of her average family income.
The study reported that at the CHC level in Alwar, 25 percent of the Yashodas were from scheduled
castes/tribes compared to eight percent at the DH. Most Yashodas lived close to the health facility. All
Yashodas in Anugul and 86 percent Yashodas in Alwar stayed less than five km from DH/CHC. As per the
recruitment guidelines the minimum qualification required was 8th grade for Yashodas. This was
maintained uniformly across the states. In both states at the DH level 17 percent of the Yashodas had a
bachelor’s degree compared to five percent at the CHC level in Alwar. Although the Yashoda recruitment
guidelines clearly mention that the Yashodas will be engaged as volunteer workers and are not entitled
to claim a regular position in the system, more than 40 percent of the Yashodas in DHs (46 percent in
Alwar DH and 42 percent in Anugul DH) had aspirations for full-time government posts. This aspiration
was reported majorly by the Yashodas who were graduates, 75 percent of the graduate Yashodas in
Alwar DH looked forward to permanent government positions. However, 85 percent Yashodas at CHC
level were happy to continue in their present positions for the next five years.
35
Table 5.1: Profile of Yashoda – Alwar and Anugul District
Indicators Alwar (Rajasthan) Anugul (Orissa)
DH (n=24) CHC (n= 20) DH (n=12)
Total number of Yashodas currently appointed 24 29 12
Median age-years 36 34 33
Marital status (percent)
Currently married 50 65 75
Widowed 33 35 0
Separated/divorced 17 0 25
Education level
(percent)
8th-12th pass 83 95 83
Graduate 17 5 17
Caste
(percent)
ST/SC 8 25 8
Others 92 75 92
Place of residence – Live less than 5 km from the health center (percent) 87 85 100
Reasons for being a
Yashoda (percent)
Desire to serve people 33 55 33
Necessity 67 30 58
other reasons 0 15 9
Aspirations of Yashoda
(percent)
Continue as a Yashoda 33 85 42
Get promotion 12 0 16
Get permanent government posting 46 15 42
Other reasons 9 0 0
Remuneration
In Rajasthan, payment to Yashodas depend on the number of deliveries in the hospital (an incentive of `
100 is paid per delivery conducted in the hospital; the total amount of remuneration given to the
Yashoda is calculated on the basis of total deliveries that happened within one month and divided
equally among the Yashodas.). In Orissa a fixed amount of ` 3000 /month was given to Yashodas. During
April-May 2010 (when the survey was being conducted), Yashodas in Alwar reported that they received
an average income of about ` 2000 per month. In the rainy season, when the number of deliveries
peaked, their income may increase up to ` 4000-- however, this was infrequent.
Yashodas in Alwar did not appreciate the linking of payments with the number of deliveries. “On one
side, you all say that we must advocate family planning, but our incentive is associated with number of
deliveries. How can we counsel mothers to control population?” (IDI, Yashoda, Alwar). Yashodas in
Orissa and Rajasthan would have liked to have some incentives attached to performance and not
necessarily to number of deliveries over which they do not have any direct control. The other concern
raised was regarding the delay in receipt of incentives – more than 90 percent of the Yashodas in the
Alwar DH and Anugul DH reported that their salary arrived between the 2nd and 4th week of the month.
36
Capacity building
The NIPI guideline has a holistic approach towards capacity building which is not only limited to training
but encompasses the following:
Training
Support systems and supervision
Simple formats and reports
Assessment and feedback processes
Clarity on the reporting and monitoring processes
Learning, sharing and career growth opportunities
Recognition and rewards
The training components includes induction training upon recruitment, continuous hands on training
and refresher training. Training activities varied across states – as of April 2010, 63 percent of the
Yashodas in Alwar district reported that they had attended two training sessions and 90 percent in
Anugul district had attended three training sessions. The trainings usually lasted two to three days.
A review of the training material and flip charts used by Yashodas in Rajasthan was done.
Booklet on role of Yashoda – This booklet is a simple and comprehensive manual to guide the Yashoda
on her role and functions in the facility. In the beginning, it explains to the Yashoda the rationale behind
her nomenclature and her expected role as ‘a sympathetic friend, assistant and counselor’ to women
coming to the facility for delivery. Her functions include ensuring a conducive/comfortable environment
before delivery, assisting in the labor room and counseling in the PNC ward. It also contains tips on
efficient utilization of work hours and effective teamwork with other staff members and fellow
Yashodas. While the format of the manual is simple, the language is technical in many places and may
not be easily understandable.
Flip charts for Yashoda to aid counseling of mothers and family members on postnatal & newborn care –
The flip chart is to be used while counseling mothers on postnatal and newborn care. This is well
illustrated, with effective guidance to enable Yashodas to use them as effective instruments in educating
the women. However, some illustrations contain English sub-heads, which need to be translated to
Hindi.
Important observations from the review are as follows:
Content: On the whole the manuals and flip chart for Yashodas are comprehensive and cover all
essential elements of birth preparation, postnatal care, newborn care including breastfeeding, care of
postnatal mothers, identification and care of high-risk newborns, and other relevant issues like
immunization and hygiene.
Format: Pictorial depictions have been extensively used in all material and are helpful in easy
comprehension. Explaining situations through simple stories is also helpful. However, at places the
language is complicated and not necessarily conversational. This may be difficult to comprehend for
women who are generally not educated above the eighth grade, that too in rural settings. Some
captions are in English and therefore not useful for Yashodas.
37
Branding / Identity: An attempt has been made to depict the Yashoda’s distinct identity in the
illustrations in all manuals and flip charts. Yashodas are shown with pink aprons and a tiny caption
‘Yashoda’ printed somewhere on the figure, which is often in English. The mode of identification needs
to be made starker and also the distinct roles of nurses and Yashodas need to be more clearly
illustrated, for the understanding of community members as well.
Role of Yashoda as ‘sympathetic friend’: Several aspects of the Yashoda’s role in comforting the mother
are illustrated in the manual, such as making her comfortable, assisting her with toilet/drinking water,
occasionally massaging her back, holding her hand and comforting her during delivery. However, at the
same time, she is expected to closely watch the nurses and learn from them the various clinical tasks
related to delivery care. This would naturally create an expectation among nurses and also a realization
among Yashodas that they need to assist nurses in their tasks. Eventually this could erode her role and
identity as a mother’s companion and assistant, and not a nurses’ aide.
It is important to suitably highlight her role as mother’s aide, possibly illustrating the importance of
emotional support in ensuring a satisfactory delivery experience and her crucial role in ensuring the
same. At the same time, less emphasis must be paid to the need for Yashoda to learn all clinical delivery-
related tasks from nurses and other hospital staff. This would help her and the staff to understand and
appreciate her role and create her unique identity in the facility.
The Yashodas found the training sessions helpful in defining their role clarity and dispensing their duties.
“After attending the trainings, we know what our exact work is. Why we are appointed as Yashoda.”
“We learned a lot about mother and child care”. “Through this training we got knowledge about family
planning, immunization, breast feeding, diet of the mother, how to receive a mother and child after
delivery, how to maintain hygiene within the hospital, what are the problems that a mother faces after
delivery etc.” (IDI, Yashoda, Alwar and Anugul).
However some Yashodas stated that many of them did not perceive themselves to be well-informed
enough to handle questions from the mother/family during counseling especially regarding
complications. “We want more information about mother and child’s complication. How do we know
immediately that the mother is having a complication?” (IDI, Yashoda, Anugul). Majority of the Yashodas
recommended refresher training to upgrade their skills. “If we have training every six months, it will be
good” (IDI, Yashoda, Alwar).
“In training we get to learn new things and clear our doubts. This training should happen more often”
(IDI, Yashoda, Anugul).
Some of the Yashodas, especially the more educated also suggested the need for more paramedical
training (nurse’s aide rather than mother’s aide).
38
Supervision and mentoring
As per NIPI guidelines overall supervision is provided by the ADMO /medical superintendent identified
by the CDMO/CMHO/PMO in the DHs as the case may be in each state. In the case of CHCs, the RCHO
could provide the overall leadership in managing the intervention. In the NIPI focus districts, the District
Child Health Managers/Maternal and Child Health Coordinators will assist the ADMO/Medical
Superintendent in discharging/coordinating all Yashoda related functions and day to day operations.
Yashodas are supervised and supported by the Child Health Supervisor (CHS) and two Deputy Child
Health Supervisors (DCHS) so that for each shift one supervisor is available. It has been suggested that
the DCHS should be from the nursing stream --- preferably a retired nurse/ANM/LHV because of their
understanding of the health system --- and can begin to support the Yashodas. The CHS on the other
hand requires more managerial skills and could be from a social sciences background.
It has been observed that the above cadres have been fulfilling their supervisory duties. The supervisors
also provide a strong support system for Yashodas within the hospital setup and ensure that Yashodas
are used for appropriate tasks. Some examples:
“The Yashoda Supervisor, after coming to Hospital, on duty, takes a round and marks attendance of the
Yashodas. She visits the labor room every half an hour and keeps a watch on the Yashoda” (Observation,
Alwar DH)
The supportive supervision role is also demonstrated effectively by the supervisors:
“Supervisor didi tells us how we can counsel the mother better and shows us by talking to the mothers”
(IDI, Yashoda, Anugul)
“The supervisor didi supervises our work personally. She interacts with mothers and asks them what
information they have received from the Yashoda. She suggests us in which way we can do our work
better.” (IDI, Yashoda, Alwar)
In Rajasthan, the supervisors were appointed after the Yashodas and hence their role in handholding
Yashodas seems to be limited. In Orissa, the supervisory cadre was appointed before the Yashodas and
hence played an important role in fitting Yashodas into the hospital environment. During the study
period there was no supervisory cadre present at CHCs in Rajasthan. This had some implications on the
discharge of duties by the Yashoda.
39
Table 5.2: Operational guidelines for Yashoda and their implementation in Rajasthan and Orissa (Data
in this table has been synthesized from NIPI process documents of both states and survey of Yashodas.)
Parameters NIPI guidelines Alwar (Rajasthan) Anugul (Orissa)
Place of work
and number of
Yashodas
Places where delivery load
is high. Adequate number of
Yashodas should be
recruited including reserves
to cover absence due to
leave and sickness.
DH and some CHCs which have high
delivery load. However some CHCs with
comparatively low delivery load also
have Yashodas.
Restricted to only DH and
not extended to the CHC
level.
Working hours 8 hourly shifts and their
leave is a local arrangement
8 hourly shifts -- leave sanctioned by
supervisor. Yashodas get a day off after
completing two shifts consecutively.
8 hourly shifts -- leave
sanctioned by supervisor.
Recruitment
process
As it locally suits, involve
some stakeholders from the
health system and some
district authorities
Under the direction of the DHS,
recruitment occurs under a committee
comprising of the CMHO, DPM,
representative of the DM, and Principal
Medical Officer (PMO).
Recruitment is a district-
based process, similar to
Rajasthan. However, here
the supervisory cadre for
Yashodas was recruited
first.
Orientation and
training
At least 2 days training, one
day for familiarizing
Yashodas with the hospital
environment and second
day focusing on counseling
Initial two days training given to all
Yashodas, about 70 percent of the
Yashodas reported to have attended
refresher training.
Initial three days of
training given to all
Yashodas. About 90
percent Yashodas reported
to have attended two
refreshers.
Supervision and
mentoring
Supervisory cadres to be
appointed, who will hand-
hold Yashodas in the
hospitals, mentor them and
ensure availability of
Yashodas at all times, etc.
In Rajasthan, the child health coordinator
and the deputy child health coordinator
fulfill this role.
On the job mentoring seems to be poor
and supervision is a monitoring rather
than a mentoring process.
In Orissa, there is a child
health supervisor. These
were recruited along with
Yashodas and the
mechanism seems to have
worked better
Payment system
Yashoda received
performance based
incentives.
In Rajasthan, an incentive of Rs. 100 in
paid to be paid to Yashodas per delivery
conducted in the hospital. There is no
fixed salary, total amount of
remuneration given to the Yashoda is
calculated on the basis of total deliveries
that happened within one month and
divided equally among the Yashodas.
A fixed salary of ` 3000 is
given per month
40
According to NIPI guidelines, monthly load of deliveries serve the basis for calculation of Yashoda
requirements. DHs and select CHCs with high delivery load were considered for implementation of the
Yashoda program. Yashodas are expected to attend to five to six mother-child dyads during any eight
hour shift. In Rajasthan, Yashodas have been placed at the DH (DH) and at some Community Health
Centers (CHC) with high delivery load. In Orissa, Yashodas are placed only at the DH. The study
observations however indicated that Yashodas placed at CHCs in Rajasthan were not being efficiently
utilized. This was especially true for facilities that reported less than four deliveries a day and had a full
time nurse available at the facility. In addition, the lack of supportive supervision for Yashodas at CHCs
contributed to the lack of clarity in their roles. Only four out of 11 CHCs in Alwar reported more than
five deliveries a day and one of them (Rajgarh) had two full time nurses and two Yashodas on duty. See
Annexure 4. Low delivery load and lack of supervision raise concerns regarding the performance of
Yashodas at the CHC level.
5.2 The Yashoda program – Health provider & community perspectives
Health provider’s perspective and interaction
The role of Yashodas as a mother’s aide seems to be generally well understood, however, there is a
thrust for the Yashodas to become a nurse’s aides rather than her envisaged role as a mother’s aide.
The Yashoda Operational Guide 2010 mentions “While the Yashoda fills a critical gap for counseling the
mother on newborn care and to coordinate services within the maternity ward, Yashoda is NOT a
substitute for nurses.”
From the point of view of the hospital staff, the most important role played by Yashodas is in reducing
the work burden of nurses (in caring for mothers):
“..After the coming of Yashodas at the hospital, we have got much help from them, because, now we do
not to worry about mothers as Yashodas take care of the mothers…” (IDI, Staff nurse, Alwar DH).
Observations recorded instances where Yashodas were being used for clinical support:
“The Yashoda told us that she is well acquainted with giving injections and drips. On asking her, “Do you
help nurse in all this?” She replied hesitatingly, “I help the nurse, and while helping, I gradually learnt all
this, with the help of the nurse”.
In general, the importance of the counseling and psychological support roles of Yashodas is not
completely acknowledged by other health staff, they see Yashoda or would like to see them as nurse’s
aides rather than a mother’s aide.
“Some Yashodas are not well-trained, they cannot give injection nor do dressing. Other than counseling
they should know some more things. Previously what the sisters were doing…it is no longer sufficient
now since the number of deliveries have increased. So someone should help them…” (IDI, Doctor,
Anugul).” Further, the Yashoda said that nurse asked her to learn all this…” (Observation, Alwar).
Doctors also felt that in an environment where clinical staff was not adequate, it would be very useful if
the Yashodas were trained to assist in simple para-clinical tasks. Many Yashodas also expressed a wish
to learn simple clinical skills. About the Yashodas, it has been said: “…skill upgrading is required
41
…training for dressing, change of saline, danger signals of pregnancy and PNC…other than counseling,
they should know about some more things” (IDI, Doctor, Anugul).
The contact between doctors and Yashodas is limited and in general, their relationship is cordial. The
most interesting relationship is the one between Yashodas and nurses. Before the arrival of Yashodas,
nurses were the main caretakers of hospital wards. Thus, while nurses recognized the advantages of
Yashodas, there was also an underlying tension between the two cadres in some places. The tension
seemed to have eased with time. “In the beginning, when Yashodas joined the hospital, hospital staff
troubled them a lot, but, at present there is better co-operation”, (FGD, Yashodas, Alwar).
“We do not have much interaction with the doctors and the nurses, because, they understand that we
are not permanent government staff and hence give us less importance.” “The behavior of the nurses has
improved, however the behavior of class IV employees is so-so – neither so good nor so bad.” (IDI,
Yashoda, Alwar)
“Overall the relation with nurses is good…they are cooperative, but at times they under estimate us. Staff
nurses feel they are more educated.” (IDI, Yashoda, Anugul)
The color of apron provided to Yashodas contributed to some of the tension—initially the aprons given
to Yashodas were white in color, which caused the community to mistake them for nurses. Later the
color of the apron for Yashodas had been changed to pink subsequently, which distinguishes them from
other health care providers in the facility. The appropriate branding and identity of Yashodas are
important; therefore a distinct uniform with specific office space and appropriate positioning within
health system is important.
The staff in the health facility generally regarded the non-clinical training of Yashodas as a limitation.
There is also concern that Yashodas affectionate behavior towards mothers is only “beginner’s
enthusiasm” and would not last over time.
Community perspective –Community survey
Demographic, socio-economic profile & pregnancy history
Demographic and socio-economic characteristics of the respondents provide useful insight into the
factors which influence population health, reproductive behaviors and some aspects of utilization of
health facilities. This section describes the household and respondent characteristics of the sample,
including background information on the current birth of the respondents (Table 5.3). As mentioned
earlier, the survey covered a total of 1652 women, 810 in intervention and 842 in control districts
respectively. Total respondents numbered 940 in Rajasthan and 712 in Orissa.
Demographic & social characteristics
Age structure: The age of the respondents ranged from 18 years to 40 years, with the median age being
23 years in Intervention group and 24 in Control group.
42
Education levels: Respondents on the whole had low levels of education. Thirty percent respondents
had no formal education while 42 percent had only basic education between first to eighth grades.
Women in Rajasthan had much lower levels of education, with 42 percent not having any formal
education and only 14 percent educated above basic level (ninth grade and above). Women in Orissa
had comparatively higher level of education, with about 40 percent women educated above basic level.
Women on the whole were slightly better educated in intervention areas as compared to control areas.
Religion and Caste status: Hinduism was the dominant religion among the respondents, which is
reflective of the religious composition of the overall population.
In terms of caste status, the vulnerable social categories of Other Backward Classes (45 percent),
Scheduled Castes and Scheduled Tribes (41 percent) together constituted about 85 percent of the
surveyed women. Proportions were similar in the intervention and control areas in both the states.
Marital status and age at marriage: Almost all women covered in the survey were currently married.
Women in Rajasthan had been married for 6 years on average while women in Orissa had been married
for 5 years. The prevailing system of marriage at very young age was evident from the age at marriage
data, with 53 percent respondents having been married below the age of 18 years.
Household size: The household size of the respondents varied from two to 17 members, with majority
(43 percent) ranging between five to seven members. The average size of a household was seven
members.
Below Poverty Line (BPL) status: Possession of a ‘Below Poverty Line’ card in poor households enables
them to access various social benefits and welfare entitlements. Among the respondents, one third had
a BPL card (although almost 41 percent were from SC/ST categories).
43
Table 5.3: Key indicators of socio-economic characteristics of respondents
Rajasthan Orissa
Intervention Control Intervention Control
Number of respondents 451 489 359 353
Median Age 22 24 23 24
Level of Education: ( percent women)
No formal education
1-8 grade
9-12 grade
More than 12 grade
29
47
17
8
54
33
11
3
12
47
38
3
16
44
33
7
Mean years of marriage 5 7 4 5
SLI Groups: ( percent women)
Low
Medium
High
8
23
69
21
43
36
30
28
42
36
32
32
Median monthly household income (`)
Median income across Income Quartile groups: (`)
First
Second
Third
Fourth
7,000
3,000
4,500
7,450
16,250
6,500
2,500
4,150
7,000
16,200
4,500
2,500
4,100
7,000
14,500
4,000
2,700
4,500
7,000
13,000
Type of House ( percent women)
Pucca
Semi-pucca
Kuccha
80
15
5
63
25
12
46
19
35
35
18
48
Economic Profile
Income and expenditure: Households in the sample had a median of two earning members per
household in both the states. The monthly household income of the sample households ranged from `
3,200 (25 percent quartile) to ` 10,000 per month (75 percent quartile). The median total household
income was ` 5,200 per month. Median household income was higher in Rajasthan (` 7000 per month)
than in Orissa (` 4000 per month). This is partly due to the higher proportion of urban sample in
Rajasthan, (especially in Alwar) than in Orissa. Median incomes were similar across intervention and
control districts in both states (Table 4.3).
Occupation: The occupation profile of surveyed households was similar across intervention and control
districts in both states. The only significant difference was a higher proportion of agricultural sector
workers in control districts. (Figure 5.1)
44
Figure 5.1: Occupational structure of sample population
Household characteristics
House type and cooking space: More than half of the respondents lived in pucca houses, 19 percent in
semi-pucca and 23 percent in kaccha houses. There is marked difference in terms of types of houses
between the two study states. In Rajasthan the majority (71 percent) lived in pucca houses, while in
Orissa an equal proportion (about 40 percent) lived in pucca and kaccha houses. A significantly higher
proportion of respondents (80 percent) lived in pucca houses in the intervention district in Rajasthan as
compared to the control district (63 percent). The trend was similar between the intervention and
control district in Orissa, though the difference was lesser (46 and 34 percent respectively).
Drinking water and electricity: About 43 percent of the total households were dependent on private
sources of water, either tap, hand pump or tube well. Forty one percent depended on public water
supply, either through piped connection or hand pump. About 87 percent of the houses had electricity
connections, the proportions being similar across intervention and control areas in both states.
Reproductive history of respondents
Some information on the parity of the respondents and details about their current birth was collected to
understand their pregnancy history and maternal care seeking behavior. This helps explain many aspects
of their overall reproductive behavior, perceptions on care and their choice of place of delivery.
Parity: Information on parity included the current birth of the respondents. The median parity level of
the respondents was two, while about 34 percent had a parity of one. A higher proportion of women in
Rajasthan had higher parity levels as compared to women in Orissa (Table 5.4).
45
Outcome of current birth: The outcome of current birth was a live birth for almost 99 percent of the
respondents. Only one percent pregnancies resulted in still birth or abortions.
Place of delivery: Fifty-five percent respondents delivered in DH or SDH in their current birth (by design
of survey), while 20 percent delivered in CHC/First Referral Units (FRU). About 12 percent delivered in
private facilities and eight percent delivered at home. Orissa showed more delivery in private facilities as
compared to Rajasthan. PHC and Sub Center (SC) deliveries together accounted for only five percent of
total deliveries. Compared to previous to last pregnancy, utilization of DH/SDH increased from 38 to 55
percent; CHC/FRU decreased from 27 to 20 percent; and home deliveries showed an almost 40 percent
decline (from 13 to eight percent).
Assistance during delivery: More than three fourths (78 percent) of the deliveries were conducted by
nurses. This was the pattern in both intervention and control areas in Rajasthan as well as Orissa. About
42 percent births were assisted by doctors and nurses. Only seven percent deliveries were assisted by
dais, five percent by ASHAs and three percent by family members.
Decision on place of delivery: The majority of respondents reported self/husband/family members as
the major influencers of decisions regarding place of delivery (79 percent), followed by ASHAs (58
percent). Both the family members and ASHAs together influenced about 40 percent of the deliveries.
ANMs and other health providers did not play a significant role in influencing decisions on place of
delivery. The actual decision was also taken largely by self/husband/family members, as reported by 91
percent respondents. Cost played an important role in influencing decisions regarding place of delivery
as reported by 41 percent respondents. But the biggest reason for choosing place of delivery was the
perception of ‘good facility’, reported by 66 percent respondents. Distance (25 percent), family/peer
counseling (22 percent) and incentives (15 percent) were other important reasons.
Utilization of antenatal care: More than 95 percent women received some antenatal care in their
current birth; however, only 53 percent reported having more than three ANC visits. About a fifth of
the respondents had three ANC visits, while a little less than a fifth (20 percent) had only two visits.
Seventy-four percent women had their first ANC visit in the first trimester, while 23 percent women had
their first ANC visit in the second trimester. The last ANC visit was in the eighth month for 40 percent
and in the ninth for 39 percent of respondents. These trends are similar across intervention and control
districts in both states.
A quarter of the respondents had their ANC checkups in DH/SDH, while a little more than one fourth (27
percent) visited the SC or AWC for antenatal checkup. Twenty six percent women had their ANC checkup
in private facilities. Eighty percent of the women reported being visited by an ASHA during their
antenatal period.
46
Table 5.4: Key Indicators on pregnancy history of respondents
Rajasthan Orissa
Percent women with: Intervention Control Intervention Control
Birth order:
1
2
3
4 and above
32
29
18
21
24
26
20
30
45
33
13
10
41
30
18
11
Live birth as outcome of current birth: 99 99 98 99
Assistance during delivery: (highest 4)
Doctors
Nurses
ASHAs
Dais
23
70
3
12
31
79
4
6
57
84
10
5
65
81
2
2
Decision on place of delivery taken by: (highest 3)
Self/husband/family members
ASHAs
ANM
87
16
1
94
11
1
98
21
1
84
46
1
Three or more ANC visits: 69 57 83 86
First ANC in first trimester
Last ANC in ninth month
77
28
71
28
73
50
77
51
Place of ANC: (highest 5)
DH/SDH
SC/AWC
Private facility
CHC
Home
27
41
10
11
20
18
50
24
11
12
37
20
65
4
1
45
22
37
21
1
JSY and health care expenditure
The cost analysis showed that the majority of households reported expenditures towards maternal care
at facilities. Break up of costs by medical and non-medical categories were provided by very few
households. Among the various cost categories, the spending on ANC was reported by 75 percent to 95
percent of the household and the median expenditure related to ANC was highest among all categories
of care: costs varied from ` 1950 in Sawai Madhopur to ` 3000 in Alwar; in Orissa, ` 2160 in Anugul as
compared to ` 2480 in Bargarh. All households reported expenditure on delivery and reported median
cost was ` 1200 in Sawai Madhopur; ` 1350 in Alwar; ` 1600 in Anugul and Bargarh in Orissa (Table 5.5).
Informal payments were reported by 25 to 46 percent of households in Rajasthan and 70 to 73 percent
of households in Orissa, and ranged from ` 300 to ` 400 in Rajasthan and Orissa. Expenditures related
to postnatal care at home were reported by six to 21 percent of households. Illness or need for medical
care was reported by almost 50 percent of the households, with 92 percent of them reporting a visit to a
47
facility and almost all of them (96 percent) reporting expenditures ranging from ` 400 to ` 500 in
Rajasthan and ` 600 to ` 690 in Orissa (Table 5.5).
Table 5.5: Median household expenditure towards maternal and neonatal care
Under the NRHM, all mothers in Rajasthan and Orissa are eligible for the JSY scheme under which they
are paid Rs. 1400 for institutional deliveries. Almost all respondents of the survey reported receipt of
money under the JSY scheme (89 to 99 percent) and 84 percent of them found the cash assistance to be
very useful. The usage of JSY funds varied across the two states, with 68 to 80 percent of mothers in
Rajasthan reported spending the money on food, whereas 65 to 71 percent in Orissa reported using the
money on medicines. However, the cost analysis showed that JSY only covers a small fraction of the
total expenses incurred by households towards maternal and newborn care.
Gender
Gender is a key social factor influencing newborn care in the patriarchal social setup of northern India.
Rajasthan in particular is among the states in India with low child sex ratios and practice of female
foeticide, indicating discrimination against the girl child. As per the census of India 2011, the sex ratio of
Rajasthan was 926 females per 1000 males. The sex ratio of the newborns covered in the community
survey was 891 females per 1000 males suggesting discrimination happening before the birth of the
child. To see the effect of gender on newborn care, four key indicators – length of stay in facility,
initiation of breastfeeding, immunization at the facility and referral – were analyzed by sex of the
newborn. No significant differences were found in these outcomes by gender.
Expenditure towards maternal and neonatal care (in `)
Rajasthan Orissa
Categories Intervention Control Intervention Control
ANC 3000 (n= 278) 1950 (n=275) 2160 (n=273) 2480 (n=309)
Delivery 1350 (n = 341) 1200 (n=367) 1600 (n=286) 1600 (n=325)
Informal Payments 300 (n=85) 350 (n=169) 400 (n=209) 400 (n=227)
PNC 800 (n= 36) 1000 (n=46) 200 (n=20) 500 (n=75)
Referrals 400 (n=209) 500 (n=198) 600 (n=173) 690 (n=141)
Receipt of JSY ` 1400 (percent) 89 90 99 96
48
Pre delivery and Delivery experience
The first responsibility listed in the operational guideline for Yashodas states that she is responsible for
“welcoming the pregnant woman heartily (in the facility) and make sure that she relaxes, and reassure
her that she is in a safe place and among people, who care for her.” Considering registration as the first
point of contact for the pregnant woman and her family members in the health facility, it is important
for the Yashoda to interact with them at this point.
Figure 5.2: Time allocation of Yashoda However, of the total time spent by Yashodas at health
facilities only one percent was spent in registering
mothers. Yashodas reported spending 17 percent of their
time in ANC wards and an almost equal proportion of time
in labor rooms (39 percent) and PNC wards (43 percent).
Responses from mothers obtained from facility and
community surveys further corroborated that Yashodas
spend minimal time at registration. While in facility survey,
only three percent mothers in Alwar DH and nine percent
mothers in Anugul DH reported having first met the
Yashoda during registration; none of the mothers from the
community survey reported having met her during registration. The facility survey reports that in Alwar,
registration was mostly facilitated by family members (82 percent) while in Orissa ASHAs assume a
prime role in registration of mothers. Close to 60 percent of the mothers both in Anugul and Bargarh
reported having received help from the ASHA during registration. In the context of continuum of care
this has significant implications – 61 percent of respondents of the community survey reported that
ASHAs accompanied them to the place of delivery. Also, the presence of ASHAs seems to influence
sharing of the ANC card at the health facility, although sharing of ANC card was reported universally in
Orissa with 95 to 97 percent of mothers in intervention and control districts reporting this; in Rajasthan
this practice was higher in the intervention district compared to the control district.
Facility survey findings show that most mothers were taken to the labor room immediately after
registration (48 to 69 percent). Of those who were taken to the ANC ward prior to delivery, 50 percent
in Alwar DH and 89 percent in Anugul DH interacted with the Yashoda in the ward.
The community survey reported that, 81 percent of the respondents in Alwar received a physical
examination/ investigation/ diagnostics prior to delivery compared to 63 percent in Sawai Madhopur.
On analyzing this variable specifically for the DH level a similar trend was observed. However, an
opposite trend was observed in Orissa where the intervention district Anugul reported lesser proportion
of respondents (46 percent) who received a physical examination prior to delivery compared to women
in Bargarh, the control district (51 percent).
49
In both these states a higher proportion of respondents from the intervention districts reported that
information regarding the physical examination/ investigation / diagnostics was shared with them or
their family members. Physical examination/ investigation/ diagnostics conducted before delivery did
not exhibit any significant variation across age groups, education levels or parity of respondents.
Yashodas do not seem to have a significant influence on reported receipt of physical examinations prior
to delivery, the event perhaps being more influenced by type of delivery and presence of any
complications.
Table 5.6: Pre delivery care (Sharing of ANC card and physical examination)
Rajasthan Orissa
Intervention Control Intervention Control
Respondents whose ANC card was shared at the health facility (n=1314)
82 71 97 95
Respondents who received any physical examination/ investigation/ diagnostics conducted before delivery (n=1314)
81 63 46 51
Respondents whose information regarding the physical examination/ investigation/ diagnostics was shared with self/ family member (n=607)
86 75 93 48
The presence of ASHAs at registration provides an excellent opportunity for Yashodas to interact with
them and take over the mother’s care from ASHA to themselves (through sharing of the ANC card
information) at the facility. Similarly, at discharge, Yashodas could provide similar information about
the mother to the ASHAs to continue care through postnatal visits at home.
Experience in the postnatal ward
An important element of the Yashoda program is to provide additional support and important
information on maternal and newborn care during their postnatal period at the facility. As per current
practices, a Yashoda spends 43 percent of her time in the PNC wards with mothers and newborn (Figure
5.2). Of the time spent in PNC ward, 60 percent of her time is devoted to counseling mothers on issues
of breast feeding, immunization, family planning, identification of danger signs, hygiene etc. (Yashoda
IDIs). In the control districts, nurses and ASHAs (who sometimes accompany mothers) undertook
counseling; however this was not a routine task.
The community survey reported that 81 percent of mothers who delivered in Alwar DH and 93 percent
respondents from Anugul DH were attended by Yashodas when they were placed in the PNC ward.
Mothers who delivered at the CHCs in Alwar reported much less interaction, only 41 percent of them
reported being attended by Yashoda in the PNC ward. It is important to note that the level of
respondents’ exposure to health personnel including the Yashoda is dependent on the length of stay at
the facility. The community survey showed that 82 percent mothers in Alwar DH, and 24 percent
mothers in Anugul DH, who had a normal delivery stayed at the health facility for at least 48 hours after
delivery. At the CHC level in Alwar, only 34 percent of the mothers reported staying at the facility for
more than two days.
50
The length of stay (LOS) at the facility therefore impacts the level of Yashoda exposure and the
associated benefits. Although it is important to note that, LOS is influenced by a variety of factors
ranging from type of delivery, to health system issues to influence of family members.
In terms of benefits related to Yashoda program, the community survey showed that a significantly
higher proportion of respondents who delivered at facilities where Yashodas were present reported
having received counseling on a variety of maternal and newborn care issues when compared to
respondents who delivered at facilities where Yashodas were not present. The proportion of mothers
who reported receipt of counseling messages however, varied across the topics (exclusive breast
feeding, family planning, immunization, nutrition, identification of danger signs and
cleanliness/hygiene). Variations were higher in Rajasthan both at the DH and CHC levels. For example,
exclusive breast feeding was the most discussed among the six issues, with 95 percent of the
respondents at the DH level in Alwar reporting having received information on it (9.07 [95 percent CI
5.71-14.41]); however only 55 percent of mothers reported receiving any information on danger signs at
this facility. This variation was much smaller in Anugul, the intervention district of Orissa, where the
percentages ranged from 83 to 97 percent (Table 5.7 & 5.8).
Further intra-district analysis in Alwar comparing responses of mothers who delivered at two different
levels of facilities with Yashodas --- DH and CHCs, showed that mothers from DH received significantly
higher levels of counseling compared to mothers who delivered at CHCs (correlates to proportion who
reported exposure to Yashoda). For example, 92 percent of mothers at DH in Alwar reported receipt of
counseling on immunization (5.48 [95 percent CI: 3.63-8.26]) compared to 80 percent mothers at CHCs.
Yashodas seemed to have enabled a significantly higher proportion of mothers to receive postnatal
checks at the facility – 48 percent in Alwar DH reported receipt of BP check compared to 14 percent in
Sawai Madhopur. However, this proportion who received basic postnatal checks is still quite low and
requires additional attention from Yashodas (Table 5.7 & 5.8). Essential PNC checkups like,
temperature and blood pressure check, which should be universally received by mothers at all facilities
were reported by around 30 to 40 percent of the respondents in intervention areas and less than 20
percent respondents in control areas. This reflects the poor quality of PNC care currently available at
these facilities. Improving postnatal care for mothers and newborn at facilities would have a significant
impact on maternal and neonatal mortality and morbidity. Although, the presence of Yashodas has
improved the level of care, there is an immense scope of improvement in postnatal care.
Some of the neonatal care indicators (keeping the newborn warm, provision of food/water at the PNC
ward, initiation of breast feeding and immunization), did not always show significant differences
between the intervention and control districts, especially in Rajasthan (Table 5.7 & 5.8); significant
differences were observed in Orissa between NIPI intervention and non NIPI areas. It is important to
note that the reported practice of almost all of these indicators, were quite high (more than 80 percent)
across intervention and control districts depicting the high impact of efforts under NRHM to improve
these neonatal care indicators.
51
Some of these indicators like initiation of breast feeding, use of supplementary feed, keeping the baby
warm perhaps could improve further with more consistent efforts by Yashoda (Table 5.7 & 5.8). The
involvement of Yashodas in assisting mothers with immunization of newborns was reflected in a higher
proportion of mothers reporting provision of BCG and OPV in the interventions areas.
In Rajasthan, education and number of ANC visits were the other significant factors influencing
counseling and practice indicators in PNC. In Orissa the counseling and practice indicators in PNC were
influenced by age and the total household income.
Table 5.7: Post natal counseling, checkup and practice, Rajasthan
DH CHC Odds Ratio (95 percent CI)
(For DH) Intervention
(n=207) Control (n=204)
Intervention (n=126)
Control (129)
Counseling indicators
Exclusive Breast feeding 95 ** 34 85 * 74 9.07 (5.71-14.41)
Family Planning 68 * 56 65 ** 27 2.48 (1.78-3.46)
Immunization 92 ** 48 80 ** 60 5.48 (3.63-8.26)
Nutrition 81 ** 66 71 ** 47 1.97 (1.38-2.82)
Identification of danger signs 55 ** 46 57 ** 11 2.83 (2.02-3.97)
Cleanliness/ Hygiene 76 ** 36 65 * 47 3.19 (2.27-4.47)
PNC Check-up indicators
Blood pressure check 48 ** 14 34 ** 9 4.13 (2.79-6.13)
Temperature check 31 ** 6 24 ** 7 5.95 (3.54-10.00)
Episiotomy stitches 34 19 24 17 1.62 (1.07-2.44)
Perineum check 33 ** 15 26 * 14 1.99 (1.32-2.99)
Injection 42 33 31 36 1.29 (0.96-1.72)
Saline 23 ** 9 19 11 2.74 (1.71-4.37)
Practice Indicators
Mothers who took measures to keep the newborn warm
91 99 84 91 0.48 (0.27-0.86)
Mothers who were provided food/water at the PNC ward
81 97 90 95 0.31 (0.18-0.56)
Initiation of breast feeding within 1 hour
41 39 58 54 1.08 (0.78-1.49)
Initiation of breast feeding from 1 - 5 hours
44 49 37 35 1.13 (0.82-1.56)
Mothers who did not gave supplementary feed to newborn
28* 17 37 17 1.67(1.13-2.47)
Newborns who received first immunization – BCG & OPV(0)
98 93 81 79 1.32 (0.78-2.23)
* p=<.05, **p=<.001
52
Table 5.8: Post natal counseling, checkup and practice, Orissa (DH)
Intervention (n=253)
Control (n=251)
Odds Ratio (95 percent CI)
Counseling indicators
Exclusive Breast feeding 97 94 1.89 (0.77-4.66)
Family Planning 84 ** 66 3.12 (2.06-4.73)
Immunization 96 * 91 2.34 (1.11-4.94)
Nutrition 83 78 1.29 (0.84-1.97)
Identification of danger signs 85 ** 49 4.74 (3.14-7.17)
Cleanliness/ Hygiene 95 ** 78 3.91 (2.09-7.31)
PNC Check-up indicators
Blood pressure check 29 * 20 1.50 (1.03-2.19)
Temperature check 23 * 15 1.39 (0.93-2.08)
Episiotomy stitches 29 ** 12 2.49 (1.64-3.78)
Perineum check 27 20 1.33 (0.91-1.95)
Injection 45 45 1.28 (0.92-1.78)
Saline 38 * 27 1.50 (1.05-2.12)
Practice Indicators
Mothers who took measures to keep the newborn warm 97 94 1.65 (0.70-3.90)
Mothers who were provided food/water at the PNC ward 95 ** 81 5.70 (2.99-10.82)
Initiation of breast feeding within 1 hour 78 73 1.09 (0.73-1.63)
Initiation of breast feeding from 1 - 5 hours 17 14 1.60 (1.00-2.56)
Mothers who did not give supplementary feed to newborn 26 21 1.31 (0.92-1.87)
Newborns who received first immunization – BCG & OPV(0) 93** 73 5.26 (3.08-8.99) * p=<.05, **p=<.001
The impact of the presence of Yashodas were most apparent for mothers who had a C-section; 76
percent of respondents who had a C-section delivery in the intervention districts reported that they
initiated breast feeding within five hours compared to 44 percent in the control district. This reiterated
the preliminary findings from the facility survey of Orissa which reported that 85 percent or mothers
who had C-section in Anugul initiated breast feeding within five hours compared to 47 percent mothers
in the control district of Bargarh. This was mainly attributed to the support provided by Yashodas to
position the baby in a less-painful manner and aiding early breast feeding. “Yashoda has told her the
right way of breast feeding & about the family planning methods also. Yashoda kept asking if she is
having any problem” (IDI, Caregiver, Anugul).
Similarly, more than 95 percent of the respondents who had a C-section delivery reported that their C-
section scar was checked and that their dressings were changed compared to 83 percent and 72 percent
in the control districts for the same indicators.
53
Table 5.9: Key post natal indicators for mothers who had a C-section delivery
Intervention (n=46)
Control (n=46)
Initiated Breast feeding within 5 hours 76** 44
Mothers whose Cesarean section scar was checked 96* 83
Mothers whose dressing was changed (for C-Section) 94* 72 * p=<.05, **p=<.001
The observation studies of Yashodas in Alwar DH and Anugul DH documented that several of the roles
prescribed to them were being fulfilled. In addition to defined roles for counseling and support,
Yashodas also performed simple tasks that humanize the atmosphere in the health facility and maintain
decorum in the ward.
One mother was feeling shy about feeding her baby as this was her first child. At this the Yashoda said,
“do not feel shy, feed the child without covering him, look…. now the child is having milk properly, every
drop of the mother’s milk is precious”. The child started crying again. Then, the Yashoda took him in her
lap and told the mother “put some clothes on the child… now-a-days, it is cold here”. Then she (Yashoda)
helped the mother in clothing the child…” (Observation, Alwar DH)
“Yashoda watches over the mother and child from time to time” (IDI,Caregiver,Alwar)
One Yashoda was giving advice to a family member: “do not comb hair inside the room, don’t wear shoes
inside the room, and don’t sit on the patient’s bed, please come one after the other to see the patient”
(Observation, Anugul)
The study found that mothers/families felt that the presence of Yashodas was beneficial to them in
several ways. In general, mothers reported being more comfortable within the hospital environment
in the presence of Yashodas. It was pointed out that “….even people from high socioeconomic status
don’t want to stay in (an exclusive) cabin because there are no Yashoda services in the cabin “. Mothers
who had visited the hospital for their previous delivery prior to the Yashoda intervention felt that the
wards were much cleaner now.
Overall experience at the facility
In both intervention and control districts 70 percent of mothers expressed confidence in the health
facility by opining that they would go back to deliver for their next pregnancy. However in the control
district of Sawai Madhopur nearly one fourth of the mothers were unwilling to go back to the facility for
delivery as compared to only 16 percent in Alwar. Majority of mothers (96 percent) also said that they
would recommend the health facility to others for deliveries. Around half (47 percent) of the mothers
reposed faith in the experience of the delivery process and cited it as one of the main reason why they
would go back to the institution—73 percent of mothers in Alwar cited this as a reason to come back to
the facility. The money received under Janani Surkasha Yojana (JSY) seems to be a powerful incentive for
women, especially those in Orissa (82 percent in Anugul and 66 percent in Bargarh) to opt for
institutional delivery (Table 5.10).
54
Table 5.10: Reason for coming back to facility for next delivery
In Sawai Madhopur district around 20 percent mothers felt that there was scope for improvement in
behavior as compared to only nine percent in Alwar district. Around 40 percent of mothers gave
suggestion for improving infrastructural gaps and cleanliness.
5.3 Summary
The profile of Yashoda (in terms of age and educational status) at the two study districts matched the
NIPI guidelines. Many belonged to economically and socially vulnerable groups. In terms of
remuneration, a mixed system of remuneration for Yashodas in Orissa was found to be more
appreciated than the incentive based system in Rajasthan. Yashoda’s training seemed to orient them
more as a nurse’s aide than a mother’s aide in the facility. Supervision systems were found to be weak in
Rajasthan as compared to Orissa.
In relation to the role and support provided by Yashoda, the study found that mothers/families felt that
the presence of Yashodas was beneficial to them in several ways. In general mothers reported that they
were more comfortable within the hospital environment in the presence of the Yashoda than without.
The community survey found that decisions regarding place of delivery were made mostly by
self/husband/family members. Nurses conducted more than 75 percent of the deliveries. The length of
stay at the facility impacted the level of Yashoda exposure and the associated benefits. Although it is
important to note that, LOS is influenced by a variety of factors ranging from type of delivery, to health
system issues to influence of family members.
A significantly higher proportion of respondents who delivered at facilities where Yashodas were
present reported having received counseling on a variety of maternal and newborn care issues when
compared to respondents who delivered at facilities where Yashodas were not present. Mothers from
DH received significantly higher levels of counseling compared to mothers who delivered at CHCs
(correlates to proportion who reported exposure to Yashoda).
Yashodas seemed to have enabled a significantly higher proportion of mothers to receive postnatal
checks at the facility – 48 percent in Alwar DH reported receipt of BP check compared to 14 percent in
Sawai Madhopur. However, this proportion who received basic postnatal checks is still quite low and
requires additional attention from Yashodas. The impact of presence of Yashoda was most apparent for
Reasons Rajasthan Orissa Total
Intervention Control Intervention Control
Distance to the health facility 3 36 48 44 33
Cleanliness at the facility 31 32 37 44 36
Delivery process 73 32 38 46 47
Cost factor/free treatment and drug 19 28 55 27 32
JSY money 27 41 82 66 54
55
mothers who had a C-section in terms of practice indicators like initiation of breastfeeding within five
hours.
In terms of cost of care, median expenditures incurred by households towards maternal and newborn
care were ` 3500, mostly towards ANC costs. It is important to note that as per current guidelines the
JSY incentive of ` 1400 covers less than half of the total expenses incurred by households towards
maternal and newborn care.
5.4 Recommendations
There is need for the Yashoda’s role as a mother’s aide to be made specific and keep her identity
distinct from that of nurse’s aide. This may require more appropriate branding of identity both
at the facility and at the community level.
The role of Yashodas as sympathetic friends and mother’s aides needs to be strengthened in her
training vis-à-vis current perceptions of her as a nurse’s aide.
Weak supervision of Yashoda’s has serious implications on discharge of duties by them, and
therefore needs to be strengthened, especially at the CHC level.
The presence of ASHAs at registration provides an excellent opportunity for Yashodas to interact
with them and take over the mother’s care from ASHA to themselves (through sharing of the
ANC card information) at the facility. Similarly, at discharge, Yashodas could provide similar
information about the mother to the ASHAs to continue care through postnatal visits at home.
Although the presence of Yashoda has improved the level of care, there is an immense scope of
improvement in postnatal care. Some of these indicators like counseling on danger signs,
facilitation of PNC checks, and use of supplementary feed could receive further focus and
attention. Customized, field based, and frequent training should be considered.
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6. HOME BASED NEWBORN CARE -- EFFECT OF ASHA TRAINING
Under HBNC program, the training of ASHAs on HBNC is one of the key areas and NIPI, in their
intervention districts, has focused on this activity. In order to understand the HBNC component
provided by NIPI and the additional value of this component the study focused on two issues, first, a
review of the training materials related to HBNC provided by NRHM and NIPI was done to identify the
complementary and the supplementary features of the NIPI sponsored program; Secondly, the study
assessed the impact of NIPI training through interviews with ASHAs and also through the community
survey of mothers who had recently delivered. This approach was expected to provide information on
critical gaps and on the functioning of HBNC component in the NIPI intervention districts of Orissa and
Rajasthan.
6.1 NRHM & NIPI training modules for ASHAs: Comparative Review
In NIPI focus states, a special training module for ASHAs in HBNC termed “Home Based Postnatal Care”
(HBPNC) is provided along with incentives to ASHAs for completing PNC checkups, and a referral fund to
ensure that sick newborns and mothers can be referred to an appropriate facility (NIPI 2011). In these
states, the HBNC training is conducted by State Health Societies. The primary aim is to build on the
ASHAs’ competency to create a structured follow-up system for both the mother and the newborn.
Under the NIPI intervention, HBNC training has been imparted to ASHAs in three districts in Rajasthan---
Alwar, Dausa and Bharatpur. The NIPI training follows a cascade model, with a two-day induction
training, which is followed by home visits undertaken by ASHAs. These home visits provide exposure to
real life situations and these experiences are shared by ASHAs during sector meetings with LHVs, ANMs
and MO/ICs who discuss issues and provide specific solutions to problems that the ASHAs face. This
exercise is to be followed by five-day skill-based practical training. The principle behind designing the
training in this manner is that after the two-day orientation and field visits, ASHAs can comprehend the
five-day skill based training better and can relate their practical experiences with the information shared
in the sessions. As the first step a two-day Training of trainers (ToTs) at the district and block levels was
organized in 2008-09. These NIPI trained experts then conducted two-day orientation training in 2009-
10 in both Rajasthan and Orissa. 1104 ASHAs in Orissa and 5000 in Rajasthan were trained in different
batches at block level. Additionally a one day meeting was organized at the block level for ANM/LHV,
M.O I/C, BPO, BADA & BMCH to sensitize them on HBNC by ASHAs. The five-day skill based training was
organized and conducted between March to September 2011 in both the states. This training by NIPI
was in addition to the NRHM training of HBNC component.
In terms of HBNC exposure under NRHM, ASHAs in Rajasthan and Orissa have received training on
modules 1-4 under NRHM, of which the first and second modules contain information on some core
elements of HBNC and the role of ASHAs, including advice on diet and nutrition, counseling on
breastfeeding and complementary feeding, weighing the baby, keeping the baby warm, recognition of
postnatal and neonatal complications and diarrhea prevention and management.37 Over the last two
years post induction ASHAs have received an initial training for seven days for module 1 and an
additional four days for modules two to four. 27
57
New modules six and seven build on modules one to four and are aimed to focus further on the HBNC
component and focus on building competency among the ASHAs in life-saving skills to be provided at
the level of the community (NRHM 2011). The modules have been introduced recently; training of state
trainers has been completed in Rajasthan and ASHA training has been planned under the current PIP
(2011-12).38
Training Content: NRHM training material
The resources for HBNC component of NRHM training for ASHAs come from three main sources – Book
5 and Modules 6 and 7 on life-saving skills. Modules 6 and 7 have been taken from the module ‘How to
train ASHAs for Home Based Newborn Care’ prepared by SEARCH, Gadchiroli. These modules have also
been included in the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) package.
Book 5: Text book for ASHAs
This book was developed by the NGO Chetna, and improved upon by the national ASHA mentoring
group. The main aim of the book is to strengthen the role of ASHAs as health activists and to develop
their leadership and communication skills. Contents include ASHA’s role and values, the concepts of
fundamental rights, human rights and the right to health, leadership, communication and decision-
making skills, participatory approaches and coordination skills. While it is useful in instilling confidence
and leadership values among ASHAs, the discussion on human rights seem too complex for a woman
with a rural background and < 10th grade education. There is much scope for simplification of contents
to make it easier for the ASHAs to comprehend.
Module 6: Skills that save lives – focus on maternal and newborn health
Module 6 aims to develop lifesaving skills among ASHAs in maternal and neonatal health. The first part
of the book is in the form of an orientation to ASHAs about their role and functions. The subsequent
chapter scheme follows the ‘continuum of care’ approach, first discussing maternal health and then
newborn health. Maternal health includes pregnancy diagnosis, birth planning, anemia management,
safe delivery, management of complications and postpartum care. Neonatal health includes immediate
newborn care, examining the newborn, breastfeeding, keeping the baby warm and managing fever in
newborns.
The module is accompanied with ASHA reporting formats and useful pictorial guides and skills checklists
on basic functions like using pregnancy detection kits, hand washing, using thermometers and weighing
the baby. The module is well illustrated with pictures and a useful summing up of ASHA’s role and the
knowledge and skills required to help her perform. The language is not conversational though, hence
effective absorption of the training by ASHAs would depend on the communication skills of the trainers.
Module 7: Skills that save lives – focus on child health and nutrition
Module 7 aims to develop lifesaving skills among ASHAs in child health and nutrition. They also deal
however, with women’s reproductive health and also prevention and treatment of infectious diseases,
specifically TB and malaria. The latter sections help complete the two modules as comprehensive
refresher modules for ASHAs. The section on child health and nutrition spans diet and nutrition,
58
identification of child malnutrition, immunization, and assessment and management of childhood
ailments. The section on newborn health covers assessment and treatment of low birth weight and pre-
term infants, prevention and treatment of respiratory problems and sepsis among newborns.
The module is quite comprehensive in terms of content. It is also well illustrated with guidance on
communication and counseling skills. It is accompanied with communication kits to help ASHAs in field
counseling. The language is again a bit complicated, and therefore effective communication by the
trainer and use of teaching aids is essential in getting the message across effectively.
Training Content: NIPI training material
The NIPI training module for ASHAs on HBNC has been developed by a team of experts from the Division
of Neonatology, All India Institute of Medical Sciences, New Delhi and supported by various professional
bodies and NIPI. Development of the module was anchored at the National Child Health Resource
Center at the National Institute of Health and Family Welfare and was critically supported by
professional bodies like the National Neonatology Forum; Trained Nurses Association of India;
Breastfeeding Promotion Network of India, WHO and INCLEN. Both NRHM and NIPI training include
Book 5 on leadership development and communication skill building among ASHAs. Other materials are
as follows:
Manuals on Role of ASHA
There are three separate manuals – one each on child nutrition, postnatal home visits and sick
newborns. These manuals have been designed as explanatory guides and ready references for assisting
ASHAs in performing their tasks relating to postnatal home visits and home-based newborn care. This
includes counseling on breastfeeding and infant feeding practices, basic newborn care, maintaining
hygiene, identification of maternal and newborn complications (including malnourished infants) and
referral related procedures. They are brief and easy to refer to, with pictorial illustrations. All essential
technical aspects have been covered, with a useful FAQ section helping to summarize the content at the
end. The contents are well illustrated, accompanied by simple text and therefore quite easy to
comprehend, though there may be some difficulty with technical terms which require the trainer’s help.
The section on how other health workers can help the ASHA is quite useful in bringing clarity to their
respective roles and encouraging coordination between them.
Training manual for ASHAs on home-based newborn care
This is a very comprehensive volume on home-based newborn care. It begins with assessing the ASHA
on her knowledge in newborn care, and then orients her on prevalent social practices and
recommended newborn care practices. A detailed guide follows, on what she needs to do in helping
families for birth preparedness, institutional or home deliveries, referral, postnatal and home-based
newborn care, including immunization and prevention of infections. However, the manual is quite
dense. It has only a few necessary illustrations; some of which do not even depict an Indian context.
There is much scope for making the manual more pictorial and simpler to understand.
59
Book on the Role of the Village Health and Sanitation Committee
This is a book meant to guide the framing of a constitution and functioning of the Village Health and
Sanitation Committee. It has been designed in an interesting pictorial format, using anecdotes to
illustrate the effectiveness of a collective voice and the experiences of such forums in improving health
and sanitation at the village level. It includes guidance about the constitution of the committee,
frequency and conduct of meetings, along with formats for monitoring and reporting. The language,
however, is not simple, and therefore could be difficult to comprehend for ASHAs as well as other village
community persons on these committees.
Flip chart to aid counseling of mothers and family members on home-based postnatal maternal &
newborn care
The flip chart is to be used while counseling mothers during PNC visits. All essential aspects of newborn
and maternal care are well illustrated, and also contain effective guidance to enable ASHAs to use them
in educating the women. Some illustrations, however, contain English sub-headings, which need to be
translated to Hindi. The illustrations on the flip charts and manuals are identical, which help establish
the critical linkage between the training of ASHAs and implementation of their technical role.
Training Structure
The nature of implementation of the training is crucial for effective uptake of requisite knowledge and
skills by the ASHAs. In this context, the structure of the training is of critical importance. Both NRHM and
NIPI have adopted participatory adult learning approaches to ASHA training, with effective use of
teaching aids and adequate field practice at the facility and community level. Training manuals and
facilitator guides for both modules provide detailed information on the structure of the training and its
implementation.
Table 6.1: Comparative summary of NRHM and NIPI state training modules for ASHAs
NRHM ASHA Training NIPI State HBNC Training
Duration 20-24 days, in four rounds of 5 days each, separated by 8-12 weeks for practice of skills
2+5 days (2 days theoretical, followed by 5 days practical field-based training)
Topics covered
ASHA role and skills
Lifesaving skills in maternal and newborn health (ANC, birth planning, newborn care)
Lifesaving skills in child health and nutrition (incl. sick newborns)
Other issues like women’s reproductive health, family planning and infectious diseases (TB, malaria)
ASHA role and skills
PNC tasks & skills needed
ANC & birth preparedness
Care of newborn at birth & mothers after delivery
Breastfeeding, newborn and child nutrition, sick newborns
PNC home visits (number of visits and role in each visit)
Additional counseling (referral; immunization; family planning)
Training methods
Residential & participatory, with field visits for practical application
Residential & participatory, with field visits for practical application
Training status
Not yet carried out in Rajasthan (planned for 2011-12)
Trainings conducted in all 3 NIPI districts in Rajasthan
Critical difference
This is a comprehensive training for ASHAs and inclusive of all her functions, knowledge and skills, with additional focus on HBNC
This training is complementary to the national NRHM ASHA training, with a specific focus on HBNC to develop that capacity
60
Summary of review of the training materials
Content: Analysis of the training materials for ASHAs under NRHM and NIPI show that both the modules
are quite comprehensive and cover all essential elements. The key difference is that the NRHM Modules
6 and 7 are quite complex in terms of content and language, thereby leading to possible difficulties in
comprehension by ASHAs. The NIPI module appears much more reader-friendly as it is in the form of
concise, pictorial booklets on key topics; such a format would be useful for all NRHM ASHA training
modules to improve ASHA’s comprehension and the retention of information conveyed in these books.
Feedback from ASHAs on NRHM training content, as per a recent evaluation of the ASHA program in
four states, showed that a fifth of ASHAs in Rajasthan thought the theoretical content on newborn care
to be too much, while more than one fourth (28 percent) thought the content on nutrition to be too
much.39 Similarly about a third of the ASHAs thought practical training on PNC, newborn care and
nutrition to be excessive.29 This highlights that the current content of the training may need
modifications.
Structure: The NRHM training structure is quite rigorous, with training for trainers and a 20-day schedule
for ASHAs. The training manuals are exhaustive and very clearly indicate the conduct of each session of
training. An appropriate mix of solidarity building exercises, participatory learning and field based
practice, ensure a productive training. However, it is important that the training is actually imparted as
per the structure. This may not be the case, as ASHA evaluation has shown that ASHAs in Rajasthan have
on an average received just 12 days of training.29 The training program should be strengthened with
complete training on Modules 6 and 7 with focus on skill building; ASHAs should have a clear idea of
what measurable outcomes they can bring about.27
NIPI’s state level HBNC training structure complements the general training of ASHAs under NRHM. It is
based largely on Government guidelines and preferably employs trainers who have earlier trained
ASHAs under NRHM. The training is focused on the specific HBNC component, and also spends a longer
and perhaps more critical time on the field experience of ASHAs, both in the facility and in the
community. The cascade model of training has just two levels – state and block – to minimize
transmission loss of information, unlike the national level training which has four levels – national, state,
district and block. Training methods are similar to the NRHM approach of participatory adult learning.
Other considerations: Besides the content and structure of training, the actual implementation of the
learning is critical. Other complementary activities include supportive supervision, regular refresher
trainings, performance monitoring and feedback. All these are essential for training to be successful in
enabling ASHAs to perform their roles effectively.29
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6.2 Assessment of NIPI training
ASHA perspective on NIPI training
To assess the nature and usefulness of the HBNC training imparted by NIPI, 10 IDIs were conducted with
trained ASHAs in Alwar district of Rajasthan.
Structure and content of the training: The ASHAs generally found this training to be useful that they
were better equipped in terms of knowledge to take care of mother and newborn. During training,
emphasis was given to newborn care, aspects of health and hygiene and identification of danger
symptoms in the newborn.
In order to improve the training, the ASHAs suggested that the training should be provided more
frequently in the local language, the duration should be more than two days and more hands-on
training through field visits. ASHAs also felt the need for training on simple clinical tasks like checking of
blood pressure, temperature, IV drip administration and management of minor ailments.
“Instead of class room lecture if we are taught with live demonstration we can understand the
concepts in a better way”
“Lots of information is shared with us in two days, which sometime we find difficult to
understand”
Due to the training program in PNC care, the ASHA now feels that she is in a better position to counsel
the mother on early initiation of breast feeding (within one hour), feeding positions, diet of the mother
and newborn and how to keep the baby warm.
“I now tell the mother that only to give mother’s milk in first six months, no supplementary food
is required, and she should have green vegetables and nutritious food”
The ASHA mentioned that she now has a better understanding in terms of the nature and type of
counseling that needs to be given to the mother on different PNC visits.
“Now I check the baby during the visit, particularly if the baby’s eyes are yellow, whether the
newborn has some water balls in the body”
In terms of referral the ASHAs generally refer to the nearest PHC. Sometimes ANMs also handle such
cases. In case of complicated cases they use the untied funds that are at the disposal of ANMs.
“Now we can conveniently explain to the mother how they can detect if the child is sick, so there
is no delay in referring the child to the health facility”
Overall the HBNC training imparted to the ASHAs was found to be very useful, and ASHAs found that
due to the training they are now aware of the importance of PNC visits as the most critically timed
interventions for newborn health.
“Yes now though I have other work like taking mothers to the health center for delivery, attend
the village and nutrition day etc. But I try to make sure that I don’t miss the PNC visits”.
Thus NIPI training can certainly play a significant role in improving HBNC if customized further in terms
of local content, imparted through more live demonstrations, held on a more regular basis instead of a
one-time affair, and with a follow-up process established in terms of supportive supervision of ASHAs,
and thus could affect considerably the health outcome for both mother and newborn.
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6.3 Community Survey -- Outcome for HBNC Indicators
Number of visits by ASHA after delivery
This section provides information on various HBNC related indicators obtained through the community
survey on NIPI intervention and control. Some of indicators include counseling of mothers on
components related to the care of newborns at birth and mothers after delivery, breastfeeding,
immunization, health and hygiene, early identification of danger signs and referrals for sick mother and
newborn.
According to NRHM guidelines, five home visits are to be provided to every newborn starting with the
first visit on the day of birth followed by visits on days 3, 7, 14 and 28. The survey showed that
respondents in Rajasthan received fewer visits than those in Orissa. Mothers in Anugul reported a
median of five visits compared to four in Bargarh; In Alwar the median visits were three compared to
two visits in the control district. The PNC visits are recorded on a PNC card which is supposed to be
signed by women/ family members after each visit. The proportion of mothers who had a signed PNC
card was higher in the intervention areas in both the states, 95 percent in Alwar, Rajasthan compared to
57 percent in the control area.
Table 6.2: Frequency of home visits by ASHA
Knowledge of PNC indicators: Role of ASHA
One of the primary tasks of ASHA during the PNC visits is to provide counseling to mothers on keeping
the child warm, initiation of breastfeeding immediately after birth (especially for home births),
counseling for exclusive breastfeeding, immunization and recognition of illness in newborn and
management and/or referral. The survey data showed that that a significantly higher number of
respondents in the NIPI intervention districts have received counseling and advice by ASHA on all
HBNC components (Table 6.3) compared to women in control districts in both the states. The result is
particularly significant in terms of advice received from ASHA for early and exclusive breast feeding and
immunization for the newborn in the intervention districts. Adjusting for variables like age, income, type
of delivery, and ANC visits, the odds ratio for exclusive breast feeding for Alwar is 2.53 (95 percent CI
1.64-3.92), and for Orissa was 6.39 (95 percent CI 2.92-13.97)and for immunization the odds ratio for
Alwar was 2.34 (95 percent CI 1.33-4.11), and for Orissa it was 3.03 (95 percent CI 1.52-6.04). This
suggests that although the number of PNC visits done by ASHAs did not vary much between the
intervention and control districts, the content of counseling and impact of that on practice did vary
between the two districts.
Rajasthan Orissa
Intervention N=337
Control N=366
Intervention N= 287
Control N= 327
No. of visits by ASHA after Delivery (Median) 3 2 5 4
No. of visits by ASHA in first 10 days after Delivery (Median)
2 1 2 2
63
The NIPI program in both the states have resulted in significant improvements in levels of awareness of
the PNC indicators, however few important indicators like the information on danger signs, use of
family planning methods after delivery needs additional attention, especially in Rajasthan.
The level of awareness of PNC indicators however, appear to be much higher in Orissa even in the
control district of Bargarh compared to Rajasthan. This suggests that the NRHM training of ASHAs on the
basics of HBNC through Modules 1-4 have yielded significant benefits in Orissa. The NRHM program was
not available in Rajasthan.
The other significant factors influencing receipt of HBNC counseling were similar to those influencing
receipt of PNC counseling and practice at the facility. In Rajasthan, education and the number of ANC
visits and in Orissa age and the total household income were the significant factors.
Table 6.3: Counseling on HBNC by ASHA
* P<.05, ** P<0.001
Intervention Control Odds Ratio (95 percent CI)
Rajasthan N= 296 N= 258
Delivery Process and events 69** 42 2.95 (2.01-4.34)
Initiation of breast feeding 82 ** 56 3.41 (2.26-5.15)
Exclusive breast feeding 85** 67 2.53 (1.64-3.92)
Birth registration 76** 29 7.12 (4.76-10.67)
Immunization (BCG and OPV) 92** 82 2.34 (1.33-4.11)
N= 387 N= 336
Keeping the baby warm 71** 38 3.62 (2.48-5.27)
Danger signs and local illness 44** 17 3.83 (2.50-5.86)
Urine and stool passed by the baby 52** 16 5.20 (3.41-7.93)
Proper food and rest for the mothers 76** 55 2.06 (1.40-3.03)
Time of initiating safe intercourse & FP 66** 34 3.55 (2.43-5.17)
Orissa N= 285 N= 323
Delivery Process and events 85** 63 2.79 (1.84-4.22)
Initiation of breast feeding 95** 68 10.27 (5.46-19.31)
Exclusive breast feeding 97** 85 6.39 (2.92-13.97)
Birth registration 94 ** 69 7.35 (4.22-12.79)
Immunization (BCG and OPV) 95* 89 3.03 (1.52-6.04)
N= 354 N= 343
Keeping the baby warm 90* 75 3.26 (2.09-5.07)
Danger signs and local illness 81** 52 4.09 (2.88-5.80)
Urine and stool passed by the baby 95** 69 9.99 (5.71-17.50)
Proper food and rest for the mothers 92** 64 7.23 (4.56-11.47)
Time of initiating safe intercourse & FP 95** 67 11.09 (4.91-25.08)
64
94 95 90
81
95 92 95
69
89
75
52
69 64 67
20
40
60
80
100
Birth registraion
Immunization (BCG and
OPV)
Keeping baby warm
Danger signs & local illness
Urine & stool passes by
baby
Proper food &rest by Mothers
Time of initiating safe intercourse
&FP
Pe
rce
nta
ge
Counseling Issues
Intervention
Control
Figure 6.1: Counseling on HBNC by ASHA, Rajasthan
Figure 6.2: Counseling on HBNC by ASHA, Orissa
Health Outcome: Key HBNC Indicators
In order to understand the level of translation of these counseling messages into actual practice, a few
of the practice indicators were analyzed: percentage of newborns registered, percentage of newborns
immunized with BCG, OPV, and percentage of babies weighed and percentage of newborns given
supplementary food. The data (Table 6.4) shows that significantly higher proportion of mothers in the
intervention area compared to those from control area reported on birth registration and weighing of
baby at home (P<.001). Proportion who reported immunization of their newborns was similar across
intervention and control districts in both the states.
76
92
71
44 52
76
66
29
82
38
17 16
55
34
0
20
40
60
80
100
Birth registraion
Immunization (BCG and
OPV)
Keeping baby warm
Danger signs & local illness
Urine & stool passes by
baby
Proper food &rest by Mothers
Time of initiating safe intercourse
&FP
Pe
rce
nta
ge
Counseling Issues
Intervention
Control
65
Table 6.4: HBNC- Health outcomes for Newborn
* p<.05, ** p<0.001
Referrals for mothers and newborn
Nature and outcome of referral for mother and newborn: One of the other major components of NIPI
training is the counseling of mothers by ASHAs to help identify danger signs for mother and newborn,
which can play a key role for timely referral.
In the survey 49 percent of respondents reported requiring medical care during the postnatal period. Of
these, more than three fourth (77 percent) required medical care due to newborn illness. A majority (93
percent) of the respondents who required medical care reported visiting a health facility and this
proportion was higher in intervention districts (94 -- 99 percent) compared to control district (85 -- 97
percent). A significantly higher proportion of mothers and newborns in intervention districts were
advised by ASHAs to visit a health facility (Table 6.5). However, family members remained the primary
advisors for referral in both mothers and newborn illnesses. Thus, there is need for further training and
supervision of ASHAs so that they are able to identify danger signs and provide referrals to
appropriate facilities. Also, the referral funds provided to ASHAs should be appropriately used
towards providing support for the transport of ill mothers or newborns to the facilities.
The main reasons for referral were infections/fever and post-partum bleeding for mothers, and acute-
respiratory Infections for newborns. The outcomes of the referral visit were not positive for the majority
of sick mothers in Rajasthan compared to patients in Orissa—more mothers in Alwar reported being still
sick compared to mothers in Sawai Madhopur. However, outcomes for newborn care were more
positive and showed less difference between intervention and control areas (Table 6.5). Most of the
respondent visited private facilities for their treatment (54 percent) and 28 percent of respondents
visited DH.
In terms of cost of transportation for referral 98 percent of the cost is paid by family members and only
2 percent by ASHA/ ANM and the situation is same for both intervention and control district. This is also
reflected in utilization of ASHA referral fund which is 20 percent (allocation: Rs. 1.12 million) in Anugul,
and 4 percent (allocation: Rs. 1.19 million) in Alwar (Details in terms of fund utilization is provided in
Chapter 7.2)
Intervention Control Odds Ratio (95 percent CI)
Rajasthan N= 449 N= 489
Newborn registered 86** 73 2.04 (1.33-3.12)
Baby weighed at home 23** 10 2.15 (1.37-3.35)
Newborn not given supplementary food 28* 17 1.67 (1.13-2.47)
Orissa N= 358 N=350
Newborn registered 90** 70 4.21 (2.74-6.49)
Baby weighed at home 61** 9 16.53 (10.76-25.39)
Newborn not given supplementary food 26 21 1.31 (0.92 – 1.87)
66
Table 6.5: Information related to Referral
6.4 Summary
The analyses show that NIPI has helped strengthen training on HBNC, which is critical for improving
ASHA’s performance in enhancing maternal, newborn and child survival. The training method of pictorial
cards, content and supportive supervision including field level follow ups perhaps were the main reasons
for the differences in newborn outcomes that were observed between the intervention and control
districts.
The data from the community survey clearly showed improvement in key areas of newborn care
outcomes in the intervention districts particularly in terms of key indicators like registration (varies from
90 percent in intervention district to 70 percent in control district), weighing of baby (varies from 61
percent in intervention district to 9 percent in control district), and not giving supplementary food to the
newborn (varies from 28 percent in intervention district to 17 percent in control district). There was also
a significant improvement in terms of the reported counseling received from ASHA for early and
exclusive breast feeding (varies from 85 percent in intervention district to 67 percent in control district)
and immunization for the newborn in the intervention districts (varies from 92 percent in intervention
district to 82 percent in control district). The identification of danger signs and subsequent referrals
including use of referral funds although higher in intervention districts were still low overall and has the
potential for improvement. The structure of the training program of NIPI with emphasis on field visits
and a skill based approach thus hold promise and can play a critical role in making HBNC training more
consistent, effective and result oriented.
Rajasthan Orissa
Intervention N= 451
Control N= 489
Intervention N= 359
Control N= 353
Referral for Mother ( percent)
Mothers required medical care after delivery 9 14 14 12
Advised to visit health facility by ASHA 14 4 34 2
Outcome of the visit
Completely cured 51 71 78 76
Still sick 49 29 22 22
Referral for Newborn ( percent)
Infants required medical care after delivery 45 35 38 33
Advised to visit health facility by ASHA 14 8 31 10
Outcome of the visit
Completely cured 67 70 82 84
Still sick 32 30 17 10
Died 2 0 1 6
67
6.5 Recommendations
Besides the content and structure of HBNC training, the actual implementation of the learning is
critical. So there is need for NIPI or NRHM to focus on other complementary activities which include
supportive supervision, regular refresher training, performance monitoring and feedback.
Moreover, HBNC training should be customized further in terms of local content, and imparted
through more field level demonstrations. The analysis highlighted the need to focus more on
counseling and advice of danger signs for mother and newborn. Thus HBNC training for the ASHAs
should focus more on identification of danger signs for mother and newborn during the postnatal
period and appropriate referrals.
Better strategy is urgently needed in terms utilization of referral funds that are to be provided to
ASHA/ ANM. Monitoring and supervision along with clear guidelines for fund usage is to be provided.
68
7. COMBINED BENEFITS OF YASHODA & HBNC PROGRAM
This section summarizes the benefits of the combined exposure to Yashoda and NIPI trained ASHAs
compared to the control group. The analysis was done in such a way that the respondents who received
services from both Yashodas and NIPI trained ASHAs (women who delivered in DH and CHC of Alwar and
DH of Anugul) were compared with respondents who only received HBNC from NIPI trained ASHAs
(women who delivered at facilities/home where Yashodas were not available) and to the control group
who did not receive any of the NIPI interventions.
The analysis clearly showed that mothers who had exposure to both Yashodas in the facilities and NIPI
trained ASHAs in the community reported improved newborn care outcomes compared to those who
received just ASHA exposure and to those from the control areas (Table 7.1). This trend was true for
almost all indicators. For example, in Rajasthan 75 percent of mothers with Yashoda and ASHA exposure
reported receipt of counseling on keeping the baby warm compared to 64 percent of mothers with just
ASHA exposure, and 34 percent of mothers in the control district (p=0.000). In other words, mothers in
Alwar were four times more likely to have received counseling on keeping the baby warm compared to
mothers in the control district (OR 3.79, CI 2.57, 5.57) (Figure 7.1). In Orissa 84 percent of mothers with
combined exposure reported receipt of counseling on identification of danger signs compared to 74
percent (p<0.05) of mothers with just ASHA exposure and 52 percent of mothers in the control district
(OR 4.98, CI 3.24, 7.65). Immunization of new born with BCG and OPV showed no significant difference
between mothers who received NIPI interventions and those who did not receive the same.
Table 7.1: Incremental benefit of Yashoda and HBNC program
Rajasthan Orissa
Yashoda + ASHA
ASHA Control p value
#
Yashoda + ASHA
ASHA Control p value
#
Counseling indicators (n=333) (n=118) (n=258) (n=253) (n=106) (n=323)
Initiation of breast feeding 83 63 56 0.000 96 97 68 0.000
Exclusive breast feeding 85 75 67 0.000 97 100 85 0.000
Birth registration 76 88 30 0.000 94 97 69 0.000
Immunization (BCG and OPV) 92 88 82 0.002 95 100 89 0.006
(n=333) (n=118) (n=336) (n=253) (n=106) (n=343)
Keeping the baby warm 75* 64 38 0.000 91 88 75 0.000
Danger signs and local illness 44 44 17 0.000 84* 74 52 0.000
Nutrition (Proper food/rest for mother) 76 79 55 0.000 93 89 64 0.000
Family planning 67 64 34 0.000 95 100 67 0.000
Practice indicators (n=333) (n=118) (n=489) (n=253) (n=106) (n=350)
Newborn registered 87 83 72 0.000 91 91 70 0.000
Baby weighed at home 22 27 10 0.000 61 63 9 0.000
Immunization (BCG) 94** 83 90 0.003 96** 78 94 0.000
Immunization (OPV) 94* 85 88 0.009 96** 76 95 0.000 #
Chi-square P values comparing three groups; * P<.05, ** P<0.001 refers to difference between Yashoda +ASHA vs. ASHA
69
Figure 7.1: Combined Effect of Yashoda and ASHA (Odds ratios with 95percent confidence intervals) Rajasthan Orissa
.
This analysis thus showed that the dual exposure of mothers to both Yashoda and NIPI trained ASHA had
an incremental effect on newborn care indicators (both counseling and practice) compared to mothers’
exposure to just ASHAs and a significant total effect compared to the control group. This study was not
designed to identify significant differences if any between these two groups of respondents, however
the trend is clear and suggest that NIPI interventions on the whole has resulted in improved outcomes
for the newborn. Further study may be undertaken to understand the impact of these two programs on
neonatal mortality.
70
8. TECHNO-MANAGERIAL SUPPORT & FINANCIAL RESOURCE ANALYSIS OF NIPI
8.1 Techno Managerial support
Techno managerial (TM) support encompasses a wide variety of activities like capacity building,
additional human resource deployment and financial aid for specific project components, advocacy
framing and program implementation support.
International experience suggests that for TM support to be effective it should be: country-owned,
country-led and demand-driven with adherence to the highest standards of quality, should be results
and partnership-oriented, with inclusive membership, and focus on national capacity, and the
strengthening of national and regional institutions and systems in ensuring sustainability40.
One of the primary inputs by NIPI is to provide TM support to state health missions in addressing
maternal and child health issues.
Program documents were reviewed to extract the techno managerial inputs provided by NIPI. These
were classified as follows:
Program planning and implementation:
Support in planning of maternal and child health activities at the national, state and district levels.
Additionally, support in implementation and supervision of such activities at the state, district and
sub-district levels.
Coordinating review meetings at the district and block child and maternal health officials.
Support to Yashodas in terms of mentoring, training, skill development , functioning etc. at various
institutions (DH, CHCs)
Identifying child and maternal health interventions which are innovative and gender sensitive
Coordinating the implementation of routine immunization and mapping of cold chain system.
Training: Organizing training on child and maternal health, for medical, paramedical, managerial
personnel and ASHA-Sahyogini/AWW at the district and sub district levels in collaboration with the
DPMU
Research: Facilitating surveys and studies on the child and maternal health issues.
Infrastructure development: Monitoring the facility up-gradation of Newborn Care Unit at district
and block levels.
Techno-managerial component at the state and district levels
NIPI teams at the state level, both in Rajasthan and Orissa, are led by senior doctors who are retired or
deputed government employees. They are supported by non-medical personnel essentially from
management and social sciences backgrounds. The positioning of these senior personnel with prior
government association places NIPI at an advantageous position as they effectively liaise with the state
health societies, have credible knowledge of state health systems and are respected by district level
officials, which facilitates streamlining of operational issues. Further, their expertise is used by the state
governments in planning for maternal and child health activities in the state.
71
At the district and block levels NIPI had planned for techno managerial support through placement of a
Child Health Manager, Child health Supervisor, District Training Coordinator, District Public Health Nurse
Manager, Data Assistant and Block Child Health Manager. However, there were variations in the
recruitment of these positions between Rajasthan and Orissa as some of the positions were district
specific requirements, for example the recruitment of the data assistant in Anugul district of Orissa.
At the district and block levels the child health managers were recruited to support the District Program
Management Unit and Block Program Management Unit respectively. Their primary functions included
facilitating the formulation, implementation and monitoring of child health and related maternal health
interventions implemented under District Program Implementation Plan (PIP) within the NRHM
framework. The district child health supervisor is primarily responsible for the management of the
Yashoda program and is assisted by a Yashoda supervisor. It is a critical position for the effective
execution of the Yashoda program as shared by NIPI team members. “The child health supervisor can
keep the flock together” (IDI, NIPI Central team)
Although the larger role envisaged for the techno-managerial staff of coordinating and providing
technical support for all maternal and child health issues at the district and block levels remains
unfulfilled, they have been largely successful in managing the Yashoda and HBNC programs in their
respective districts. Routine checks on the performance of Yashodas and providing supportive
supervision to them were undertaken by child health supervisors. An important achievement has been
the on-the-ground post-training support to ASHAs on HBNC by the district and block child health
managers. This ranged from regular filling up of the PNC cards to discussing experiences of ASHA home
visits during sector meetings. However the compilation of data collected by the Yashodas and ASHAs has
not been done routinely, resulting in lack of empirical feedback. Also, in order to facilitate effective
monitoring of its activities NIPI had provided for a mobilization fund for its staff. The utilization of this
fund was considerably delayed due to government protocols and affected monitoring activities.
The timely recruitment of the techno-managerial positions plays a pivotal role in the execution of the
NIPI interventions. However this recruitment process was a major bottleneck. In line with NIPI’s strategy
to engage the government in the implementation of its intervention, the recruitment process of all
positions was done as per government guidelines. This resulted in substantial delay in recruiting the
personnel owing to extensive paperwork, state elections, etc.
“When we work with the government such delays are expected, there is nothing we can do about it.”
(IDI, NIPI state team, Rajasthan)
A significant impact of this was noted in the functioning of Yashodas at the CHC level in Alwar,
Rajasthan, where due to the delay in placement of the supervisors the performance of Yashodas
suffered.
Retention of existing staff at the district level was also a pertinent issue that needed attention. The high
turnover of staff at the district levels lead to loss of program learning and experiences. It was also
72
observed that NRHM employees at the district level do not consider NIPI staff as part of the public
health system. “They (NRHM staff) consider us to be outside people who are here for a short term…our
names are also not there in the list of employees in the DPMU” (IDI, NIPI state team, Rajasthan)
There is considerable scope in developing the techno-managerial component of NIPI and emphasis needs to
be given to the district and sub-district levels. Recruitment of the staff at this level should also be directly
taken up by NIPI in the future as the delays caused by government processes have significant implications on
the success of a time bound intervention such as NIPI’s. Skill up-gradation of the staff should also be
undertaken so that the role envisaged for them can be fulfilled.
8.2 Financial resource analysis
Performance in a program is intrinsically linked to adequacy and utilization of financial allocation and
utilization within the program. To analyze the financial management practice within NIPI, a resource
analysis of NIPI funds in Alwar and Anugul was conducted with the purpose of analyzing the fund flow
system from state to district level, analyze the utilization and absorptive capacity of districts to utilize
the funds allotted under NIPI, through some basic financial performance indicators, and identify the
bottlenecks in the financial management of NIPI.
The study team visited Anugul and Alwar, and met the key program officials including the Yashoda
Coordinator, District and Block MCH Officer, District Accounts Manager responsible for NIPI fund
management and State Program Manager, NIPI and Finance and Accounts Controller of NRHM. Further
the team analyzed key financial parameters like approved budget, released fund, utilized fund, and
performance of the district in utilization of funds. An exchange rate of $1 to `44 was used.
Fund Utilization in Anugul, Orissa
During 2010-11, Anugul received a total of ` 22,975,603 ($522,173) of NIPI funds. Utilization was only 34
percent of the total available funds, which is lower than the 49 percent utilization in the preceding year.
Figure 8.1 shows the year-wise NIPI fund utilization for last three years (2008-11).
Figure 8.1: Year-wise fund utilization in Anugul
73
Maximum funds were utilized in Yashoda component (85 percent), and ASHA HBNC package (45
percent) (Table 8.1). Activity-wise fund utilization for Anugul (2010-11) shows that while funds available
for Yashoda, particularly salary and incentive component, registered maximum utilization (85 percent),
other activities like untied fund (33 percent), mobility support, salary of supervisory staffs (27 percent),
and SNCU support (0 percent) reported low utilization (Annexure 6). Frequent revisions of financial
guidelines, financial monitoring and follow-up, and coordination added to poor fund utilization in
NIPI, and have implications on program activities.
Table 8.1: Key Budget head fund utilization Anugul (2010-11)
Fund Available ` in million (USD in ‘000)
Utilization (percent)
Total Yashoda Fund 0.84 (18.99) 85
Other activities under NIPI 2.24 (50.08) 27
TOT on ASHA PNC 2.20 (49.95) 12
ASHA referral Fund 1.12 (25.53) 20
ASHA PNC Package 6.49 (147.43) 45
Meeting Expenses 0.11 (2.45) 33
Untied Fund 8.37 (190.28) 33
Immunization 0.12 (2.68) 0
Sick Newborn Care Unit 0.29 (6.57) 0
Fund Utilization in Alwar, Rajasthan
The Program Implementation Plan (PIP) for 2010-11 under NRHM for Alwar amounted to ` 278,565,000
(6,331,023 USD). The PIP states facility based newborn care (including Yashoda and SNCU), newborn
stabilizing unit at FRUs, consumables drugs and supplies for child health, and hiring of district MCH
coordinators as budgeted to NIPI. Approved allocation under NIPI (2010-11) was ` 16,083,000 (365,523
USD), which is about six percent of total NRHM allocation for the same year. While the first year fund
utilization was a mere four percent in Alwar district, utilization increased gradually to 13 percent by
2009-10, and to a significant 40 percent in 2010-11.
Figure 8.2: Year-wise fund utilization in Alwar
74
Fund utilization is high for HBNC component (84 percent), followed by Yashoda (35 percent) (Table
8.2). Among activities with significant fund allocation, strengthening HBNC during PNC period, salary to
Yashoda supervisor (80 percent), and orientation of ASHA in HBNC (66 percent) had significant fund
utilization. Funds allocated for other activities with significant allocation like salary of BMCH, referral
fund for sick newborn, salary of pediatrician, strengthening immunization, IEC activities, setting SNSU
were left significantly unutilized. (See Annexure 7).
Table 8.2: Key budget head fund utilization Alwar (2010-11)
Fund Available ` in million (USD in ‘000)
Utilization percent
HBNC 4.4 (99) 84
Yashoda 3.6 (82) 35
SNCU 1.3 (30) 14
Managerial Support 4.9 (112) 26
Improving Immunization coverage 0.7 (16) 7
IEC/BCC 0.5 (11) 0
Flexi Fund 0.2 (5) 10
Challenges in NIPI Fund Management
Some of the biggest challenges faced in the implementation of NIPI programs seem to be intrinsically
linked to procedures in the NRHM such as recruitment, fund-flow, retention of staff, and procedures in
procurement. It has been pointed out that “whatever plays out for NRHM interventions will be the same
for NIPI interventions also”, since NIPI functioned within the context of NRHM. The team felt that
solutions for such problems must be explored as system-wide interventions within the larger framework
of NRHM. At the state level, NIPI functions closely with the NRHM and bottlenecks in both programs are
similar.
Uniformity of financial management practices: Financial Management practices in NIPI vary by states.
Table 8.3 highlights some key difference in Orissa and Rajasthan. It will be prudent for NIPI secretariat to
encourage the state program officers to study each other’s strengths and adopt the best practices.
Table 8.3: NIPI Financial Management in Orissa and Rajasthan
NIPI Financial Management in Orissa and Rajasthan
Parameters Orissa Rajasthan
Funds Transfer Funds transferred in a separate account of NIPI managed by MO I/C and BMCH.
Funds transferred in NRHM flexi pool.
Fund Management Activity-wise fund release, advance, opening balance, expenditure and closing balance statements available for each quarter.
Activity-wise fund allocation and expenditure details not available.
Fund Utilization Thirty Four percent of released funds were utilized in Anugul by end of March 2011.
Forty one percent of released funds were utilized in Alwar by end of March 2011.
Yashoda Honorarium
Fixed honorarium Incentive linked @ ` 100 per delivery, up to a maximum of ` 3,500
ASHA referral Fund Guidelines
ASHA can only refer cases with BPL card BPL card guidelines do not exist
75
Financial Review NIPI review meetings are primarily meant for programmatic progress and limited review of financial
progress. Financial review happens at the district level and once in six months at block level. Review is
based on a financial management review (FMR) format.
Untied Fund Each block reported receiving untied funds, on average ` 50,000 in Alwar, and ` 200,000 in Anugul. In
Rajasthan, Block officials did not prepare a plan of action, however, in Orissa, all Block program officers
reported preparing a plan of action that was approved in the Rogi Kalyan Samiti (RKS) meeting. In both
states, block officials reported that guidelines were changed several times. PHC Medical Officers
reported difficulty in spending the money, as RKS members differed in their views on expenditure
patterns. In Alwar, untied funds were utilized for ASHA referral, repairing hospital furniture,
recruitment, advertisement, and printing of formats. In Anugul, more robust utilization of untied funds
were reported, which included: renovation of labor room and maternity ward, PHC renovation,
equipment for newborn care including purchase of baby mosquito net, organizing special programs to
promote institutional deliveries, repairing and procuring equipment like ILR point, AC stabilizer etc.
ASHA Referral Fund Utilization of the ASHA referral funds (` 1000 per ASHA) was low in both states. In 2010-11, utilization of
ASHA referral fund is 20 percent (Allocation: ` 1.12 million) in Anugul, and 4 percent (Allocation: ` 1.19
million) in Alwar. The criteria for utilization of ASHA referral fund are different for Rajasthan and Orissa.
In Orissa, ASHA could use the referral fund only for families with BPL card; however, no such restrictions
existed in Rajasthan. Officials in Orissa reported that ASHAs had difficulty referring cases from lower
socio economic strata that did not possess a BPL card. The low utilization of referral funds is reflected in
the inability of the ASHAs to use these to support referral transport in the field (2% of survey
respondents mentioned ASHA as a source for referral transport support).
8.3 Summary
NIPI funds contribute about six percent of total NRHM district allocation for 2010-11. NIPI fund
utilization has been around 40 percent in both Anugul and Alwar, which is a significant improvement
from utilizations in the initial program year. Across both Rajasthan and Orissa, maximum funds
utilization was for Yashoda and HBNC components. This is reflected in the coverage survey comparing
Yashoda and HBNC outcome in intervention and control districts, as discussed in the preceding section.
However, low utilization of untied fund and ASHA referral fund leaves scope for better financial
management practices, authorization, utilization guidelines, monitoring and decentralization in financial
planning and delegation. Frequent revisions of financial guidelines, financial monitoring, follow-up, and
coordination added to poor fund utilization in NIPI, and have implications on program activities. Some of
the biggest challenges faced in the implementation of NIPI programs seem to be intrinsically linked to
procedures in the NRHM such as recruitment, fund-flow, retention of staff, and procedures in
procurement. At the state level, NIPI functions closely with the NRHM and bottlenecks in both programs
are similar.
76
8.4 Recommendation
NIPI can encourage the state program officers to study each other’s strengths and adopt best
practices.
NIPI should develop appropriate system of authorization, whereby District Child Health Coordinator
and the District Accounts Manager should be authorized to release the honorarium for Yashodas,
referrals and untied funds.
Guidelines for utilizing untied funds should suggest a list of possible and permissible activities.
Program managers should be adequately sensitized about the guidelines. This, along with a NIPI
financial management manual specifying authority and delegation of financial control and
accountability to district and block officials can help in better utilization of untied funds, which play
critical role in facilitating program progress.
NIPI program should attempt to implement uniform system of financial reporting based on activity-
wise resource allocation and expenditure, statement of total fund release verses utilization, and
reporting of efficiency in incurring of expenses by blocks. Performance grading of blocks and districts
in terms of utilization of funds, can help improve fund utilization. NIPI state program managers can
facilitate the process through proper sensitization training and regular review a should include both
programmatic and financial performance indicators.
77
9. CONCLUSION AND RECOMMENDATIONS`
The assessment of NIPI interventions using various methodologies has thrown light on different aspects
of the program. The ethnographic studies concluded that a well trained Yashoda working as a mother’s
aide in the facilities can provide the much required support to mothers. She can serve as an important
negotiator between traditional practises and facility-based care. Both Yashodas and ASHAs could change
the way people engage with the health system and these workers could create active demand for good
quality health services.
Yashoda program
The qualitative assessment of the Yashoda program revealed that Yashodas generally came from
economically vulnerable groups and their jobs added to the household income. They were placed in
facilities to be a mother’s aide and this role is generally understood by other health providers; however,
there is a constant push for her to become a nurse’s aide. Supervision was an important factor affecting
their performance. With regard to remuneration, Yashodas preferred a mixed system combining
incentives with a regular salary.
Mothers generally reported comfort and were happy with the support provided by Yashodas and this
may have an impact on length of stay at facilities.
The community survey showed that significantly higher proportion of mothers in the NIPI districts
reported receipt of (i) counseling messages related to breast feeding, nutrition, immunization and
danger signs and (ii) postnatal checks in the facility (BP, temperature, perineum). However the actual
levels of post natal checks were low and require attention. Yashoda’s presence was most useful for
mothers who had C-section deliveries as they reported two-fold higher rates of initiation of breast
feeding within five hours as compared to mothers who had C-section but no exposure to Yashodas.
HBNC program by ASHAs
The assessment showed that the NIPI training method and content of the training materials used by NIPI
has strengthened the HBNC component. This was evident from the two to four fold differences in
knowledge (exclusive breastfeeding, birth registration, keeping baby warm, danger signs) and practice
indicators (birth registrations, use of supplementary food) related to newborn care reported by mothers
in NIPI districts compared to mothers from control districts. The identification of danger signs and
subsequent referrals including use of referral funds although higher in intervention districts were still
low overall and have potential for improvement.
The analysis of the combined effect Yashoda and HBNC on new born care indicators showed that
mothers who had exposure to both Yashodas in the select facilities and NIPI trained ASHAs in the
community reported improved newborn care outcomes compared to those did not receive any NIPI
interventions.
The fund flow analysis showed that NIPI remained within the NRHM structure and provided catalytic
support to NRHM. However, some of the biggest challenges faced in the implementation of NIPI
78
programs were also intrinsically linked to procedures in the NRHM such as recruitment, fund-flow,
retention of staff, and procedures in procurement. The fund utilization improved over time and the
Yashoda and HBNC component reported the highest expenditure. Low utilization of ASHA referral fund
has affected the ability of ASHAs to sufficiently support referrals in the study districts (two percent of
referral transport costs paid by ASHAs).
The study thus showed that the Yashoda and HBNC programs supported by NIPI in select districts of
Rajasthan and Orissa have resulted in significant improvements in the knowledge and practice of
important maternal and new born indicators. These interventions could be scaled up in rest of the
districts in the state and perhaps in the country in a phased manner with due considerations to the
various recommendations provided below and in various sections of this report. The recommendations
below represent the most important from this study. These could have an impact on both maternal and
neonatal outcomes. However, it is important to have active participation of communities as a non-
negotiable precondition for such programs to be sustainable and have long lasting impact.
Recommendations
Active demand for institutional births supported by Yashoda should be promoted by building in
strategies for community participation and involvement of local communities (through
increased awareness).
Branding of the Yashoda through her clothing and work as a mother’s aide perhaps with supply
of newborn kits to support the mother and new born would be important. Yashoda’s role as a
mother’s aide could be made specific and clear during recruitment, such as by keeping
education level below tenth grade and training to keep her identity distinct from that of nurses
or other staff.
There is need to increase focus on normative behavior (dignity, ethical norms, human rights,
protection) in the training modules for both ASHA and Yashoda.
Weak supervision of Yashodas has serious implications on discharge of duties by them, and
therefore supervision needs to be strengthened, especially at the CHC levels. Supportive
supervision through appropriate support at the facility and encouraging their role as mother’s
aide is important.
To improve continuum of care, the presence of ASHAs at registration provides an excellent
opportunity for Yashodas to interact with them and take over the mother’s care (through
sharing of the ANC card information) at the facility. Similarly, at discharge, Yashodas could
provide similar information about the mother to the ASHAs to continue care through postnatal
visits at home.
Counseling on danger signs, facilitation of PNC checks, and use of supplementary feed could
receive further focus and attention. Customized, field based, and frequent training should be
considered.
HBNC training should be customized further in terms of local content, imparted through more
field level demonstrations. Continued focus on supportive supervision, regular refresher
training, performance monitoring and feedback are integral and should be emphasized.
79
ASHAs should be provided more information and training on the identification of danger signs
for the mother and newborn and appropriate referral should be strengthened and referral funds
for transport made available to ASHAs.
Guidelines for utilizing untied funds should suggest a list of possible and permissible activities.
Program managers should be adequately sensitized about the guidelines.
NIPI program should attempt to implement uniform system of financial reporting based on
activity-wise resource allocation and expenditure and reporting of efficiency in expenses
incurred by blocks.
80
ANNEXES
Annexure 1: Baseline data on Intervention and Control districts In Rajasthan and Orissa
INDICATORS Rajasthan Orissa
Alwar SWM* Source Anugul Bargarh Source
Population Characteristics
Population 2,990 1,117 Census 2001 1140.0 1346.0 Census 2001
Population Density (2001) 357 248 Rajasthanstat.com 179 231 angul.nic.in, bargarh.nic.in
Decadal Growth rate (1991-2001) 30.2 27.4 Census 2001 18.6 11.5 Census 2001
Sex Ratio * 887 889 Census 2001 941 976 Census 2001
Percent Rural population 85.5 81.0 Census 2001 86.1 92.3 Census 2001
Percent Urban population 14.5 19.1 Census 2001 13.9 7.7 Census 2001
Percent SC population 18.0 20.0 Census 2001 17.2 19.4 Census 2001
Percent ST population 8.0 21.6 Census 2001 11.7 19.4 Census 2001
Female Literacy Rate (7 years and above) 44.0 35.4 Census 2001 55.4 50.3 Census 2001
Male Literacy Rate (7 years and above) 78.9 76.8 Census 2001 81.4 77.4 Census 2001
Standard of Living Index (Rural)
Low (percent) 62.7 83.3 DLHS III 73.2 84.4 DLHS III
Medium (percent) 26.8 13.2 DLHS III 10.7 10.6 DLHS III
High (percent) 10.6 3.5 DLHS III 16.1 5.0 DLHS III
Health Infrastructure
District Hospitals 1 3 Various Progress Reports of the Health Dept 2008-2011
1 1 angul.nic.in, bargarh.nic.in
CHC 21 4 1 8
PHC 70 23 27 51
Family Planning
Current Use: Any Method (percent) 61.2 53.1 DLHS III 51.7 44.6 DLHS III
Current Use: Any Modern method (percent) 58.3 50.3 DLHS III 35.4 42.3 DLHS III
Total Unmet Need for Family Planning (percent) 19.4 19.0 DLHS III 23.9 30.1 DLHS III
Maternal Health:
Mothers registered in the first trimester when they were pregnant with last live birth/still birth (percent)
21.7 26.7 DLHS III 57.3 59.0 DLHS III
Mothers who had at least 3 Ante-Natal care visits 14.4 18.1 DLHS III 60.4 64.3 DLHS III
Institutional births (percent) 45.9 48.6 DLHS III 40.7 43.6 DLHS III
Delivery at home assisted by skilled personnel (percent) 10.6 8.5 DLHS III 11.5 40.2 DLHS III
Mothers who received post natal care within 48 hours of delivery of their last child (percent)
28.3 28.8 DLHS III 97.9 92.2 DLHS III
Child Immunization :
Children (12-23 months) fully immunized 25.1 26.4 DLHS III 62.0 70.4 DLHS III
Children (12-23 months) who have received BCG (percent) 75.7 64.6 DLHS III 97.3 98.8 DLHS III
Children (12-23 months) received 3 doses of Polio Vaccine (percent)
55.6 47.9 DLHS III 85.6 93.4 DLHS III
Children (12-23 months) received 3 doses of DPT Vaccine (percent)
28.5 34.3 DLHS III 74.9 86.5 DLHS III
Children (12-23 months) received Measles vaccine 54.7 45.5 DLHS III 89.2 81.2 DLHS III
*SWM- Sawai Madhopur
81
Annexure 2: Detailed data collection table February-May 2010
Sr.no Respondent Category / Observation report Anugul Bargarh Alwar SWM
Supply side
1
Qu
alit
ativ
e
ANM FGD 1
2 ANM IDI 1 1 4
3 ASHA FGD 2 3 2
4 ASHA IDI 4 4 13 8
5 Additional District Medical Officer IDI 1
6 Doctor, Medical Officer 1 1 6 1
7 Matron/ Head Nurse 1 1 1 1
8 Deputy Child Health Manager IDI 1
9 District Child Health Coordinator IDI 1 1
10 Maternal Child Health Coordinator IDI 2
11 Staff Nurse IDI 1 2 2 2
12 Yashoda IDI 4 6
13 Yashoda Supervisor IDI 1 1
14 Yashoda FGD 1
15 Hospital Manager IDI 1
16 District Program Manager 1 1 1
17
Qu
anti
tati
ve Semi Structured Interview – Yashoda 12 44
18 Semi Structured Interview – ASHA 94 42 67 38
Demand Side
19
Qu
alit
ativ
e
Community Woman's IDI 3 3 8 4
20 Community Woman's Case Study 2 2 1
21 Community Woman's FGD 2 1 1 2
22 Observation study 6 Days 4 days 16 days *
23
Qu
anti
tati
ve Semi Structured Interview – Mothers 60 45 68 42
24 Semi Structured Interview - Mothers (with infants referred)
6 0 14 0
Others
25 VHSC FGD 2
26 Panchayati Raj Institution Member FGD 1 1 1
* Not done as Yashoda were placed at the facility
82
Annexure 3: Listing process
The following steps were followed to recruit the respondents in Rajasthan:
1. The sample size for Rajasthan was 1000 with 500 each in Alwar and Sawai Madhopur.
2. To recruit 250 respondents who had delivered at the district hospital in the mentioned period
Doctors, Nurses and Yashoda’s at the DH were consulted and blocks were identified in Alwar which
accounted for high case load at the DH.
3. At this point it was checked if the blocks identified in point no 2 are similar to the 8 CHCs that were to
be covered in Alwar and 5 CHCs in Sawai Madhopur. The common blocks were the focus for data
collection.
4. At the CHC level, the Chief Medical Officer, Nursing Head (Matron) and Yashoda were consulted to
generate a list of at least 3-4 villages from the CHCs catchment area from where majority of pregnant
women came for deliveries.
5. Once the villages were identified the mobile no. of the ASHA(s) who are responsible for these villages
were collected.
6. The total number of deliveries that had taken place in the ASHA’s area in the defined time period was
estimated.
7. All women who had an institutional delivery at the concerned CHC or DH Alwar from that village were
contacted. Additionally, mothers who have had a delivery at home or any other institution were also
contacted.
8. In Alwar 8 CHCs were covered. The respondent recruitment for each CHC area were as follows:
a. 20-25 respondents who had delivered in the concerned CHC
b. 12 -15 respondents who had delivered in home or other institutions
c. Any respondent who had delivered in the district hospital
The following steps were followed to recruit the respondents in Orissa:
1. The sample size for Orissa was 1000 with 500 each in Anugul and Bargarh.
2. To recruit 250 respondents who had delivered at the district hospital in the mentioned period
Doctors, Nurses and Yashoda’s at the DH were consulted to identify the blocks and villages in both
districts which account for high case load at the DH.
3. Once the villages were identified the mobile no. of the ASHA(s) who are responsible for these villages
were collected.
4. The total number of deliveries that had taken place in the ASHA’s area in the defined time period was
estimated.
5. All women who had an institutional delivery at the DH from that village were contacted.
6. Additionally, mothers who had a delivery at home or any other institution were contacted.
83
Annexure 4: Details of PNC beds and manpower in select Alwar CHCs
S. No. Name of Block No. of beds
Number of Nurses
Nurses on duty in one shift
No of Yashodas
Yashodas on duty in one shift
Average deliveries per day
1 Bansur 8 3 1 4 1 4
2 Bardod 14 1 1 3 1 6
3 Behror 17 2 1 4 1 4
4 Kherli 18 1 1 2 1 NA
5 Kishangarhwas 10 1 1 4 1 4
6 Kotkasim 12 4 1 4 1 3
7 Malakhera 10 2 1 4 1 6
8 Mundawar 10 3 1 4 1 2
9 Ramgarh 14 1 1 3 1 6
10 Rajgarh 19 5 2 8 2 7
11 Tijara 24 1 1 4 1 5
Malakhera: there were 2 staff nurse and rest were helping hands including 2 male nurses; staff
nurses rotate their eight hourly duties during 24 hrs.
Ramgarh: there was only 1 staff nurse and 1 LHV.
Kherli: there were no staff nurses; only one ANM was deputed who had charge of a staff nurse.
Except for Malakhera in all other CHCs there were no staff nurses for night duty, they were
available in the morning and evening shift.
Annexure 5: Activity-wise fund utilization in Anugul for year end 2010-11
Total Fund Available ` in million (USD in ‘000)
Utilization
ASHA PNC PACKAGE 6.49 (147.43) 45 United fund (District ) 5.80 (131.73) 18
United fund (Block) 2.58 (58.56) 67
TOT on ASHA PNC (Block Level) 1.84 (41.75) 4
ASHA Referral Fund (Block Level) 1.12 (25.53) 20
Salary -Jr. Manager, Child Health 0.91 (20.70) 39
Salary of Yashoda 0.47 (10.65) 92
Salary-Dy. Manager, Child Health 0.44 (10.05) 25
Mobility support-J.M.C.H 0.37 (8.49) 19
TOT on ASHA PNC (District level) 0.36 (8.20) 52
Sick New Born Care Unit 0.29 (6.57) 0
Mobility support for Dy Manager 0.24 (5.47) 1
Salary of Child Health Coordinator 0.18 (4.11) 80
Flexible fund (office Contingency) 0.16 (3.62) 30
Salary of Child Health Supervisor 0.13 (3.00) 91
Meeting Expenses 0.11 (2.45) 33
84
Annexure 6: Activity-wise fund utilization in Alwar 2010-11
Budget head Amount ` in million (USD in ‘000)
Utilization ( percent)
Incentive to Yashoda 3.5 (80) 35 Salary of Block Manager-Child Health 2.7 (61) 28
Strengthening Home Based Neonatal Care (HBNC) during PNC period through ASHAs’
2.2 (50) 139
Shishu Raksha Fund (Referral fund for sick newborn)
1.2 (27) 4
Salary to Pediatrician at DH 0.8 (19) 0
Re-orientation of ASHAs in HBNC 0.8 (19) 66
Strengthening immunization 0.7 (15) 0
Consumables & Operational Expenses 0.5 (11) 0
IEC Posters and Charts for Improving nutrition, breast feeding and other child rearing practices
0.5 (11) 0
Setting up of Sick Newborn Stabilizing Units (SNSU) At 18 CHCs in Alwar-8, Bharatpur-7 and Dausa-03, Repair of equipment & Consumables @ Rs .50 Lakhs per SNSU
0.4 (9) 0
Salary of Hospital Supervisor Maternal & Child Health
0.4 (9) 80
Salary of District Manager-Child Health 0.3 (7) 15
Salary of District Public Health Nurse Manager
0.3 (6) 20
Salary of Nurses at DHs 0.2 (5) 0
Equipment for SNCU at Districts Hospitals 0.2 (5) 0
Civil Work at SNCU 0.2 (5) 0
Flexible Fund at District level 0.2 (5) 0
Re-orientation of Supervisors (ANM, LHV & MOs)
0.2 (4) 0
85
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