An Accredited Social Health Activities (ASHA) evaluation was commissioned by the National ASHA Mentoring Group and coordinated by National Health System Resource Centre (NHSRC) in 16 States.The said evaluation was conducted in three rounds as follows:

Round one (2010-11)	Assam, Bihar, Odisha, Rajasthan, Jharkhand, Andhra Pradesh, Kerala and West Bengal
Round two (2011-2012)	Madhya Pradesh, Uttar Pradesh and Uttarakhand
Round three (2013-14)	Delhi, Gujarat, Haryana, Punjab and Maharashtra

 

The key findings of this evaluation are given below:

 

Key findings of ASHA Evaluation in Round One:

 

This evaluation commissioned by the National ASHA Mentoring Group, in two districts each in eight states, which included five high focus states (Assam, Bihar, Orissa, Rajasthan, and Jharkhand) and three Non High Focus states (Andhra Pradesh, West Bengal, and Kerala).

 

·        Most ASHA’s in the sample of this study are educated upto class VIII and above. Most ASHAs come from poor households, and the proportion of ASHAs who are SC/ST is equal to or more than the proportion of the SC/ST population on in most states. Only Andhra shows conscious affirmative action with regard to SC representation and tribal districts have usually preferred ASHAs from ST background. Minorities appear under-represented

·        The density of ASHA deployment varies across and within states, with most states having over 50% of ASHA catering to a population of less than 1000. In tribal areas of Jharkhand, Khammam and Banswara, ASHA density is less than one per 500, indicating that states have interpreted the norms to suit their contexts to some extent.

·        The vast majority of ASHAs are functional, irrespective of context and other constraints, although there is a wide variation in the exact set of tasks and services that an ASHA carries out.

·        In terms of coverage, the access to ASHA services was highest in Kerala with 85% of the potential users reported receiving Services from ASHA and lowest in AP with 50% while Orissa, Assam, Rajasthan and Jharkhand followed with 73-76%.

·        Of the high focus states institutional deliveries rates were highest in Orissa and Rajasthan (93%) followed by Bihar at 82%. At least three ANCs were received by the highest of 89% and 82% of service users A in Kerala and AP while among high focus states it drops to the highest of 70% in Orissa and less than 54% in all other states with the lowest of 21% in Bihar.

·        For New born care, a high proportion of service users A reported receiving advice on early initiation of breastfeeding which was over 73% in all states except for Assam & Bihar with 64-69% and Rajasthan where it was the lowest. However over 80% of all service users A reported breastfeeding the newborn in first four hours of birth across all states except Jharkhand.

·        In care during illness of the sick child at least 65% of ASHAs are being consulted. However despite her being “functional” on this task, her effectiveness is lower.

·        The opportunity to provide appropriate care appears to have been lost in the majority of cases, due to lack of skills, supplies, or limited support. For example the number of cases of diarrhea, for whom the ASHA was able to supply ORS from her kit, was 27% in Bihar, 37% in Jharkhand, 56% in Rajasthan, and 54% in Assam except in Odisha.

·        Similarly for children with symptoms suggestive of ARI, ASHAs were consulted by 67- 92% of the mothers and a majority of the service users B (over 90%) sought treatment indicative of high referrals rates made by ASHA.

·        Most of the ASHAs were making household visits which ranged from 57% in Jharkhand to 97% in Kerala. Of the high focus states, 88% ASHAs in Orissa reported making routine household visits.

·        The figure was less than 70% for the rest of the high focus states. ASHA are already making home visits for promotion of antenatal care, institutional delivery, immunization, seeing the newborn and being consulted on the sick child, and there is a considerable loss of opportunity, when the programme fails to leverage these home visits for achieving improved health practices and better child survival.

·        There was no evidence found on ASHA charging fees, setting up private practice, becoming a Dai or a tout of the private sector. ASHAs reported from a 1 % to 5% range of private sector commissions across the 16 districts. Exceptions to this are 9% in East Godavari, 11% in Bundi and 17.5% in West Singhbum. There is no significant preferential referral to the private sector evident in any state. There is no evidence of any major conflict between ANMs, AWWs and ASHAs.

·        In terms of the support the ASHAs require to perform better, about 70% to 90% articulated the need for better training as the single greatest requirement. Monetary support and timely replenishment of the drug kit was a distant second. The levels of political and administrative leadership for the programme also vary between states. Stability in senior leadership levels appears to correlate with better outcomes as seen in Assam, Orissa, and Andhra. Kerala demonstrates that while high political commitment is key to deciding to actually implement the programme, clarity in design, outcome and support which are important programmatic elements in ensuring ASHA effectiveness opting for the programme itself have not been addressed. One factor accounting for slow pace and limited effectiveness of the programme in Rajasthan, Bihar and Jharkhand could be frequent leadership changes and little drive and initiative at mid-levels.

·        The ASHA programme has been successful in terms of promotion of institutional deliveries and in immunization however the marginalized are yet to be covered, with between 15% to 50% of women in some districts have not been reached. The ASHA is not as effective in influencing critical health behaviours such as three ANC checkups, breastfeeding, adequacy in complementary feeding, with the same intensity, which undermines her effectiveness in bringing about changes in health outcomes.

·        The study concludes that greater support is to be given to the health rights dimension of the ASHA through a more meaningful engagement with NGOs, provision of competency based training, adequate drug supplies, and mentoring and motivation (beyond cash incentives). Research on CHW programmes worldwide show that such support does lead to saving lives of children and newborns. For India, such support will enable the ASHA to become an effective provider of community based care of newborns and sick children, improve her credibility and expand her reach into marginalized communities. Without this support NRHM will have missed the opportunity of universal coverage with community based care and likely faces a poor return on the substantial investment in the ASHA programme.

 

Key Findings from ASHA Evaluation Round two:

 

The evaluation of the ASHA Programme was commissioned by the National ASHA Mentoring group and coordinated by the NHSRC in the three High Focus states of Madhya Pradesh (MP), UttarPradesh (UP) and Uttarakhand (UK) conducted between November 2011 to March 2012. Two districts each were selected Udhamsingh Nagar and PauriGarhwal in Uttarakhand, RaisenandBhind in Madhya Pradesh, and Sonbhadra, Hamirpur, Aligarh and Lakhimpur were selected in Uttar Pradesh.

 

Profile of ASHAs:

·        Most of the ASHAs in all districts are educated up to class VIII and above; and reported family income between Rs.1000-5000 per month. In terms of representation of SC/ ST communities in selection of ASHAs, the selection was found to be equitable in all sample districts except District Sonbhadra of UP. However the representation of minorities was found to be significantly lower than the proportion of minority populations in all districts.

·        The population coverage of ASHAs varied across and within states. However, majority of the ASHAs in five of the sample districts reported covering between 501-1000 populations. The density was reported to be higher in the three districts of UP – Hamirpur, Sonbhadra and Aligarh where ASHAs reported covering between 1001-2000 populations

 

Functionality and Effectiveness of the ASHAs-

 

·        The majority of the ASHAs reported being functional on promoting institutional deliveries and Immunization. About 82-95% ASHAs across the three states reported accompanying women at the time of delivery, 72-82% reported providing counseling to pregnant women and 87-92% said that they promoted and coordinated the immunization days. Regarding household visits 68% of ASHAs in UP, 53% in Bhind District of MP and fewer than 40% in UK and Raisen district of MP, reported making such visits. Newborn visits were reported by 81% ASHAs in Aligarh, 52-62% in Bhind, Udhamsingh Nagar and the three remaining districts of UP as compared to only 37% in Raisen and Paurigarhwal. The lower reporting of home visits in Pauri despite the training could be due to geographic dispersion and weak support and mentoring.

·        In terms of coverage, as reported by Service Users A, access to ASHA services was highest in PauriGarhwal and Hamirpur with 88%. In the remaining districts this was 65-75% except for Raisen district where coverage was reported to be lowest with 44%.

·        The functionality of ASHAs in terms of promoting institutional delivery and counselling during ANC was 70% in UK as compared to 56% in UP and 48% in MP. But only 56% of Service Users A in UP, 44% In MP and 29% in UK reported getting three or more ANCs, which reflects the poor outreach services.

·        A high proportion of Service Users A reported delivered in institutions, - 89% in MP, 79% in UP and 70% in UK, over 70% cited ASHAs as the main motivator, and more than three quarters reported that ASHAs accompanied them to the institution. For early initiation of breast feeding the functionality was between 65-70% but the effectiveness was reported by 81% ASHAs in Aligarh, 52-62% in Bhind, Udhamsingh Nagar and the three remaining districts of UP as compared to only 37% in Raisen and Paurigarhwal. The lower reporting of home visits in Pauri despite the training could be due to geographic dispersion and weak support and mentoring. In terms of coverage, as reported by Service Users A, access to ASHA services was highest in PauriGarhwal and Hamirpur with 88%. In the remaining districts this was 65-75% except for Raisen district where coverage was reported to be lowest with 44%.

·        The functionality of ASHAs in terms of promoting institutional delivery and counselling during ANC was 70% in UK as compared to 56% in UP and 48% in MP. But only 56% of Service Users A in UP, 44% In MP and 29% in UK reported getting three or more ANCs, which reflects the poor outreach services.

·        A high proportion of Service Users A reported delivered in institutions, - 89% in MP, 79% in UP and 70% in UK, over 70% cited ASHAs as the main motivator, and more than three quarters reported that ASHAs accompanied them to the institution.

·        For early initiation of breast feeding the functionality was between 65-70% but the effectiveness was even higher as 80% of the service users reported that they started the breast feeding within three hours of birth. For post partum care however, ASHA functionality on knowledge of an important message such as foul smelling discharge as a sign of post partum complication drops considerably, with about 32 % ASHAs in UK, and less than 20% in UP and MP.

·        Home visits by ASHAs for post natal and newborn care were reported to be highest in UK; where 61% Service User (As) reported that ASHA had visited them more than three times during the first one month of the delivery. The respective figure was much lower with 40% in UP and 32% in MP. Coverage by ASHAs in case of a sick child was highest in UK with 41% followed by 32% in UP and 17% in MP. The functionality of ASHAs i.e. Service User (Bs) who reported that ASHAs helped them in managing the child hood illness was between 78-93% across states, while it was highest in UK with over 90%.

·        However this is not translated in to high levels of effectiveness as ASHAs were able to give ORS to in only 46-56% of cases. This reflects problems with supply and replenishment. In cases where she was not able to supply ORS directly she was referring the child for treatment, even then about 22% to 37% children who had diarrhea did not get ORS from any source. In case of ARI about 98% of the Service Users B sought treatment reflecting high referral rates of ASHAs. The knowledge of ASHAs about identifying chest in drawing as a danger sign for ARI and about making ORS was found to be low in UP and MP, and about 54% and 65% in PauriGarhwal and UdhamSingh Nagar respectively in UK.

·        ASHAs in all three states are more functional and effective on tasks related to promotion of institutional delivery and immunization which are also the most commonly incentivized tasks for ASHAs. The effectiveness of ASHAs in other areas such as ensuring three or more ANCs, providing appropriate advice in case maternal and newborn complication and community mobilization was found to be low in UP and MP. Skills levels of ASHAs for identifying danger signs of pregnancy and sick child were found relatively better in UK where ASHAs have completed training in two rounds of Module 6 and 7. But even here the high levels of day to day mentoring could have yielded better outcomes, particularly with regard to home visits. Clearly, in Madhya Pradesh and Uttar Pradesh there is a great urgency to rapidly establish and strengthen support structures and step up the pace of the programme. In Uttrakhand the priority is for the state to take ownership of the programme and work closely with the NGO support structures to make them more effective, by enabling quality standards of skill based training and effective performance monitoring. All three states also need to institutionalize a system of monitoring the functionality and outcomes of the ASHA programme. This is even more important in UP and MP, in order to identify and support poorly performing ASHAs, where the selection of ASHAs in the early phases was not community led and was influenced by vested interests. All three states, and more particularly MP and UP stand to benefit greatly from having a skilled ASHA at the community level to promote maternal, newborn and child health, and family planning.

 

Support Structure:

 

·        The data demonstrate clearly the influence of programme and support structures on the effectiveness and functionality of the ASHA. In all states the two functions of promoting mothers for institutional delivery and mobilizing for immunization appear to be the most common. In Uttarakhand where the training was rolled out and the support structures instituted early on, outcomes appear to be better. However geographic dispersion in hilly districts coupled with poor outreach services limit the functionality of the ASHA.

·        A further compounding factor may be that performance monitoring systems are not in place despite the training and support. Low coverage figures in Uttar Pradesh and Madhya Pradesh indicate that there may be significant exclusion. The slow pace of implementation particularly in training has limited the functionality and effectiveness of the ASHA in both states.

·        Institutional arrangements across the three states have significant variations, as reflected in the nature of support systems established, programme management, and influence on ASHA functionality and effectiveness. Uttarakhand was among the first high focus states to set up an ASHA Resource Centre at the state level which was outsourced to an NGO, the Himalayan Institute Hospital Trust (HIHT) in the year 2008. The same pattern was replicated at the district level as well, with the state opting to outsource the District ASHA Resource Centres (DARC) to the Mother NGOs working in districts. This facilitated rapid roll out of ASHA training, with the result that Uttarakhand was the first high focus state, (after Chhattisgarh) to complete training in all the modules. However the day-to-day hand holding of the ASHAs, support and mentoring need substantial strengthening.

·        In the state of Madhya Pradesh, where the programme was dormant until July 2010, significant achievements have been made in scaling up the training systems, both training institutions and trainers, given a determined Mission Director and a dynamic state nodal team of a few committed officers. This has resulted in galvanizing the ASHA training in Modules 5, 6 and 7 which has begun earlier this year. However the state still does not have a full complement of staff needed at the state level for the ASHA programme, nor district and sub district support structures. The state is planning to set up the support structures in this fiscal year.

·        In Uttar Pradesh, the state has appointed one General Manager, Community Processes, who manages the nearly 1,36,000 strong ASHA programme. He also holds additional charge of Training and Child Health for the state. He is supported by a team of three consultants from NHSRC. This is an interim arrangement, since the state has not been able to set up a dedicated state ASHA Resource Center. The state has appointed District Community Mobilisers in 62 out of 72 districts and at the block level the existing Block Extension Educator (BEE) is expected to support the programme. However the orientation of these personnel to the ASHA programme and training in supportive supervision and mentoring is weak, since no specific capacity building workshops have been organized as yet. They have not been trained in the ASHA modules either. Given these institutional constraints, the overall implementation of the programme including training of ASHAs has progressed slowly in the state. The state has also recently adapted the national Modules 6 and 7 to build skills of the ASHA. The state is in the process of creating the training systems for scaling up the training. The section below summarizes the data from the quantitative survey, which included ASHAs and the beneficiaries.

 

Key Findings from ASHA Evaluation in Round three:

 

·        The support structures for ASHA Programme have been set up at three (district, block and sub block) levels in Maharashtra and Haryana, at two levels– (district and sub block) in Punjab, only at sub block level in Gujarat and is supported by existing staff at these levels in Delhi. State level Community Processes Resource Centre exists only in states of Gujarat and Haryana, of which CPRC in Haryana was set up in the year 2012-13 and has about 11 team members.

·        In Gujarat though the State ASHA Cell has been created it and is led by Deputy Director Rural Health but had only one dedicated programme manager till recently. The team in Gujarat however has now been expanded with two additional appointments. In the remaining three states, the programme is managed by a team of members/consultants based within SPMU.

·        While Punjab has two consultants dedicated exclusively for community processes, there is on as one programme specific consultant supported by a data assistant in Maharashtra and Delhi has one State programme officer supervising a team of one state ASHA coordinator and two support staff for the ASHA programme. Training of support structures has been completed in Haryana and Punjab and it is underway in Maharashtra and Gujarat while it is yet to begin in Delhi.

·        These group of states barring Haryana and Delhi launched the training of ASHAs in Module 6 and 7 in 2011 but the pace and quality of training varied across states. The first Round of training of trainers was completed in 2011 for states of Gujarat, Haryana, Maharashtra and Punjab. This was followed by training of ASHAs in all states except Haryana, which initiated the training only in the year 2013. The state of Haryana decided to launch the training of ASHAs in Module 6 and 7 in the year 2013-14 only after the completion of training in HBPNC supported by NIPI in all districts. Delhi also started training its ASHAs in FY 2013-14, only after adapting the modules as per state’s context.

·        In an attempt to complete the training of ASHAs at the earliest, state of Gujarat considerably modified the agenda and shortened the duration of training sessions. This affected the training quality across districts and led to some incompleteness. As of now, training of ASHAs in Gujarat has been completed in Round 4 without completing the Round 3 Training of trainers.

·        Coverage of ASHAs for service users A is found to be quite high in states of Gujarat, Punjab and Maharashtra within the range of 80-90% and is significantly lower in Haryana (53.4%) and Delhi (65%).

·        The functionality of ASHAs in terms of visiting the service users during antenatal period is higher as compared to visits within three days of birth in the post natal period across all states. Lowest figures in these respective categories are 70% in Gujarat for ANC visits and of 49% from Delhi for PNC visits.

·        The functionality further drops for the minimum six visits specified under HBNC, in which the highest figure reported is only 39% from Maharashtra followed by 35% in Punjab, 31% in Haryana, 26% in Delhi and only 11% in Gujarat. Such low levels of functionality of ASHAs for HBNC can be linked to the pace and quality of training, post training supervision and non-availability of all components of HBNC equipment kit.

·        Despite a high proportion of service users reporting that ASHAs visited them at least three times during ANC period and within three days of delivery (except for Delhi with 48%), less than 45% of women who had any maternal complication sought ASHA’s advice for care in Delhi, Gujarat and Punjab while this figure was slightly better in Haryana and Maharashtra with 67% and 64% respectively. This is likely a reflection of the ASHAs skill levels.

·        ASHA’s knowledge to classify a newborn as low birth weight with less than 2000 gms of weight at birth is relatively better. It is over 50% in three states (highest being 73% in Haryana) and 48% and 43% in states of Gujarat and Delhi respectively. Also, her knowledge on specifying the actual cutoff date to classify a baby preterm was found to be accurate in less than 20% ASHAs in three states (Gujarat, Punjab and Maharashtra) while it was 42% in Haryana and 52% in Delhi. The effectiveness of ASHAs in terms of access to care for service users is within the range of 78-92% for antenatal care, 78-93% for institutional delivery, 70-99% in seeking care for maternal complications and 82-97% for seeking care for a sick newborn.

·        ASHA’s coverage in providing services to children who had any episode of illness in last one month shows huge variations among states, eg. Coverage for service user B was higher than ASHA’s coverage in case of service user As in Haryana (92%) and Maharashtra (93%) but in other states a significant drop is noted when compared with service user A.

·        Acceptance of ASHAs in service provision roles for child hood illnesses in states of Haryana, Punjab and Maharashtra can be attributed to better institutional support with improved availability of drugs and accessibility of the SHC/PHC staff. As anticipated out of the service users who approached ASHA, about 82-98% of service users said that ASHAs helped them in seeking care.

·        Better access to care is seen in cases of symptoms with ARI where over 96% sought care as compared to cases of diarrhea where less than 77% got the ORS (from any source) in three states and only in Maharashtra and Haryana it was made available in 97% and 82% cases respectively. In all states except for Maharashtra, ASHAs could give ORS to the child from her kit in less than 70% of cases.

·        The skill sets of ASHAs are also found to be low (less than 50%) when asked about how they would prepare ORS, advising increased intake of fluids during diarrhea and to identify chest wall in drawing as a sign in cases of symptoms with ARI.

·        Though less than 38% of the non- service user A and less than 65% of non- service users B could correctly tell the name of the ASHA working in their area, about 39%–56% of non- service user As and 68%–89% of non- service users B said that ASHAs visited their household at least once.

·        Despite not receiving any services from ASHAs, a high access to care is observed in both the categories i.e., over 87% of non- service users A opted for institutional delivery and over 90% of non- service users B sought treatment for childhood illnesses.

·        However except for state of Delhi where 46% reported going to private sector for institutional delivery and 56% for treatment of childhood illness, in other two states both categories of non- service users predominantly went to private sector. Eg –Delivery in private sector was reported by 71% in Gujarat and 82% in Punjab and over 90% of non-service users B went to private sector for treatment of their child’s illness. This is also reflected in the high OOP, the highest being from the state of Punjab – 64% of non- service users A reported an expenditure of Rs. 5000 or more and 46% of non- service user Bs of over Rs. 500. The respective figures were 39% and 29-32% in other two states.

·        In comparison to access to care, the findings with regards to behaviour change are not found to be as positive. Of the total non- service users A, less than 70% breast fed the newborn within 3 hours of birth and less than 39% said that they did not give any pre lacteal feeds or anything other than breast milk in first three days. Also less than 45% of non- service user Bs said they continued feeding the child during illness and of the total cases of diarrhea, the child got extra fluids only in up to 42% cases, exclusive breast feeding was followed in 75% of cases and complimentary feeding was started at 6th month in less than 51% cases. Except for Punjab where a very high proportion of Non services user As -57% and 66% Non- service user Bs said that they do not need services from ASHAs only 15%-17% in Delhi and 5-7% in Gujarat said the same. Of these respondents, over 95% in Punjab and 70% in Delhi gave their preference for private sector as a reason for not wanting the services from ASHAs.

·        Irrespective of ASHAs functionality, low levels of skill set across all states highlight the need for regular refresher training for ASHAs to address the low levels of skill attrition. Unlike the High focus states, the ASHA programme did not receive attention of the programme managers in these Non High Focus states till recently. As a result the focus on ensuring quality in trainings, setting up and building capacities of support structures for effective mentoring was limited. States need to strengthen the support structures to ensure regular and high quality of training along with effective field level mentoring support for ASHAs.

 

Action taken to address some of shortcomings aregiven below:

The measures have been taken over the last five years to strengthen the ASHA programme are as below:

 

1.      Training - Most states have now invested in creating a pool of trainers for ASHA training to expedite the pace of training.  To facilitate regular refresher training of ASHAs, MoHFW has issued guidelines for PHC monthly meeting as a forum of refresher training sessions in 2014.

 

In order to standardize the skills of ASHAs and to ensure training quality as well as to facilitate career progression of ASHAs, a proposal; for ASHA certification has been approved which envisages certification of  Training curriculum, training sites, trainers and ASHAs by the National Institute of Open Schooling

 

2.      Coverage – A training brochure ‘Reaching the unreached” was developed in 2012 in response to the finding of low coverage of ASHAs (excluding 30% of the total potential beneficiaries). Most states have trained the ASHAs in this brochure to sensitize ASHAs on the issue of marginalization. 

 

3.      Support Structure – States have made substantial progress in setting up support structures for ASHA programme. Handbook for ASHA facilitators was introduced in 2011 for training the ASHA facilitators in their roles of supportive supervision and performance monitoring of ASHAs. System of grievance redressal for ASHAs was introduced in 2012-13 and most states have set up processes of grievance redressal for ASHAs which include grievance redressal committees at district level, setting up toll free numbers and post boxes for registering of complaints.

 

4.      Incentives - In order to further streamline the payments of ASHA incentives MoHFW has introduced the publicly financed management systems. This would help in eliminating delays in ASHA payments and ensure regular monitoring of funds flow at all levels. 

 

In addition to the monetary incentives support is being provided to states to provide non-monetary incentives to ASHAs uniforms, I Card, cycle, CUG Sim, radio and ASHA awards. Support is also being provided to states to facilitate ASHAs enrolment in education equivalency programmes and give preference to ASHAs in ANM / GNM schools subject to their meeting eligibility criteria for their career progression. These improve the motivation and social recognition.

Public health being a State subject, implementation of the ASHA programme lies within the domain of the State Governments. However, performances of ASHAs are monitored on a set of selected indicators related to tasks of ASHAs. Performance monitoring is used as a tool for supportive supervision by ASHA facilitators to identify poor / non-functional ASHAs and supporting them for improving their performance. Performance monitoring of ASHAs is currently being done in about 20 states on a regular basis.  In all states, incentives amounts earned by ASHAs are used as a proxy to assess ASHA performance.

In line with their role as honorary community volunteers, ASHAs receive only performance based incentives. There are currently about 30 activities approved at the national level. Further, States are also supported under NHM for providing state specific incentives to ASHAs. In December 2013, the Mission Steering Group of the National Health Mission not only approved the enhancement of rates of existing incentives to ASHAs but also approved new incentives including those for routine and recurring activities so as to enable each ASHA to earn at least Rs. 1000 per month subject to her performing the said activities.

The Health Minister, Shri J P Nadda stated this in a written reply in the LokSabha here today.

 

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MV/BK/LK