This document summarizes a study on the role of Accredited Social Health Activists (ASHAs) in implementing comprehensive primary healthcare in Bihar, India. Key findings include: 1) ASHAs had limited understanding of their stated roles beyond maternal and child health. 2) Their recruitment and training did not follow NRHM guidelines and most received inadequate initial training. 3) ASHAs received little support from the community and healthcare workers. 4) The study recommends strengthening community involvement in selecting and training ASHAs, and establishing ongoing mentorship programs to better support their roles.

1. The contribution of Accredited Social Health Activist (ASHA) under National Rural Health Mission (NRHM) in the implementation of Comprehensive Primary Health Care in East Champaran district, Bihar (State) India Dr. VandanaKanth, Dr. Anil Cherian, Dr. Jameela George – Emmanuel Hospital Association, New Delhi. Teasdale Corti Research Project on CPHC

2. ASHA & NRHM The NRHM 2005-2012 launched to revitalize the public health system. Key health reform initiative : Accredited Social Health Activist (ASHA) ASHA represents the latest in a long series of attempts to introduce a lay village level health worker. ASHA scheme has been undertaken by 10 states and 1.2 lakhs

3. Comprehensive Primary Health Care Global initiative to revitalize “health for all” which is also resonant in the call for Universal Health Care. Comprehensive Primary Health Care Increased equity in access to health care. Reduced vulnerabilities through community empowerment. Reduced exposure to risk by addressing the social determinants of health.

4. NRHM in Bihar Launched in July 2006 Village Health & Sanitation Committee’s have not been constituted. 92% of targeted number of ASHA’s have been selected. 79% have received Module 1 training according to the RET Report for East Champaran. ASHA training was assigned to the PHE department.

5. Overarching Research Question How can the contributions of the ASHA to Comprehensive Primary Healthcare be strengthened?

6. Research Objectives To study the apparent contradictions in the stated roles of the ASHA’sand their current practice. To study the recruitment & training process of ASHA’s, the nature and levels of community support and their effect on her ability to contributing to CPHC in communities. To study the contextual factors (enabling and barriers) affecting the ASHA’s functioning, specifically in bring about improvements in health seeking behaviours, increasing utilisation of primary care services, timely referrals to appropriate secondary levels of care, building community capacities to assess, analyze and act on social determinants of health

7. Methodology Study location: 2 blocks of Purbi (East) Champaran District in Bihar. Study period: June 2009-October 2010 Mixed methods Focus Group Discussions (FGDs) with CBO’s & ASHA’s Key informant interviews ASHA’s , ANM’s , AWW, Panchayat members and Mukhiya’s (Villages chiefs). Participatory methods such as a Venn Diagram(chappati), Quantitative Methods: Household KABP survey ( Sample size= 300 households)

8. Location of the study

9. Findings ASHA’s understanding of their roles as given in the NRHM ASHA Guidelines 22% had a reasonable understanding 53% had some understanding 25% had very poor understanding of their roles. Universal perception: Welfare of pregnant mothers and immunization of children. Registration of pregnant women ( JSY Scheme) Immunization of mothers and children Facilitation of Institutional Delivery.

10. Perception of ASHA (self-perception), Auxiliary Nurse Midwives (ANM) and Anganwadi Workers (AWW) on the roles and responsibilities of ASHA’s

11. Other roles of ASHA None of the ASHA’s were involved in village level health planning. Concept of community monitoring was not understood. They were not involved in the facilitating the construction of toilets or in the promotion of sanitary and hygienic practices. Concept of “social health activist was not well understood. Most ASHA’s assumed that the term was related to volunteerism and the fact that she was not paid a salary

12. Factors contributing to the ASHA’s understanding about their roles Bi-variate analysis, N = 199 ASHA’s, Dependent variables = poor knowledge/ good and adequate knowledge)

13. Recruitment of ASHA’s The recruitment of ASHA’s in East Champaran Bihar has not been according to NRHM norms. Most of the ASHA’s were recruited by the Village headman (Mukhiya) and in one of the two blocks studied; the medical officer of the PHC selected 33.9% of the ASHA’s. The Gram Panchayat was involved in the selection of less than 10% of ASHA’s.

14. Training of ASHA’s The training received by the ASHA’s in East Champaran was very varied. 33% (1 out of 3) the ASHA’s in Adapur block were not even trained at induction. The remaining 67% ASHA’s only received 7 days of initial training The PHC medical officer conducted training. The main training method used was reading from the manual.

15. ASHA support and linkages The ASHA’s were hardly supported by the Panchayat. The Village headmen (Mukhiya) were only involved with her recruitment. Even the assistance that they received from Auxiliary Nurse Midwives or the Anganwadi worker was limited. Only 40% of ASHA’s said they received assistance from ANM’s and 60% from Anganwadi workers. Assistance to ANM,s was in immunization of children and pregnant mothers Anganwadi (Child Development)worker it was in identifying pregnant women.

16. Discussion Major gaps in the roll out of ASHA scheme in Bihar. The community involvement or the involvement of civil society in the whole process –recruitment / training has been limited. ( Compare Mitanin Programme Chhatisgarh). Activist role of ASHA’s in mobilizing the community, addressing the social determinants and equity issues not happening.

17. Discussion Training of ASHA’s – 67% vs 79% ( RET) of Module 1. Method of training inadequate. The only factor that was mildly significant was the length of the training day. Training may be an important aspect in the capacity building. The financial incentives appears to determine the role that the ASHA play’s.

18. Recommendation Greater involvement of civil society and community based institutions in the roll out of the ASHA schemes. Training of ASHA’s on their role is important. Sporadic training however may not be adequate and needs to be replaced by a ongoing mentorship programme. ASHA mentorship programme should be taken up through a SHRC. Attention needs to be given to the training methodology. VHSC are important to support the ASHA’s and need to develop.