Community_Processes

1. COMMUNITY PROCESSES -

2. Key elements of community processes
 ASHA and her support network at block, district and state levels.
 Village Health Sanitation and Nutrition Committee (VHSNC) and
Mahila Arogya Samiti (MAS)
 Rogi Kalyan Samitis.
 Community Based Monitoring
 Engagement with NGOs /civil society organizations to support
implementation,

3. ASHA-
Rural – 8.9L +
Urban – 63,312
Skill
building
Incentives
Career
Opportuniti
es
Grievance
Redressal
Equipment/
kit
Support
structure

4. Policy and Programme Evolution
 Expansion From High focus to Non High Focus and now urban areas
 Focus on skill building of ASHAs and strengthening training systems at National and State
level
 ASHA evaluation and Parliamentary Committee Report led to major policy changes – role
clarity, (3 roles), training expedited, support structures, payment streamlined
 Focus on newborn care with incentive + strengthening of equipment kit
 Performance Monitoring / Handbook for ASHA Facilitators and Grievance Redressal
Mechanism introduced
 Revised Guidelines –Roles of support structures defined, increase of ASHA budget from
10,000 to 16000 , VHSNC guidelines
 Routine and recurring incentives introduced
 ASHA certification roll out
 Launch of CPHC and universal screening for common NCD guidelines which envisage her as
a critical member of primary health care team.
 Launch of social security benefits for ASHAs and AFs
 Increase in routine and recurring incentives for ASHAs and honorarium for AF

5. Background
- Phase –I: starting 2006: ASHAs were trained and deployed in 18 high focus
states and in tribal districts of the remaining states: 400,000 ASHAs:
- Phase-II, starting January 2009, extended programme to all districts in all
states: except Himachal, Goa, Puducherry, and selected districts in Tamil
Nadu
- Phase III: - December 2013: Launch of the National Urban Health Mission –
urban ASHA and Mahila Arogya Samities
- Currently: VHSNC and MAS universal; ASHA in all states except Goa.

6. Understanding the ASHA’s role
A. A facilitator or link worker – where there is low use of health services, the
ASHA enables people to access health services
B. A volunteer and activist- to enable access to health entitlements and
reaching the marginalized.
C. A community level care provider- important for her credibility, to respond to
local health needs, particularly in in underserved areas.
- Getting the mix right is the challenge. If limited only to “link worker” role – she
is unable to reach the marginalized or in providing first level care, resulting in
a huge missed opportunity to save lives.
6

7.  NRHM – 8.92 Lakh ASHAs against the target of 9.48 L – 94% in
33 states and UTs ( except Goa, Delhi and Puducherry)
Less than 90% in 5 states and Uts- Tamil Nadu (57%), Kerala (78%), Daman & Diu
( 74%) ,West Bengal and DNH (83%)
 NUHM – 63312 ASHAs against the target of 73726 – 85.9% in 32 states and UTs
(except Goa, A&N islands, Chandigarh and Lakshadweep
Up to 85% in 5 states - Meghalaya – 81%, AP – 77%, J &K – 59%,
Karnataka- 83% and Kerala – 48%
Selection

8. Challenges with selection
 Challenge of selecting ASHAs in small (dispersed) areas still remains in few states (MP,
UP, Rajasthan, Bihar and Gujarat.)
 Non resident ASHAs selected in states like Kerala and Maharashtra to adhere to the
educational criteria
 Gaps also seen in states that provide incentives from state budgets or other budget
heads- (Sikkim, WB, Karnataka, Tripura, Rajasthan) – no revision of target is being
undertaken
 Reports of political influence in removal of non functional ASHAs and ASHA selection
 High Attrition rate in urban and peri urban areas because of availability of better
opportunities

9. ASHA Training
1. Induction Training – (Modules 1-5) - Originally consisted of 21 days of training in
five module ; but now modified to an eight days training in one Induction Module
2. Module 6 & 7- 20 day training to be completed in four rounds.
3. Supplementary or refresher Trainings - At least 15 days of training annually
planned in which new topics and skills can be added/ or to reinforce existing skills
Introduction of Home Based young child care and Non communicable
diseases module training

10. Skill Building
300 state trainers
trained in three
rounds ofTOT
Over 6700 district
trainers trained in three
rounds ofTOT
ASHAs under NRHM
Round 1- 8.5L (93%) ;
Round 2-8.1 L (91%);
Round 3- 7.7 L (85%);
Round 4- 5.4 L (60%)
RefresherTraining – 19 states
PHC monthly meetings- used
as a
platform for refresher
training sessions in 19 states
ASHA CERTIFICATION-24
states and UTs
ASHAs under NUHM-
Round 1- 61%
Round 2- 55%
Round 3- 42%
Round 4 – 23%
Attrition of trainers
Limited availability of
training sites
Limited availability of ASHAs
due to multiple campaigns
Plateau noted across states –
slow progress in completing
Round 3 /4 training

11. Training Modules

12. Support Structures
12
State
• MD, NRHM
• ASHA/Community Processes Resource
Centre
• State ASHA Mentoring group
District
• District Community Mobilizer
/Coordinator
• Supported by DPMU/District Health
Society
Block
• Block Community Mobilizer
• Block Programme Manager
Sub block
• ASHA Facilitator- one per ten to twenty
ASHA/VHSNC
• VHSNCs
 Substantial progress made in
establishing support structures
across states
 All high focus states have support
structures at four levels except
Odisha
 North Eastern states have 3-4
levels of support structures except
Sikkim with only one level
 Non high focus states like Andhra
Pradesh, Telangana, Tamil Nadu
and Kerala, have support
structures only at one level- rest
managed by existing staff.

13. On job mentoring Support
ASHA facilitators – 36039/ 39838 (90%) in 20
states
+
Existing staff ANM/ LHV support ASHAs in
remaining states
BCMs– 4064/4846 (84%) in 19 states
District level- 541/648 (83%) in 26
states
Low investment in regular capacity
building
Poor coordination between ANM
and AF
Low utilization of Performance
monitoring of ASHAs

14. State specific incentives
• 15 states provide monthly honorarium –
 Top up incentives – Chhattisgarh, Meghalaya, Tripura, Gujarat, Haryana,
 Rs. 1000-Rs. 2500 pm – Odisha, Rajasthan, Uttarakhand, Delhi, Haryana, HP,
Kerala and West Bengal
 Rs. 3000- Rs. 6000 pm –AP, Karnataka, Sikkim
• Social Security Benefits –
 Insurance – Chhattisgarh, UP, Assam, Kerala, West Bengal
 Corpus fund – Jharkhand, Odisha, UK
 ASHAS covered under existing schemes- Gujarat, Haryana and Maharashtra

15. Career Opportunities
• Facilitation of enrolment in ANM courses - Ten states - Chhattisgarh, Jharkhand
Assam, Madhya Pradesh, Uttrakhand, J &K, Maharashtra, Arunachal Pradesh, Assam
and Tripura.
Out of 2030 ASHAs, 674 have completed their courses and 519 have been employed.
( About 431 ASHAs took admission in ANM/ GNM courses through their own efforts in
Haryana. 229 have completed their courses and 52 have received employment)
• Enrollment in education equivalency programmes -Bihar, Jharkhand, Chhattisgarh
and Delhi
• Selection as ASHA facilitators
Challenges–
• Ensuring job as ANM/ SN after completion of course
• Selection of new ASHAs to fill the gaps
• ASHA facilitators continue to work as ASHAs - in Bihar, Jharkhand, Odisha and Sikkim
- which has increased their work load immensely and affects their functionality in
each role

16. ASHA Certification
• Worked out in coordination with National Institute of Open School to-
 Enhance competency and professional credibility of ASHAs
 Improve quality of training and ensure desired programme outcomes.
 Enhance quality of services being provided by the ASHA.
 Provides credibility and promotes sense of self recognition
• Four components of Programme will be certified: Training Curriculum,
Training Sites, Trainers and ASHAs and ASHA Facilitators.

17.  States Criteria- Completion of training of ASHAs in Rounds 1-4 of Module 6 & 7
 Implementation in currently 23 States and 1 UT namely-
Arunachal Pradesh Madhya Pradesh Tripura
Assam Maharashtra Uttarakhand
Chhattisgarh Manipur West Bengal
Delhi Meghalaya Dadar and Nagar Haveli
Gujarat Mizoram Haryana
Himachal Pradesh Nagaland Telangana
Jammu and Kashmir Odisha
Jharkhand Punjab
Karnataka Sikkim

18. ASHA CERTIFICATION –PROGRESS
Accredited Training
Sites
35 state training
sites across 21
states;
95 district training
sites across 12 states
Certified Trainers
 179 state trainers
across 21 states
 468 district trainers
across 12 states
Certified ASHAs and
ASHA Facilitators
About 6212
certified; and
 Result awaited for
10966 ASHAs and
ASHA Facilitators
from 15 states

19. Practical
Skills-
Essential and
Random
Skills
Evaluation of
ASHAs

20. ASHA-Theory
Examination

22. RECENT
INITIATIVES

23. HOME BASED YOUNG
CHILD CARE

24. • POSHAN Abhiyaan (PM’s overarching scheme for holistic nutrition)- launched
for reduction in childhood stunting, undernutrition, anaemia, low-birth
weight, etc. for child survival and development
• Home Based Care for Young Child (HBYC) launched to expand community-
based care of infants beyond 42nd day after birth.
• As part of HBYC initiative, five additional home visits by ASHA after the 42nd
day, in addition to the 6/7 visits for HBNC -
• 3 months, 6 months, 9 months, 12 months and 15 months.
• First Phase roll out planned in aspirational districts.

25. Brochure on
HBYC :
Improving on
Health and
Nutrition through
home visits by
ASHAs
Job Aid for
ASHAs on
HBNC and
HBYC
Handbook for
ASHA on
HBYC
Revised MCP
card

26. Status Update -
• FY 2018-19- 23 States & 108 districts (82 aspirational districts)
• FY 2019-20 – 240 districts (115 aspirational districts) in all States & UTs except
Goa, Lakshadweep & Puducherry
• Training update -
 National Trainers – Pool of 28 trainers created
 State Trainers – 128 state trainers trained from 27 states in four National Level
TOTs at NHSRC
 State level TOT – 496 district level trainers (64 districts-12 States) prepared
for HBYC roll out

27. COMPREHENSIVE PRIMARY HEALTH
CARE SERVICES
Health andWellness Centres

28. Role of ASHAs as Primary
HealthTeam Member
• Population Enumeration
• Community Based Health Risk Assessment
for Chronic Illness
• Health promotion – Life style and health risk
modification for prevention and
management of NCDs
• Follow up for treatment adherence and
enabling lifestyle changes
• Creating and supporting Patient Support
Groups

29. Continuum of care for chronic diseases – built on existing work flows
Village/Urban
Ward
• Population Enumeration
• Outreach Services
• Community Based Risk Assessment
• Awareness Generation
• Counselling: Lifestyle changes; treatment compliance
SHC-HWC
• First Level Care
• NCD Screening
• Use of Diagnostics
• Medicine Dispensation
• Record keeping
• Tele-health
• Referral to PHC for
confirmation/ complication
Diagnosis for NCDs
Prescription and Treatment Plan
Gate Keeping role for out patient and inpatient
referral / PMJAY
Teleconsultation with specialists
PHC-HWC
• Advanced diagnostics
• Complication assessment
• Hospitalization
• Tertiary linkage/PMJAY
CHC/SDH/DH
Follow
up post
secondar
y and
tertiary
care

30. Incentives under HWCs
 Performance linked team based incentives –
- MLHP – Up to Rs. 15,000 pm
- MPW- Up to Rs. 3000 pm for MPWs
- ASHAs – Up to Rs.5000 pm for team of ASHAs
• Common indicators (15) to be measured for estimating performance of all team
members
 ASHA Incentives - CPHC guideline include provision for incentives for new
service packages as part of CPHC roll out under HWCs - (Rs. 1000/ASHA/per
month linked with activities).

31. NEW INCENTIVES

32.  Doubling of routine and recurring incentives for ASHAs from Rs. 1000 to Rs.2000/month.
 Increase in supervisory visit charges for ASHA Facilitators from Rs. 250 per visit to Rs. 300
per visit.
 Home-Based Care for Young Child (HBYC) incentive additional 5 home-visits at 3rd month,
6th month, 9th month, 12th month and 15th month- Rs.50 /visit- Rs. 250 per child
 Kala Azar elimination (under National Vector Borne Disease Control Programme)- ASHAs
will be given incentive for referring suspected cases of Kala Azar and ensuring complete
treatment of the same (Rs. 500/per notified case).
 Incentives for maintaining data validation and collection of additional information for
enrollment of households in Pradhan Mantri Jan Arogya Yojana under Ayushman Bharat
(Rs. 5/form/family).
 Immunization –
 Complete immunization per child up-to two years age – Revised from Rs, 50 to Rs. 75 per
child
 DPT Booster at 5-6years of age – Rs. 50 per child

33. SOCIAL SECURITY BENEFITS

34.  Pradhan Mantri Jeevan Jyoti Bima Yojana (PMJJBY) - Eligibility Criteria - 18 to 50 Years
Benefit Rs. 2 Lakh in case of death of the insured, due to any reason.
 Pradhan Mantri Suraksha Bima Yojana (PMSBY) – Eligibility Criteria - 18 to 70 Years
Benefits –
• Rs.2 lakh for accidental death
• Rs. 2 lakh for total and irrecoverable loss of both eyes or loss of use of both hands or feet
or loss of sight of one eye and loss of hand or foot
• Rs. 1 lakh for total and irrecoverable loss of sight of one eye or loss of use of one hand or
foot
 Pradhan Mantri Shram Yogi Maandhan Yojana (PM-SYM)-
• Pension scheme for unorganised sector for 18-40 years of age with a monthly income of
Rs. 15,000 or below.
• Monthly premium will depend on the age of enrolment of beneficiary ranging from Rs.
110 to Rs. 400 pm. 50% contribution by beneficiary and 50% by beneficiary
• Benefit – Rs. 3000 pm after age of 60 years.

35. ASHA Programme: Then and Now
• Mature programme
• Attributable success in improved access to
care and reduction in mortality indicators.
• High equity potential
• Progressive increase in tasks and incentives
• Integral to the system
• Streamlined Payments
• Evidence from India and globally- CHW role in
chronic diseases
• Support Structures in place
• Training and certification progress
• Sustainability????
• ASHA not considered in health
workforce planning
• Selective MH focus
• Tenuous link to the health
system
• Limited ownership of
programme officers
• Unclear identity
• Delays in payment
• Poor training quality

36. Some unresolved issues
• New incentives and benefits being offered to ASHAs but larger issues of improving
working conditions for ASHAs with focus on safety/ security measures are yet to be
addressed.
 Few (9- Assam, Bihar, Meghalaya, Jammu & Kashmir, Jharkhand, Tripura, Karnataka,
Sikkim and Uttarakhand) states have invested in creating ASHA rooms at high delivery
case load facilities
 Grievance Redressal Committees constituted in 23 states but are yet to become fully
functional in most states
• Performance measurement mechanism with regular feedback is yet to be
institutionalized
• Streamlining replenishment of kits
• Role of ASHAs in urban areas not in sync with the local context and health needs
• High turnover rates in urban areas – retention of ASHAs is a challenge in view of other
opportunities

37. Village Health, Sanitation, and Nutrition Committees
• Over 500,000VHSNCs across the country; GP/Revenue village level
• Key platform for social determinants and convergence at village level
• Experience demonstrates effectiveVHSNC functioning where ASHA has a
convening role- mutually supportive
Challenges –
 Reconstitution ofVHSNCs is yet to be completed
 Ad hoc orientation – limitation of trainingVHSNC members at scale
 Low levels of engagement with trainers who understand social mobilization
 Limited functionality ofVHSNCs with irregular meetings
 ASHA and AF not yet fully equipped and supported to serve the fulcrum role as
envisaged.

38. VHSNC training
- Need to build capacities for addressing the social determinants of
health and acquire complex skills of community based planning and
monitoring.
- Ideal process would be 2-5 day training for all members but there are
resource constraint
- Options: Training Facilitators so that they could provide leadership and
training for a batch of twentyVHSNC; engage NGOs who could deploy
multiple teams and trainVHSNC members for one round, to be
followed by periodic refreshers through ASHA training system.

39. VISHWAS – Village based Initiative to Synergise Health, Water
and Sanitation
• Launched as part of Swachh Bharat – Swastha Bharat initiative drawing
upon intersectoral Convergence
• VISHWAS campaign would build awareness and enable collective
community action onWater, Sanitation and Hygiene for improving Health
Outcomes
• VHSNC are envisaged to lead and organize 11 monthly campaign days over
one year- Initiative will strengthenVHSNCs as the community institution for
convergent action
• Each Campaign day will focus on a select theme, to build convergent action,
using programme and resources of Swachh Bharat Mission
• Gram Panchayat to play oversight and support role - approve the campaign
days and review its successes and challenges in Gram Sabha

40. VISHWAS
Structure of 11 Monthly Campaign Days
• Annual Planning Day for SwachhataCampaign
• Village Health and Sanitation Day
• Open Defecation Free (ODF) Day
• HandWashing day
• School andAnganwadi Sanitation day
• Liquid and SolidWaste Management Day
• Individual and Home Hygiene day
• Healthy Life Style Day / Health Promotion and
Communicable Diseases (NCD) Day
• Communicable Diseases andVector Control Day
• Celebration day for SwachhataChampions
• Gram Sabha on Sanitation & Cleanliness

41. Mahila Arogaya Samiti (MAS)
• One MAS for every 50 to 100 HHs
• Four MAS in every ASHA’s area
• Strong focus on using or aligning with existing community groups -
Community structures under NULM (SHGs) and existing women groups etc
can be co – opted
• Slow pace of constitution and training of MAS.
• Good practices noted from Odisha,Chhattisgarh,Gujarat and Rajasthan –
for training and grading of MAS

42. THANK YOU