Evaluation of Accredited Social Health Activists in tribal blocks of India

Author(s) Satish Saroshe1, Suraj Sirohi2, Sunilkant Guleri3, Sanjay Dixit 4.
Affiliation(s) 1Community Medicine, M.G.M Medical College, Indore, India, 2Community Medicine, M.G.M Medical College, Indore, India, 3Community Medicine, M.G.M Medical College, Indore, India, 4Community Medicine, M.G.M Medical College, Indore, India.
Country - ies of focus India
Relevant to the conference tracks Advocacy and Communication
Summary ASHA (meaning Hope in Hindi) is a program of Accredited Social Health Activists who works at basic grass roots level in one of the world's largest healthcare programs, NRHM- National Rural Health Mission. The present study was carried out in Bagli block (primarily a tribal block) of Dewas district of Madhya Pradesh (state with highest Infant Mortality Rate= 56 in India) to evaluate ASHA based on the 8 factors critical for success of ASHA identified by Government of India.
Background ASHA is a program of grass roots workers under NRHM (National Rural Health Mission), the largest health care program of the Government of India which started in the year 2005. ASHA are female health activists in the community who creates awareness on health and its social determinants and mobilizes the community towards local health planning and increased accountability of the existing health services. The 8 factors identified by the Government of India critical for the success of ASHA are 1. Selection of ASHA by a prescribed process as per the ASHA guidelines. 2. Linkage with nearest functional health facility for referral services. 3. Identified transport for referral of cases from village to facility. 4. Priority and recognition of cases referred by ASHA to MO/ANM. 5. Successful organization of monthly Village Health Sanitation and Nutrition Committee (VHSNC) and Village Health Sanitation and Nutrition Day (VHSND) in every village with the ANM ( Auxiliary Nurse Midwife) and AWW (Angan wadi worker). Angan wadi is the basic unit of Govt. of India ICDS (Integrated Child Development Scheme) 6. Monthly meeting of ASHA at PHC. 7. Timely payment of incentives to ASHA. 8. Timely replenishment of ASHA Kit.-which contains 13 Items.
Objectives Broad Objective
To evaluate the function, knowledge & skills of Accredited Social Health Activist (ASHA) in a tribal block of a state with highest Infant Mortality Rate in India.
Specific Objectives:
To study the working of ASHA & identify the problems experienced by them within their workplace.
To assess the knowledge & skills of ASHA.
To study the training status of the ASHA.
To assess the beneficiary satisfaction of ASHA as experienced by Community .
To identify recommendations based on present study.
Methodology Type of study: Cross Sectional Descriptive.
Study Duration: June to August 2013.
Study site: 30 densely tribal villages of Bagli Tribal Block of Dewas District of Madhya Pradesh state of India.
Study Tools: 1. Pre-designed semi structured questionnaire 2. Observational check list.
Ethical Concern: Written informed consent was obtained by all the ASHAs.
Sampling Technique: Convenient sampling (Due to shortage of funds & logistic problems 50 ASHAs were selected from 30 densely tribal villages of Bagli Tribal Block of Dewas District of Madhya Pradesh State of India.
Selection Criteria:
Inclusion Criteria- 1. Those ASHAs fulfilling the selection criteria laid by NRHM guidelines identified in the selected 30 villages. 2. Those ASHAs giving written informed consent.
Exclusion Criteria:Those ASHAs not giving written informed consent.Data Analysis: Microsoft, Excel & Spread Sheet and SPSS ver. 19.
Results 100% ASHAs were the primary female residents of the village that they had been selected to serve.
84% are married, 12% are widowed and 4% of ASHAs are divorced.
4% are graduates, 14% are 10th grade pass, 82% are 8th grade pass.
26% are in age group 25-29 years, 58% are in age group 30-34 years and 16% were from 35 years to 45 years.
100% ASHA had good rapport with ANM (basic health worker posted at Sub Health Center & Primary Health Center) & AWW (Anganwadi worker – basic nutrition worker posted at Anganwadi Center which is the basic nutrition centre located in a population of 1000 in both rural & urban areas.)
100% ASHAs mobilizes the community and facilitates them in accessing health and health related services available at the village such as the Sub Health Center & Primary Health Center.
All the ASHAs (100%) coordinate with 108 Emergency Ambulance and Janani Express obstetric care Ambulance for referral of cases from villages to healthcare facility.
In 93% of the villages the Village Health Sanitation and Nutrition Committee is operational to deal with health & Nutrition issues. Sanitation is covered only in 7% villages in the present study.
Out of the 13 items to be provided in ASHA Kit, 12 were present in 95% ASHAs- DDK (Dai Delivery Kit ) which were for delivery at homes: Tab. Iron Folic Acid, Zinc based ORS Packets, Tab. Paracetamol, Tab Dicyclomine, Providine Ointment Tube, Thermometers, Cotton Absorbent Roll, Bandages (4cm x 4 meters), Tab. Chloroquine, Condoms, Oral Contraception Pills. The only item not found in the ASHA Kit during the present study was Tab. Punarvadu Mandur (ISM Preparation of Iron).
100% ASHAs complained of irregularity in the timely incentive payments of ASHAs.
100% ASHAs were trained in all the 7 mandatory modules of ASHA Training.
In 100% of the villages the beneficiaries were satisfied by the work of ASHAs in the community experience.
Conclusion In present study the ASHAs were married, widowed & divorced because according to Indian cultural norms after marriage a woman leaves her father’s house (and village) & migrates to that of her husband in accordance with the selection norms laid under NRHM. As per criteria ASHAs should be minimum 8th grade pass which was 82% in the present study. The maximum (94%) were in the 25 to 35 age bracket which is in lines with the criteria of age group 25 to 45 years according to NRHM. It is worth noted that, for selection of ASHA as per guidelines, Gram Sabha (Democratically elected local village body) or VHNSC recommends five names of suitable candidates to the Block Medical Officer (BMO). Appointment letter is issued by the BMO. Since VHNSC is not fully operational in most of the 30 villages, all the 50 ASHAs in the identified villages were selected by Gram Sabha. The 4 most common reasons for Community Mobilization for Health and Health related services by ASHA in order of frequency are as follows: immunization, antenatal care check-up, nutrition related problems and postnatal care check-up. There is no Community Mobilization by ASHA for sanitation and related services. The 108 Emergency Ambulance & Janani Express Obstetric Care Ambulance has connected almost every village to health facilities. At present in Bagli Community Health Center (CHC) there is 1 BLC (Basic Life Care) 108 and 1 Janani Express Obstetric Care Ambulance in Udai Nagar Tribal Primary Health Care Center. In Dewas District (under which Bagli is one of the Blocks) there is only 1 ALC (Advance Life Care) 108. The most common reasons for the referral of cases by ASHA to Medical Officer/ANM in order of frequency are: pregnancy and pregnancy related, GI (Gastro-Intestinal) related problems and respiratory tract infections. Recently the NGOs have trained the 7th comprehensive module to all the ASHAs of the identified villages. In all the villages the community was completely satisfied with the work of ASHA.

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