Study Team. Bella Patel Uttekar Nayan Kumar Vasant Uttekar Jashoda Sharma Shweta Shahane

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2 Study Team Bella Patel Uttekar Nayan Kumar Vasant Uttekar Jashoda Sharma Shweta Shahane

3 PREFACE JSY, Janani Suraksha Yojana, is an integral component of the National Rural Health Mission, launched in April JSY aims to reduce maternal and neo-natal mortality by promoting institutional deliveries, focusing on women living below the poverty line (BPL). Another core strategy of the NRHM is to have a female Accredited Social Health Activist (ASHA) for every village with a 1,000 population to act as an interface between the community and the public health system. As a volunteer she receives performance-based compensation for promoting a variety of primary health care services such as referral and escort services for institutional deliveries, universal immunization, DOTS treatment for tuberculosis or construction of sanitary toilets. In response to a request by the Ministry of Health and Family Welfare (MoHFW) to assess JSY in West Bengal, the German Technical Cooperation (GTZ) partnered with the Centre for Operations Research and Training (CORT) to conduct the study. The aim was to assess the current status of the ASHA intervention and JSY in three districts of Assam, Jorhat, Goalpara and Nalbari. The present report documents the findings of the assessment, highlights evidence of success as well as points out areas that need to be addressed in order to further improve JSY. This document aims to provide useful information for policy makers and programme managers at the national and state levels for further strengthening the scheme as well as to develop training and IEC strategies and campaigns. It may also be pointed out here that the study was conducted in the initial stages of the programme being implemented in the state, which has been undergoing modifications, and the situation remains dynamic. As far as possible we have tried to incorporate all the themes, but in case of any lapses we are responsible for the same. We are very grateful to Mr. K. D. Maiti, Director, Ministry of Health and Family Welfare for his valuable inputs in framing the questionnaire and analyzing data. We would also like to acknowledge Dr. Dinesh Baswal, ASHA Training Coordinator at national level and Dr. J. B. Ekka, NRHM Mission Director and Dr. A. C. Baishya, Director North-East Regional Resource Centre, Assam, CMO of the selected districts and Managers of DPMU for all the support extended by them. At the outset, we take this opportunity to thank the GTZ Health Sector Support (HSS) for having entrusted the work of conducting the assessment to CORT. Our sincere thanks are due to Dr. J.P. Steinmann, Principal Advisor Health, Dr. Paula Quigley, Program Advisor, Ms. Judith Buesch, Project Manager, and Dr. Urvashi Chandra, Technical Specialist, for the cooperation extended to us during the various stages of the study. We appreciate their inputs in helping us develop the research tools, in administering the study in the field and commenting on the draft report. We are especially thankful to Ms. Judith Buesch and Dr. Paula Quigley for their meticulous work, quick replies and immense patience. We thank our respondents officers at the state, district and block levels, trainers of ASHA, PRI members, members of CBOs, ASHAs, ANMs, community members and of course the JSY beneficiaries without whose cooperation it would not have been possible to complete the study successfully. I wish to put on record my deep appreciation for Dr. Bella Patel Uttekar, the Principal Investigator of this project, and all the team members for contributing their might in the success of this project and thereby ensuring quality. Prof. M. M. Gandotra, Director Centre for Operations Research and Training (CORT), Vadodara

4 CONTENT Executive summary... i-vi Chapter 1: Introduction Background... 1 Objective of the study... 2 Study design... 3 Study area... 3 The sample... 3 Interviews of ASHAs... 4 Interviews of beneficiaries of JSY... 4 Other stakeholders... 4 Study tools... 5 Field operations... 5 Ethical considerations... 5 Data management and analysis... 5 Presentation of the report... 6 Chapter 2: Operationalization of ASHA Intervention and JSY in Assam State scenario... 7 Adaptation and operationalization of ASHA intervention... 7 Programme management processes... 8 Selection of ASHAs... 8 Training of ASHAs... 9 Adaptation of JSY guidelines and its operationalization Linkages and integration Accreditation of private institutions Monitoring and supervision Community s perception about ASHA and JSY Chapter 3: Involvement of ASHA in JSY Background characteristics of ASHA About ASHA: Their selection and motivation to work Training of ASHA Quality of Training... 21

5 Payments during training...22 Use of reading materials...22 Knowledge of ASHA about ANC and child care services...22 Pregnancy, delivery complications and actions...23 Knowledge about newborn care...24 Knowledge about responsibilities of ASHA...24 Organization of work by ASHAs...25 Availability and utilization of drug kits...26 ASHAs role in JSY...26 ASHAs awareness about cash assistance under JSY...27 Promoting JSY...27 Accompanying JSY cases and arranging for institutional delivery...28 Cooperation and cash assistance payment to JSY beneficiaries...28 Handling of delivery at natal place...29 ASHA s views about preference for home delivery among women...29 Beneficiaries of ASHAs...30 Networking of ASHA The role of other stakeholders...31 Panchayati Raj Institute...32 NGOs/CBOs...33 Block officials...33 Incentives received as ASHAs...34 Supervision and monitoring of ASHA...35 Opinion about the ASHA component...35 Difficulties and challenges faced by ASHA...36 Chapter 4: Beneficiaries of JSY in Assam Background information of JSY beneficiaries...39 Awareness about JSY Process of registration under JSY Utilization of ANC services by JSY beneficiaries Role of ASHAs in micro-birth planning...41 Intention versus actual place of delivery...42 Impact of JSY on institutional delivery...42 Motivation and decision making for institutional delivery...43 Process of arranging transport...43 Difficulties faced in reaching the place of delivery...44 Persons accompanying JSY beneficiaries to the health institution...44 Quality of services available at the place of delivery...44 Payments incurred for services at the health centre...45 Satisfaction with the services at the place of delivery...45

6 Persons who assisted delivery at home and views about TBA Child mortality Dynamics of delivery at home Who prefers delivery at home? Mode of payment and difficulties faced Use of cash assistance received for delivery Appreciation of JSY by the beneficiaries Role of ASHAs in helping JSY beneficiary Complications during delivery Chapter 5: Evidences of Success, Challenges and Policy and Programme Implications Programme management ASHA s contribution Cash assistance Increasing institutional delivery Community perceptions about ASHA and JSY Challenges Competency of ASHA Increasing institutional deliveries Lack of facilities Cash assistance Policy Implications Policy Programme management Demand generation Appendix 1: ASHAs tables Appendix 2: JSY tables

7 LIST OF TABLES Table 1.1: Sample covered for qualitative and quantitative components in Assam... 4 Table 2.1: Number of JSY beneficiaries by place of delivery from service statistics in Assam up to March Table 2.2 Number of ASHAs selected and trained in Assam up to January Table 2.3: Mother s cash assistance package for JSY beneficiaries in Assam Table 4.1: Intention versus actual place of delivery, Assam Table 4.2 Shift in the place of delivery before and after JSY, Assam Table 5.1 Table 5.2 Motivation factors leading to institutional delivery as against intension, Assam Pregnancy expenditure including cost incurred during ANC period, transport and delivery as against the amount received by JSY beneficiaries, Assam... 58

8 LIST OF FIGURES Figure 3.1: Scoring knowledge of ASHAs in Assam Figure 3.2: ASHAs awareness about her responsibilities Figure 3.3: Networking of ASHA with stakeholders Figure 4.1: Time when the beneficiary heard about the JSY Figure 4.2: Sufficiency of cash incentives as perceived by JSY beneficiary Figure 4.3: Role of ASHAs in helping JSY beneficiary... 49

9 APPENDIX TABLES Appendix 1: ASHAs Tables ASHAs interviewed in Assam Table A1: Profile of ASHAs in Assam, Table A2: Work history of ASHAs in Assam, Table A3: Number of living children and place of previous delivery for ASHAs in Assam, Table A4: Source of information and selection of ASHAs in Assam, Table A5: Topics covered and arrangements made in the training of ASHAs in Assam, Table A6: ASHAs views on logistic arrangements at the place of training, Assam, Table A7: Views about the training among ASHAs in Assam, Table A8: Payments received during training by ASHA in Assam, Table A9: Utilization of guidelines by ASHA in Assam, Table A10: Scoring of knowledge of ASHAS in Assam, Table A11: Knowledge of ASHAs about ANC care in Assam, Table A12: Knowledge about complications during pregnancy among ASHAs in Assam, Table A13: Knowledge about common complications during pregnancy / delivery that can result into death of a woman, Assam, Table A14: Knowledge about immunization and child care among ASHAs in Assam, Table A15: Responsibilities, recognition and feelings about being an ASHA in Assam, Table A16: Functioning of ASHAs in Assam, Table A17: Knowledge about care for pregnant women, Assam, Table A18: Availability and utilization of drug kits by ASHAs in Assam, Table A19: Awareness about JSY and its benefits among ASHAs in Assam, Table A20: Cash assistance available under different schemes for ASHA and JSY beneficiaries in Assam, Table A21: ASHA s role in promoting JSY in Assam, Table A22: Role of ASHAs in accompanying JSY cases and arranging for institutional delivery in Assam Table A23: Average time taken to reach the institution by distance of the facility from residence of JSY beneficiary, Assam, Table A24 Cooperation and cash assistance received at the place of delivery as perceived by ASHA in Assam Table A25: Handling of women visiting natal place (other village) for delivery in Assam, Table A26: Reasons for preferring home delivery despite cash assistance for institutional delivery, Assam,

10 Table A27: Brief details of ASHA s interaction with her last client in Assam, Table A28: Details of ASHAs when last accompanied women for delivery in Assam, Table A29: Networking of ASHAs with other stakeholders in Assam, Table A30: The roles of other stakeholders in the implementation of ASHAs in Assam, Table A31: Process of receiving cash incentive money as ASHA in Assam, Table A32: Average amount received from government (other than training) by ASHA in the last three months Table A33: Reported satisfaction with the cash incentive in Assam, Table A34: Supervision and monitoring of ASHA in Assam, Table A35: Knowledge and opinion of ASHAs about their work with the government in Assam, Table A36: Suggestions of ASHA for further strengthening their work in Assam, Table A37: Difficulties and challenges faced by ASHA in carrying out activities in Assam, Appendix 2: JSY Tables Coverage of sample in Assam Table J1: Background information of JSY beneficiary, Assam, Table J2: Source and type of information heard about JSY, Assam, Table J3: Process of registration, Assam, Table J4: Awareness about index pregnancy, Assam, Table J5: Contacts with health personnel during index pregnancy, Assam, Table J6: Frequency and place of antenatal check-ups during index pregnancy, Assam, Table J7: Persons who motivated JSY beneficiaries for antenatal check-ups, Assam, Table J8: Persons who accompanied the beneficiary and cost incurred for ANC visits, Assam, Table J9: Reasons for not seeking ANC services, Assam, Table J10: Role of ASHA to JSY beneficiary during index delivery, Assam, Table J11: Intentional and actual place of delivery among JSY beneficiaries, Assam, Table J12: Intention versus actual place of delivery, Assam, Table J13: Shift in the place of delivery before and after JSY, Assam, Table J14: Process of arranging transport to reach health institution, Assam, Table J15: Difficulties faced in reaching the place of delivery, Assam, Table J16: Persons accompanying JSY beneficiaries to the health institution, Assam, Table J17: Quality of services available at the place of delivery, Assam, Table J18: Payments made for services at the health centre, Assam, Table J19: Satisfaction with the services at the place of delivery, Assam, Table J20: Persons who assisted delivery at home, Assam,

11 Table J21: Views about TBA, Assam, Table J22: Perceived reasons for women to deliver at home despite cash assistance paid under JSY for institutional delivery, Assam, Table J23: Background information of JSY beneficiaries, Assam, Table J24: Contact with health personnel during index pregnancy by place of delivery, Assam, Table J25: Utilization of ANC services during index pregnancy by place of delivery, Assam, Table J26: Payment made to JSY beneficiaries, Assam, Table J27: Difficulties faced by JSY beneficiaries in getting cash assistance for delivery, Assam, Table J28: Opinions of beneficiaries about JSY in Assam, Table J29: Complications during index pregnancy, Assam, Table J30: Profile of last and last but one child, Assam,

12 EXECUTIVE SUMMARY Towards achieving the objectives of the National Rural Health Mission (NRHM), Janani Suraksha Yojana was launched in April 2005 to promote institutional deliveries among the BPL population through provision of referral, transport and escort services. JSY integrates cash assistance with delivery and post delivery care for women to have healthy outcomes of pregnancy and childbirth. The NRHM aims to have a villagebased female Accredited Social Health Activist (ASHA) in 18 high focus states, which are low performing with respect to institutional deliveries, to act as the interface between the community and the rural public health system and negotiate health care for poor women and children. ASHAs would reinforce community action for universal immunization, safe delivery, newborn care, prevention of water borne and communicable diseases, improved nutrition and promotion of household toilets. They would inform, interact, mobilize and facilitate improved access to preventive and promotive healthcare, and have drug kits to provide basic curative care. The Ministry of Health and Family Welfare (MoHFW) decided to undertake an assessment of JSY. The Centre for Operations Research and Training, CORT, based at Vadodara conducted this assessment of the JSY for GTZ and the MoHFW to understand the process of implementation of the programme, involvement of ASHAs and experiences of JSY beneficiaries. This report is based on the qualitative and quantitative assessment of JSY in Assam covering three districts of Goalpara, Jorhat, and Nalbari. Using semi-structured study tools, 181 ASHAs and 240 JSY beneficiaries were interviewed through a quantitative survey. In-depth interviews were conducted with key persons associated with the implementation of JSY. Implementation of ASHA Intervention and JSY As per the national guidelines, with 18 percent institutional deliveries as per NFHS-2 Assam is categorized as a low performing state. The implementation of the ASHA intervention is taking place in a phased manner; in phase 1, eleven districts were covered while the remaining 13 districts would be taken up in phase 2. Around 26,000 ASHAs, one for every 1,000 population, were required. In 11 districts of phase 1, selection and first round of training of ASHAs was completed by January The selection process and training of ASHAs in 12 districts of phase two was ongoing at the time of fieldwork. At the state level, the State Programme Management Unit (SPMU) supported by the North-East Regional Resource Centre gives directives to implement the programme. At the district level, District Programme Management Units (DPMUs) implement the trainings and programme activities, monitor the programme and bring in intersectoral convergence. A team comprising of Block Medical Officers, Health Supervisory staff, District public Health Nurse, and NGOs was involved in implementing the scheme at block level. At the village level, under the leadership of sarpanch, ANM, AWW and ASHAs worked together to provide ANC and PNC services. ASHAs were paid performance-based payment of Rs. 600 under JSY by the ANM of the concerned sub-centre and PRI.

13 Centre for Operations Research and Training, Vadodara Besides, they were paid under the respective national programme as per the services provided by them including family planning, DOTs treatment for tuberculosis, and promotion of sanitary latrines. JSY is administered by the state JSY nodal officer. CMO and BMO in-charge are responsible for JSY intervention at district and block level. The scheme was publicized widely through print and electronic media, however, TV propaganda cannot be viewed as the ideal means to promote the scheme as only 56 percent households in rural areas have access this medium, even less so with the target group of JSY, the BPL population. Newspaper advertisements were circulated in local language showing the roles and responsibilities of ASHAs. ANMs, Anganwadi workers and ASHAs worked for creating awareness about the scheme. Organizing immunization weeks and Village Health Days is used as a conversion point where AWW, ASHAs, ANM, PRI, SHGs, and NGOs work together on issues related to health and development of the village. Instead of offering JSY benefits to only BPL women Assam decided to give cash assistance to all pregnant women delivering in Government health centres like subcentres, PHC, CHC, FRU and general wards of District and state hospitals or accredited private institutions are eligible for getting JSY benefits of Rs. 1,400 if from a rural area and Rs 1,000 for those belonging to urban areas. Further, BPL women delivering at home receive Rs PRI managed untied fund of Rs. 10,000 at the Village Panchayat level along with ANMs. The process of accreditation of private institutions has just begun and partnership with existing Tea Garden and Red Cross hospitals is being sought. Monitoring and supervision is happening at all levels, with DMUs playing a key role. Yet, there is a need to develop a simple and sustainable monitoring system. Involvement of ASHA in JSY Most of the ASHAs are middle-aged, educated and married staying in the same village where they were functioning. Seventy percent of the ASHAs belonged to SC/ST or other backward classes. Of the 181 ASHAs interviewed, one-fourth of the ASHAs did not fulfill one or the other eligibility criteria. Before JSY, 68 percent of the ASHAs had opted to deliver their child at home. On average, the respondents worked as ASHA for 7.4 months. The study shows that 26 percent of ASHAs did not receive any payment until the date of survey. On average, ASHAs who were paid received Rs monthly from working as ASHA. Forty-six percent of the respondents first came to know about the ASHA from ANM and 13 percent from Gram panchayat. Hoardings, pamphlets, radio, TV, health personnel, anganwadi workers, and Sugam workers also informed them about the ASHA. ANMs, sarpanch, local political leader, mahila samiti, PHC staff and sugam worker also played a role in selection of ASHAs. In most cases (76 percent) Gram Sabha approved their name. The main motivation for being an ASHA was to serve the community (90 percent), save the children (57 percent), earn money (56 percent) and remove misconception (24 percent). ii

14 Executive Summary In Assam, training of ASHAs was done, on average, 7.2 months ago for seven days. Most (94 percent) of the ASHAs attended trainings conducted at PHCs, while logistic arrangements were poor. Food arrangements accommodation and sitting arrangements need to be improved. However, ASHAs appreciated the training sessions and regarded trainers and training methods as good and useful. However, only 77 percent of the ASHAs received their allowance during training and only 14 percent of the ASHAs received the total due amount. On average, they received Rs Informal discussions with the stakeholders revealed that the ASHAs were given transport allowance depending on the distance they travelled (instead of Rs. 100 irrespective of the distance travelled as per the guidelines). Ninety-four percent of the ASHAs received reading materials/guidelines while 75 percent of them were largely able to follow the materials. Seventy percent of the ASHAs scored Grade A or O for answering 8-10 out of 10 questions correctly. Scoring knowledge of ASHAs in Assam Grade A Grade 45% 'O' 25% ASHAs claimed to know about complications during pregnancy, but only percent talked about weak or no foetal movement and abnormal position of the foetus. In such situation, ASHAs said that they would Grade C 5% Grade B 25% immediately refer the pregnant woman to the nearest functional FRU or accompany them, while surprisingly 48 percent said that they would ask the pregnant woman to consult the ANM the next day. ASHAs mentioned that their main responsibilities were to support the immunization programme (85 percent) and accompany delivery cases (82 percent). While every second ASHA mentioned registration of birth and death, provision of ANC care, awareness creation on health and every third ASHA mentioned working with ANM/AWW, awareness creation regarding basic sanitation and hygiene, and mobilization of the community to utilize health services as their responsibilities. Family planning, village health planning, counseling, promoting good health practices and providing basic curative care were mentioned by few ASHAs. ASHAs visit house to house (98 percent), besides attending immunization session and accompanying women for delivery. ASHAs provided constellation of services and played a potential role in providing primary medical care as their last client came seeking services related to get advice about place of delivery, immunization, ANC care, registration of vital events, for receiving IFA tablets, post natal care, and procuring spacing family planning methods. Eighty-eight percent of the ASHAs had accompanied an average of 4.4 JSY cases (ranging from 1 25) for institutional delivery, mainly to PHC and government hospital. ASHA accompanied the last case around 35 days ago and 80 percent of them stayed with JSY beneficiaries at the place of delivery. iii

15 Centre for Operations Research and Training, Vadodara ASHAs network with the various stakeholders in the village to implement JSY. All ASHAs met ANMs, followed by AWW (98 percent), PHC staff (87 percent) and PRI members (65 percent). They also met block facilitators, Village mandals, Health and Sanitation Committee, as well as NGO staff. Eighty percent of the ASHAs received some cash incentive money, mainly for attending JSY beneficiaries, antenatal care, immunization of children and DOTs treatment. The mean monthly amount received for attending JSY beneficiary in three months varied between Rs (ranging between ) and for immunization of children between Rs (ranging between ). Sixty-two percent of the interviewed ASHAs were satisfied or somewhat satisfied with the cash incentives mainly because they were able to serve people and received payment. Thirtyeight percent ASHAs were unsatisfied with the cash assistance as it was too much work and too little money (53 percent), or because of delay in payment (37 percent). ASHAs spent on average 3.9 hours every week in preparing various registers while their work was mostly monitored by the ANMs and MO PHC. Supervisory support from other officials was lacking. Beneficiaries of JSY in Assam The JSY beneficiaries were young (mean age, 23.8) and mostly those who had schooling up to primary, middle or secondary level. Fifty-two percent of the JSY beneficiaries belonged to SC/SC and 14 percent to the other backward classes. The average monthly family income of the JSY beneficiaries is only Rs It can be said that JSY reached to the socio-economically lower strata women covering poor segment of the society, as at least two-thirds of the JSY beneficiaries belonged to this group. The beneficiaries learnt about JSY during various stages of pregnancy, however, nine percent learnt about the scheme only after delivery. The majority of beneficiaries (77 percent) got registered in the first or second trimester, and on average, women had 4.4 antenatal check-ups during their index (JSY) pregnancy. Since ANC card showing that the women had taken full ANC is required for claiming payment of cash assistance, women ensured that they had at least 3 or more ANC check-ups done. ASHAs (71 percent) and husbands (50 percent) accompanied the beneficiary for ANC visit(s). Fifty-four percent of the women received antenatal care at PHC and another 22 percent at the sub-centre. The majority (83 92 percent) of JSY beneficiary received advice about diet, delivery care and newborn care and breast-feeding, but advice regarding danger signs and family planning was mentioned by only 71 and 48 percent respectively. Two-thirds of the beneficiaries were told about four or more aspects (out of 5) of micro-birth planning. The cross-tab of intention vs. actual place of delivery shows interesting results. Of the total JSY beneficiaries interviewed, five percent (n=12) women delivered at home though they intended to deliver institutionally because of lack of time and nonavailability of transport facilities. iv

16 Executive Summary Twenty-five percent of the total sample intended to deliver at home, out of which 16 percent (n=39) changed their mind and finally delivered in institutions because of Intended place for last delivery Institutional At home Intention versus actual place of delivery Place where last delivery of JSY beneficiary took place Institutional At home Total 70.4 (169) 16.3 (39) 5.0 (12) 8.3 (20) 75.4 (181) 24.6 (59) Total 86.7 (208) 13.3 (32) 10 (240) support provided by ASHAs (77 percent), safety of mother and child (36 percent), complications (26 percent), more facilities at the institution (21 percent) and previous child born in an institution (8 percent). Majority (76 percent) of the institutional deliveries took place in PHC and district/sub-district hospital. Among all the beneficiaries who opted for institutional deliveries support provided by ASHAs (81 percent), safety of both mother and child (38 percent), and cash assistance (31 percent), better care at hospital, and previous experience of complicated delivery were the motivating factors. Out of the 100 JSY beneficiaries who had two or more children, 57 percent of the previous deliveries were reported as home deliveries. Forty-three percent of the women with two or more children delivered their last (JSY) baby at the institution while 18 percent continued to prefer home delivery. Nevertheless, between two deliveries, 39 percent (n=41) of the beneficiaries shifted from home to institution due to support provided by ASHAs (n=32, 80 percent), safety of the child (n=18), cash assistance available (n=16) and better facilities at the institution (n=10). It shall be pointed out here that at the state level, as per the services statistics for April 06 February 07, 72 percent of JSY beneficiaries delivered in an institution, a very encouraging trend. The demand for institutional delivery calls for upgrading of the public health infrastructure to provide quality care, especially in the realm of subcentres and PHCs. In Assam, JSY beneficiaries had to travel, an average of 6.6 kms to reach the ultimate place of delivery. Women spent approximately 1 hour and 9 minutes to arrange transport and reach the ultimate place of delivery and another 40 minutes after reaching the institution on registration and administrative processes as well as waiting time until someone attend to them. Thirty-seven percent of the JSY beneficiaries did not receive their cash assistance, while 99 percent of those who received cash got payment in one go (but much later or a week after the delivery, 77 percent) from the CHC/PHC MO, accountant or ANM. The JSY beneficiaries spent an average of Rs during ANC period, Rs for transportation to the place of delivery and Rs for delivery, against which they received an average of Rs. 796 from the government as cash assistance. The study evidently shows the cash assistance is not enough to cover all the expenses for institutional deliveries with women spending a substantial amount out of their own pockets. For those, who delivered at home, only 6 percent had negative balance and others gained Rs. 30 on average. While in the case of institutional deliveries, 70 percent spent more than what they received and on average, those who had v

17 Centre for Operations Research and Training, Vadodara institutional deliveries spent Rs additional to the cash assistance. A JSY beneficiary said, it is better to deliver at home as we get Rs. 500 against no expense, whereas in the case of institutional delivery we spend more than what we get. Fortyfive percent of the JSY beneficiaries felt that the cash assistance received was not sufficient. While JSY is evidently reaching out to poorer segments of society it can be assumed that the poorest of the poor cannot take advantage of the services simply because their economic situation leaves them with no option but to opt for home deliveries. It is encouraging that husbands and ASHAs each accompanied the majority (83 percent) of women for delivery. Other family members, mothers, mothers-in-laws and neighbours also accompanied the women. On average, after normal delivery (n=186) women were discharged after 24 hours, for assisted delivery (n=13) after 36 hours and for caesarean (n=6) after 7 days. Most of the women were satisfied with JSY and would recommend relatives or friends/ neighbours to benefit from it, mainly because of courteous hospital staff, clean health facilities, counseling received for breastfeeding/immunization, follow-up visits, newborn care/diarrhoea management and safety of children. JSY beneficiaries perceived that despite cash assistance paid under the JSY, women still prefer to deliver at home because of extreme poverty, hospital expenses, fear of doctors, and nurses, Illiteracy, lack of transport facilities, shyness and opposition from family members. On the success side, the process of programme implementation such as selection and training of ASHAs has progressed well as per plan, and involvement of other parallel departments, PRI, and AWWs is evident. The state needs to nurture and further intensify this network. In Assam, ASHA s contribution is significant. They are enthusiastic and motivated to serve the community, save children and earn some money. They also got the opportunity to learn new things, move out of the village and meet many people. ASHAs have been able to generate demand and mobilize clients for reproductive and child health services. ASHAs informed women about JSY, contacted them first, registered for JSY, advised during pregnancy, explained benefits of institutional deliveries, and accompanied women for institutional deliveries. Fiftynine percent of all interviewed beneficiaries said that it was actually the ASHA who decided to go for institutional delivery on behalf of the JSY beneficiary, while 37 percent of ASHAs arranged for transport and 83 percent accompanied women to the health institution. Beneficiary interviewees would also recommend JSY to others. The communities have heard about the scheme but lack knowledge about its detail. It can be said that JSY has shown impact in Assam. However, the quality of care at the hospitals and particularly at PHC and sub-centres needs to be improved to provide services for normal deliveries. The state needs to reach the unreached and motivate the poorest of the poor for institutional delivery by proper campaigning, addressing their fears regarding hospital setting and staff, making arrangement for transport and making due payments on time to the beneficiaries. vi

18 CHAPTER 1 INTRODUCTION Background The Government of India launched the National Rural Health Mission (NRHM), in The aim was to provide accessible, accountable, affordable, effective and reliable primary health care, especially to the poor and vulnerable sections of the population. The Mission envisages equitable, and quality health care services to rural women and children in the country with greater emphasis on 18 highly focused states. It adopts a synergistic approach by encompassing non-health determinants that have a bearing on health such as nutrition, sanitation, and safe drinking water. The mission also aims to achieve greater convergence amongst related social development sectors. To accomplish the goals, one of the core strategies proposed was to have a female Accredited Social Health Activist (ASHA) for every village covering a 1,000 population. It has been suggested that ASHA would be chosen by and would be accountable to the panchayat. She would act as an interface between the community and the public health system. As an honorary volunteer ASHA would receive performance-based compensation for promoting variety of primary health care services in general and reproductive and child health services in particular such as universal immunization, referral and escort services for institutional deliveries, construction of household toilets, and other healthcare interventions. In order to enable the states for proper implementation, detailed ASHA guidelines have been prepared by the Ministry of Health and Family Welfare (MOHFW), Government of India (GoI) wherein institutional arrangements, roles and responsibilities, integration with ANM and Anganwadi workers, working arrangements, training, compensation, fund-flow etc have been discussed. Further, training modules and facilitators guide have been prepared and shared with the states for training programme. The guidelines have accorded flexibility to the states in designing the operationalization of the intervention. Many states depending on the local context have modified the guidelines to suit their requirements. As part of NRHM, the Honorable Prime Minister of the country launched safe motherhood intervention in the form of Janani Suraksha Yojana (JSY) for reducing maternal and neo-natal mortality on April 12, The scheme aims to promote institutional deliveries among pregnant women belonging to families below poverty line in all the states and Union Territories (UTs) of the country with special focus on low performing states (LPS). It is a 100 percent centrally sponsored scheme and links cash assistance with delivery and post-delivery care. In availing institutional delivery services, the client needs to be escorted, need transportation to reach the institution. In case of complications, referral services are required. The scheme has considered all these elements and has made provision for transport including referral and escort (by

19 Centre for Operations Research and Training, Vadodara ASHAs) and at the same time invested in improving public health institutions and services through the Reproductive and Child Health (RCH) Programme interventions. Moreover, flexibility has been given to the states to evolve public-private partnership (PPP) mechanism and accredit private health institutions for providing institutional delivery services. As stated earlier, special dispensation has been made for LPS in both rural and urban areas and linked to the ASHA intervention. The LPS are states that have low institutional delivery rates and includes Uttar Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa, and Jammu and Kashmir. In the remaining states and UT s categorized as High Performing States (HPS) similar provisions have been made wherein anganwadi worker, traditional birth attendant, ASHAs or ASHA like activists could be engaged and be associated with JSY. To facilitate the states in implementing JSY, a set of guidelines articulating the criteria of eligibility of beneficiaries and provisions have been worked out in detail. The guidelines of the scheme have undergone four revisions and certain clauses have been modified for both LPS and HPS states. Both ASHA intervention and JSY are in operation for over a year and the LPS are in different stages of implementation. To understand the status of implementation and the processes adopted for operationalization in the states of Assam, Himachal Pradesh and West Bengal, MOHFW sought the assistance of GTZ. GTZ commissioned it through a professional research agency Centre for Operations Research and Training (CORT) based in Vadodara, Gujarat. Objectives of the Study The common objectives for ASHA and JSY were as under: 1. Review adaptation of the national guidelines by states and its operationalization 2. Study programme management processes (planning, MIS and supervisions, etc.) and institutional arrangements established for implementation of the schemes. 3. Analyze funds flow mechanisms from state to district and to lower levels of service delivery system and reimbursement. 4. Ascertain the level of understanding about these two schemes amongst the programme managers, service providers and other stakeholders 5. Map community perceptions about the two schemes For ASHA intervention study attempted to: 1. Assess adherence with guidelines for community involvement / NGOs / CBOs in the selection of ASHA 2. Review the training strategy including design, plans, material developed, training of trainers, quality of training and post-training follow-ups 3. Analyze support of health system to ASHA 2

20 Introduction 4. Study engagement of PRI, NGO, SHGs and other CBOs engagement in extending support to ASHA 5. Gauge satisfaction of ASHAs with the delivery of scheme including that related to compensation / reimbursement. For JSY, specific objectives were as under: 1. Assess adequacy and simplicity of the processes set out by the state for claiming benefits under JSY 2. Examine the utilization of the scheme and analyze factors influencing impeding utilization 3. Review engagement of private sector including accreditation and compensation 4. Analyze nature and scope of IEC interventions for raising awareness of JSY. Study Design The assessment of ASHA and JSY was based on a blended methodology and included application of quantitative and qualitative techniques. The study covered three districts of Assam selected on the basis of performance of the number of ASHAs who had completed the first round of training and represented good, average and poor performing districts. The NRHM Mission Director, from the Department of Health and Family Welfare in Assam provided data regarding number of ASHAs trained in first round of training in each district. Secondary data on ASHA training was collected, analyzed and categorized to group districts as good, average and poor performing districts. This was discussed with the State officials and the study districts were finalized by GTZ. Likewise, procedure of district-level consultation and secondary data review was undertaken in each of the districts to select the two blocks by CORT. Thus, in all six blocks from three districts were covered in Assam. Study Area This report is based on the assessment study conducted in Assam covering Goalpara, Jorhat, and Nalbari districts. The Sample The sample covered in the state included ASHAs and beneficiaries of JSY. Several people associated with the scheme such as state and district programme managers, block-level providers, trainers of ASHA, Auxiliary Nurse Midwife (ANMs), members of Panchayati Raj Institutions (PRIs), AWW, Community Based Organizations (CBOs), and community members were interviewed and included in the study. 3

21 Centre for Operations Research and Training, Vadodara Interviews of ASHAs: In all, 181 ASHAs who had undergone first round of training and had been in action in the three months prior to the survey were interviewed and included in the study. It was planned to interview 30 ASHAs fulfilling the selection criteria from each of the six study blocks. In Tamulpur block of Nalbari district 31 ASHAs were covered and included in the analysis. In six cases, ASHAs interviewed had worked for less than 3 months. To cover 30 ASHAs, 30 villages were visited in each of the study block, which included one CHC village, 2 PHC villages; 9 subcentre villages (3 SCs within each selected PHC/CHC), and 18 remote villages (2 remote villages from each of the selected subcentre). Interviews of beneficiaries of JSY: Altogether, 240 JSY beneficiaries who availed services under the scheme in the six months prior to the survey were included in the study. From each of the study block, 40 such JSY beneficiaries were planned to be interviewed. Thirty-nine and 41 JSY beneficiaries were interviewed from Kamalabari block of Jorhat and Agia block of Goalpara district respectively from the list of JSY beneficiaries. List of JSY beneficiaries was obtained from PHC and SC to select the beneficiary. ASHAs/ Anganwadi workers at times helped in locating the respondent. Other stakeholders: In addition to quantitative survey of JSY beneficiaries and ASHAs, other people including state and Table 1.1: Sample covered for qualitative and district programme managers, blocklevel quantitative component in Assam providers, trainers of ASHA, Type of stakeholders Number of stakeholders interviewed ANMs, PRIs, CBOs, AWWs and community members were also interviewed. The NRHM Mission Director, Regional Director for Health & Family Welfare and ASHA and JSY nodal officials were interviewed. Specific questions related to the implementation of the scheme, processes involved and challenges faced were addressed to them. The Qualitative study State officials 3 District level officers 12 Block level provider 15 Trainers of ASHA 12 PRI/NGO/SHGs/AWW 24 ANMs 60 Members of Community 18 based organizations Community members 24 Quantitative survey ASHA functionaries 181 JSY Beneficiaries 240 state mentoring group was also approached and discussions were held on adaptation of national guidelines, selection and training of ASHA, suggestions and challenges faced. Three block development officers were interviewed about the utilization of the scheme, profile of the beneficiaries, and steps required for future improvement of the scheme. In each block, ASHA trainers and facilitators were approached to understand the implementation of the training programme, participation of the ASHAs as trainees, training pedagogy and logistics. Again, at block level, members of panchayati raj institutions, NGOs, self-help groups, CBOs, ANMs and AWWs were interviewed to assess the networking of ASHA, its benefits and challenges. Awareness and understanding of the scheme at the community level is important to enhance utilization of the scheme. Informants both male and female, in each district were asked about their awareness of JSY, attitude, and utilization. 4

22 Introduction Study Tool The study tools were developed by CORT in collaboration with the professionals from UNFPA, Ministry of Health and Family Welfare, and GTZ. Several questions were openended. For qualitative in-depth interviews, guidelines were used for collecting the requisite information from the stakeholders. The guidelines facilitated in the comparison and analysis of data across respondents within the state. The type of queries addressed differed depending on the type of stakeholder, including adaptation of the national guidelines, programme management processes, funds flow mechanisms, community perceptions about ASHA and JSY. Field Operations Experienced Field Manager and Field Coordinators from social sciences coordinated the entire fieldwork. Twenty-one field investigators, males and females were trained at Gauhati for 7 days to conduct the fieldwork. At the grassroots level, female field investigators interviewed JSY beneficiaries. Supervisors checked the selection of the eligible sample and ensured that the questionnaires were filled accurately and completely. GTZ professionals actively participated during the fieldwork, facilitated the fieldwork and helped in ensuring the quality of data. Back-checks were conducted to ensure consistency in the data at site thereby ensuring quality, validity and reliability. Fieldwork in Assam was carried out during February 2 nd and 26 th Ethical Considerations MOHFW and GTZ had informed the authorities of the selected states, districts and blocks about the study and the need to share the information about ASHAs and JSY beneficiaries with the research team of CORT. The field coordinators ascertained that informed consent procedures were pursued and that privacy and confidentiality was ensured during interviews to minimize the potential for distress, if any. The research staff did not share individual information obtained during the study with staff of any other organization. Data Management and Analysis CORT s in house specialist, who has been involved in the complete analysis of largescale surveys like NFHS and RCH, handled the data management and analysis. The CORT programmer prepared data entry screens for the study using CS Pro. A data entry package was developed by CORT for the study, which checked range and consistency. This was used to enter data collected from the field. Double data entry was done to ensure the quality of data entry and eliminate mistakes, if any. The analysis of data was done using SPSS package. The data was tabulated and analysed as per the analysis plan developed by CORT, GTZ and UNFPA. Preliminary results were shared with the GTZ and their suggestions and feedback were incorporated in the final report. 5

23 Centre for Operations Research and Training, Vadodara Presentation of the Report The report has five chapters, the present chapter gives a brief introduction of ASHA component and JSY and the study design for assessment. Chapter 2 elucidates programme inputs and processes adopted in implementation of the scheme in the state of Assam. ASHA s profile, selection, training, knowledge about different aspects of reproductive and child health and other related issues are discussed in Chapter 3 while utilization of JSY by the beneficiaries, their views about the scheme and suggestions are discussed in Chapter 4. Chapter 5 provides an overview of evidence of success, challenges and policy and programme implications for enhancing ASHA intervention and JSY. 6

24 CHAPTER 2 OPERATIONALIZATION OF ASHA INTERVENTION AND JSY IN ASSAM The features and implementation of ASHA intervention and Janani Suraksha Yojana (JSY) are discussed in this chapter. It includes selection and training of ASHAs, and understanding of JSY amongst stakeholders, the process of decentralization, and funds flow mechanisms. State and district officials were interviewed to get their perceptions regarding the linkages and integration amongst ASHA, ANM, anganwadi workers and other stakeholders. Their support, monitoring and supervision are also highlighted in the chapter. The findings are based on in-depth interviews with the NRHM Mission Director, Regional Director for Health and Family Welfare, State Nodal Officers for JSY and ASHA, and state coordinator of ASHA Resource Centre (State Programme Management Unit) and state NGO. Besides, at the district level, Chief Medical Officer, Block Officer, Project Manager of the District Project Management Unit (DPMU), ASHA and JSY nodal officers and district finance officers of the three districts were interrogated to understand the implementation of JSY. State Scenario According to the National Family Health Survey 3, in 2006, in Assam 40 percent of births took place in health facilities, 46 percent in the women s own homes and 13 in their parents homes. In rural areas, only 31 percent of the total deliveries took place in health institution. In NFHS-2, the proportion of institutional delivery was only 18 percent categorizing Assam as low performing state. As per the service statistics, during the period of JSY, as high as 72 percent Table 2.1: Number of JSY beneficiaries by place of delivery from service statistics in Assam upto March, 2007 Number of deliveries (April 06 Feb 07) At home Institutional delivery Total deliveries Percentage institution delivery Total number of JSY beneficiaries 46, , in Assam Jorhat Nalbari Goalpara of the deliveries were reported to be institutional deliveries. It becomes important to know about the implementation of JSY. Adaptation and Operationalization of ASHA Intervention The Government of India has issued detailed guidelines for implementing JSY, covering various aspects including roles and responsibilities of ASHA, institutional arrangements, selection and training of ASHAs, working arrangements, and linkages with Anganwadi Workers and ANMs, compensation to ASHAs, fund-flow mechanism and evaluation. The States have been given some flexibility to modify the guidelines, if felt necessary. The national guidelines were translated into three popular local languages Assamese, Bengali, and Boro. Modifications were effected in the scheme

25 Centre for Operations Research and Training, Vadodara at the state level in relation to eligibility criteria of ASHAs by including ASHAs who had studied up to 5 th grade in the tribal areas. The officials knew about JSY since the NRHM was launched and some of them came to know about it when they joined the programme. The communication from the national to the state level and state to the district level was quick and hence within a week all the officials at the state and district levels were informed through written circulars about the national programme and any modification in the programme thereby. This shows that the state is serious and committed in implementing JSY. Programme Management Processes As an important initial task, the state nominated the state ASHA nodal Officer responsible for the implementation of ASHA intervention in the state. The state ASHA nodal Officer is supported by the State Programme Management Unit (SPMU) and at the district level by the District Programme Management Unit (DPMU). DPMUs have been set up to implement ASHA in the district and monitor the progress on regular basis. For this, a district nodal officer has been nominated. At the block level, the block Medical Officers and other supervisory staff, including District Public Health Nurse, NGO working in the area provide support to the DPMU. In Assam, at the time of fieldwork, the State Nodal Officer for ASHA/JSY had retired and the post was vacant. A mentoring group and a North-East Regional Resource Centre also have a major role in the implementation of ASHA intervention. While the mentoring group takes major decisions related to the implementation of the programme, the NE RRC is implementing and administering the training, and other aspects of the programme. Selection of ASHAs As per the selection criteria in the national guidelines, ASHAs should be a resident of the village, who is at least eighth grade pass aged between 25 and 45 years old age. In Assam, according to the state officials, 26,000 plus ASHAs are required to be recruited for the complete coverage of the state as per the national norm of having one ASHA per 1000 population. The selection of ASHAs was first done in eleven districts of Assam. By January 2007, the selection of ASHAs and first round of training was completed in eleven districts, and in the remaining 12 districts, the process of selection and training was continued. It was hoped by the state officials that they would be able to meet their requirement of recruiting and training 26,000 plus ASHAs by Mid In February 2007, at the time of fieldwork, a state officer said, There are eleven districts where ASHAs have been selected, in the remaining districts the selection process and training of first round will be achieved soon. 8

26 Operationalization of ASHA Intervention and JSY in Assam It was difficult for the state to find women fulfilling the selection criteria, particularly in the tribal and hilly Table 2.2: Number of ASHAs selected and trained in Assam areas. Therefore, the upto January, 2007 guideline was modified Selection Selected up Trained in Percent for tribal and hilly areas target to January, first round trained and the educational (06 07) 2007 up to (against attainment was reduced from 8 th to 5 th grade. January, 2007 the target) Table 2.2 shows that till January, 2007, most (98 percent) of ASHAs were selected and 93 percent Total number of ASHA-Sahyogini Jorhat Nalbari Goalpara of the targeted number had been trained. In the districts under study, 100 percent of the selection and training has been accomplished. The ASHA guidelines envisaged the role of DPMU Manager, an NGO, and the block officials, Block Medical Officer in the selection of ASHAs. However, their involvement in the selection process was limited. Village gram sabha and committee were involved in the selection of ASHAs, who are accountable to the PRI. A senior state official explained, PRI and NGOs are part of the facilitators for selection of ASHA. Three names of potential candidates are suggested and Panchayat does the final selection of one person, and forward the name to Gram Sabha. Hence, ASHA is selected by the Panchayat, which is actively involved in the process. Female panchayat members, however, were unaware about the selection procedure. Gram Sabha would approve the name of the ASHA and send them to CHC/PHC. The PRI is informally informed about the eligibility criteria of the ASHAs. Training of ASHAs Training of the state level trainers was held at the national level in New Delhi. The National Institute of Health and Family Welfare (NIHFW) organized Training of State Trainer s (ToT) workshop where staff members of Assam were trained as trainers. The North-East Regional Resource Centre organized training of district trainers for four days. NE-RRC has trained 120 district trainers. The district training teams, one for each district, were trained in a batch of four districts in one go. The team of trainers for each district had four to five members including a Medical Officer, a person from the social department, a Panchayat member, and a NGO staff member. The team of district trainers in turn were expected to impart training to the block training team and they in turn trained ASHAs. Block level officials were trained for six days for implementing JSY in their respective areas with the involvement of NGOs. 9

27 Centre for Operations Research and Training, Vadodara The training programme of ASHA is of 23 days initial training for 7 days and four sessions of four days each. First round of training for 7 days for phase 1 area covering 11 districts was completed in the state by January, State, district, and block level officers of Medical and Health Department monitored the implementation of training of ASHAs. Seven days residential training of ASHAs was organized at the district and block levels. In each batch, 40 ASHAs were trained and were given guidelines presenting their roles and responsibilities. A senior state level official said, Roles and Responsibilities of ASHAs Create awareness and provide information to the community on determinants of health Counsel women on importance of safe delivery Mobilise the community and facilitate them in accessing health services such as antenatal check-up, institutional delivery, post natal checkup Work with the Village Health and Sanitation Committee of the Gram Panchayat Escort / accompany pregnant women to the nearest pre-identified health facility Provide primary medical care for minor ailments Act as depot holders of basic medicines, essential provisions like oral rehydration therapy, Iron and Folic Acid Tablets, and contraceptives Inform about the births and deaths in her village Promote construction of household toilets By October, 2006, 50 percent of our training work was accomplished. A district Chief Medical Officer (CMO) said, The first round of training for ASHA of 7 days was organized at PHC level. All the ASHAs unde r the PHC were called at the block level for residential training. Senio r medical officers, NGO members and others trained them in seven-day training. Another CMO, said, In Assam, the first training of all the batch was almost over by January Now second round of training is being planned on the kinds of services ASHAs are going to deliver A district nodal officer, mentioned, We have completed the first round of training of ASHAs and now ASHAs will be trained for second module. A state level official said that it is difficult to get trainers (qualified and capable). He said, Suppose you want to give training at the block level.one has not much choice there in quality but we are trying that we give proper training to ASHA so that she is good. One does not have much choice as we cannot select trainers from the district or the state lev el and send them to the district. Whatever manpower or personnel we have we are imparting training through 10

28 Operationalization of ASHA Intervention and JSY in Assam them and we try to ensure that we train them properly so that the quality improves. Commenting on the problems faced in identifying the trainers, a state officer said, The problem was in identifying a panchayat member as a trainer. In some places the Panchayats did not coming forward, in others, they did. In some districts, the Panchayat members were not available; they were out fo r attending some other training. The Panchayat job was more of fieldwork, implementation of other schemes also. There were Panchayat members in every team of trainers. Some places the motivation was high, some places the motivation was low. The training materials in the form of booklets for first module were received from the GoI. These were translated into local language without any modifications. Discussing the implementation of training, a senior state officer said, In the first eleven districts, it took some time but then it picked up. Now whenever ASHAs are selected they are given training. Therefore, since the training is at the block level, even if the district has not completed the selection at the block level the training can take place immediately. We don t wai t for the whole district to finish the selection process. Along with the guideline, it is planned to provide ASHAs with a radio set to listen to a health program, which is broadcast once a day in a simple language. ASHA could listen and would impart awareness to the villages. A tutorial booklet was prepared and given to ASHAs as a reading material with which they could explain to the villagers in a simple manner showing pictorial messages. As per the national guidelines, ASHA are paid performance-based payment by ANM of the concerned sub-centre. ANMs monitor the activities of ASHA and number of pregnant women motivated or number of children immunized by ASHAs. Gram Panchayat runs an account with Gram Pradhan and ANM as the joint signatories. ANMs maintain disbursement of the payment to ASHAs. ANMs maintain a register of the payment made to ASHAs. The compensation package of ASHA is as follows: Motivation for Sterilization: Rs. 50 for male and Rs. 25 for female Compensation under JSY-Rs. 600/- provided she spends Rs. 350 for transport and Rs. 250 for accompanying Complete ANC and PNC-Rs 50 DOTS provider-rs 250 Toilet promotion-apl families Rs. 30 and BPL families Rs. 20 and Rs. 10 per month if continued for six months Attending bi-monthly meetings at block-rs. 100 per meeting 11

29 Centre for Operations Research and Training, Vadodara Adaptation of JSY Guidelines and its Operationalization The state of Assam has adapted the national guidelines for JSY with some modification for implementing JSY in relation to cash assistance being given to every woman that delivers in public facility irrespective of their income status. The state JSY nodal officer administers the JSY implementation in the state. At the district level, the Chief Medical Officer or the Reproductive and Child Health Officer (RCHO) were made responsible for JSY intervention. Program Manager at DPMU was responsible for the performance and financial monitoring. At the block level, block Medical Officer Incharge was the key person implementing the JSY. At the community level, ANMs, Anganwadi workers, and ASHAs were responsible and were accountable to PRI members for promoting the scheme. To promote the JSY, the state started specific programmes and IEC activities. Besides circulars and s, discussions are held regularly to inform the health staff members about the JSY and any modifications in the guidelines thereafter. The JSY implementation guidelines and the section on frequently asked questions was translated in local languages and was circulated to all the stakeholders at the state, district and block level including medical, paramedical and a few beneficiaries. The scheme was widely publicized through print media, radio, TV, hoardings, wall paintings and writings at strategic locations. Besides, special programmes were frequently and regularly (weekly twice) broad caste through All India Radio targeting the ASHAs. The survey team during their visits to PCH, SC and distant remote villages confirmed that the scheme was widely publicized. A senior state officer said, Through advertisements on radio and TV, we are targeting the key stakeholder s. We are advertising about the roles of ASHA and targeting sometimes the women, sometime s the husbands, sometimes the mother-inlaw, and like that propagating the scheme Inter-personal communication is also very important. Newspaper advertisements were circulated in local language showing the roles and responsibilities of ASHAs, which were as under: Every woman is given the benefit of JSY Every pregnant woman gets ANC, TTT and iron tablets Women would be accompanied to the hospital for delivery ASHAs would help women in giving immunization to children ASHA would organize one health day in a village once a month This seems to be a good way to let people at ALL levels including men and women in the community and the stakeholders know about the details of the project activities. However, the implementers need to develop strategies to reach the poorest of poor illiterate women with the messages related to the programme. Moreover, only 56 percent of women in rural areas of Assam have access to TV. Most likely, the poor women being focussed by JSY would not have access to TV and hence propaganda of the scheme through TV would not be reaching the potential beneficiaries. 12

30 Operationalization of ASHA Intervention and JSY in Assam Cash Assistance: Earlier, the guidelines were that women who are 19 years or more, with upto Table 2.3: Cash Assistance Package for JSY Beneficiaries in Assam two births, Particulars Rural areas Urban areas and from BPL Mother s ASHA s Total Mother s ASHA s Total families package package package package would be Institutional delivery eligible for Home delivery (only for receiving BPL pregnant women) cash assistance. The scheme was only for BPL women and they needed to show BPL certificate to avail benefits. However, Assam decided not to check those women that opt for institutional delivery in government facilities. Hence it was Assam s decision to modify the guidelines. As per a senior state officer, Earlier the guideline s were very complicated, the Government asked fo r women to be below poverty line, it was only up to two children and all that. And then we gave a proposal to the Governmen t saying who goes to the Government hospital? Only poor people go to the Government hospitals, rich people don t go there, that s a fact. Maybe there could be the exception, maybe 1 or 2%, but if we start insisting on the BPL certificate the scheme will fail. So we proposed that any woman who goes to a Governmen t hospital should be deemed to get JSY assistance unless and until they occupy a paying cabin. However, during modification of the scheme, these eligibility criteria have been removed. Now, as per the national guidelines for LPS, all the pregnant women delivering in Government health centres like sub-centre, PHC/CHC/FRU/ general wards of District/State Hospitals or accredited private institutions are eligible for receiving cash assistance (Table 2.3). As mentioned later in the chapter, at present the process of accreditation of private institutions is in process and they are not yet included in the programme. For home deliveries, only for BPL pregnant women in both rural and urban areas, cash assistance of Rs. 500 has been sanctioned. The process of decentralization of administration power has begun, as per the national guidelines, and district, block and village level stakeholders actively participate in putting JSY into action. PRIs have been involved in implementing the scheme. As per the funds flow mechanism and according to NRHM guidelines, state/ district authorities advance Rs. 10,000/- to each ANM in low performing state as untied fund. This money is to be kept in the joint account of ANM and Sarpanch/Gram Pradhan for ANM to further advance it to ASHA/AWW for accompanying delivery case and for arranging the referral transport for escorting the pregnant women to the institution. Decentralization of the financial management and monitoring of the activities is being carried out by panchayat members. In words of the state official, At the village level, under the leadership of sarpanch, ANM, AWW, SHG and ASHA provide ANC and PNC services, and work in close collaborations. Financial monitoring is also done by the Panchayat. 13

31 Centre for Operations Research and Training, Vadodara At the block level, an accounts officer suggested that 2 days orientation training needs to be organized for the stakeholders including ANM who handle accounts and money for the first time. For implementing JSY, advance money is given to the districts, which in turn gives money to all the health institutions related to JSY. The JSY beneficiaries are paid in the institution where they deliver. In the institution, they do not have to do much of paper work; they maintain the register and pay the money. They also have a month-wise JSY beneficiary report with details on number of institutional deliveries, number paid and number to be paid. The institution itself pays the money from the funds available with them. A district official said, We are trying to ensure that the mother leaves the hospital with the money. If a woman delivers at home she gets 500 Rs from the ANM. ASHA payment is being done at the ANM level. ANMs are supposed to monitor the activities of ASHA and number of pregnant women motivated by ASHAs, number of children immunized by ASHAs. Therefore, ASHAs are paid through the ANM. All the institutions receive the money in advance and the ANMs also get 5000 Rs in advance from the Medical Officer in-charge of the PHC/CHC specifically for JSY, which they are using to pay the ASHAs. On submitting the accounts, ANMs get further advance from the PHC/CHC accounts department as sanctioned by the MOIC. Linkages and Integration In Assam, immunization week covering almost every village is being organized in the Anganwadi centre by AWWs and the ASHA working together. The ANMs are given the responsibility of guiding 4 to 5 ASHAs working under their area, so ANM is a leader for them. A senior state officer visualized, ANMs help ASHAs in organizing one health day in a village every month. ASHAs cannot organize a health day, but would mobilize people, while ANMs would be there for ANC and immunization, and if possible a doctor may be available. It is expected that a Panchayat leader and Mother NGOs will be involved in organizing health day. In this connection, state officers had to say, There are two things that we are going to monitor very closely. One is that o f organizing village health days and the othe r is that ANMs stay in the subcentres. If we can ensure those two things I think half our battle is done. 14

32 Operationalization of ASHA Intervention and JSY in Assam Village Health day is a conversion point where AWW, the ASHA, ANM, and members of Panchayat, SHGs and NGOs will be there. So once they are ther e and converge other activities would also be done. The success of JSY to a great extent depends on understanding of the scheme amongst the various stakeholders and their networking. At the state and district level, the concerned officers were aware of the objectives of JSY, their role and ASHA s role in the implementation of JSY. The other stakeholders at block, district and village level were also aware of JSY, which was evident while investigating the involvement of stakeholders in implementing JSY. A state officer said The biggest challenge we are facing is that we have to ensure that the ANM stays in the sub-centre. If we ensure that the ANM stays in the sub-centre and the doctors stay in the PHCs, well, that is the biggest challenge. Money, equipment, infrastructure is not an issue, we can take any number o f contracts with people, but unless and until we assure that those people stay there. Accreditation of Private Institutions A private institution with 24x7 days services of gynaecologist, an anaesthetist, and a surgeon who could perform caesarean section, has easy access to blood transfusion facility, proper OT and labour room with power back up can be considered for Accreditation as per the guidelines. In Assam, the process of accreditation of private institution has just begun and partnership with existing Tea Garden and Red Cross hospitals is being worked upon. According to the state official, We have just started the process, and soon planning to have a part nership with charitable hospitals, Red Cross hospitals, and tea garden hospitals. Every tea garden has its own hospit al, some are well equipped, others are not, but I think all o f these institutions can provide institutional delivery. They extend those services only to their employees. Howeve r, there are surrounding villages; there are a lot of casual workers there, so we would like to have a partnership with the Tea Garden hospitals to extend the benefit to all the surrounding villages. In return, the DoHFW would provide them with drugs and the y can then provide the benefits unde r JSY. Besides, it is important that each ASHA should know where they could refer or escort the case for institutional delivery or emergency obstetric care. During training, all the ASHAs were specifically told about the health facilities where they could refer the patient. ASHAs in Assam knew about the linkages hospitals available under JSY. Monitoring and Supervision The state Department of Health and Family Welfare utilizes senior officials to monitor and supervise the whole implementation of JSY. Besides, there is District Programme Management Unit (DPMU) to implement the NRHM and monitor the whole process of implementation at the district level. At the grassroots level, PRIs are involved in 15

33 Centre for Operations Research and Training, Vadodara monitoring both performance and cash flow. According to district authorities, monthly monitoring activities are planned and reports of monthly meetings are sent to the state from the district. During the meetings organized at the PHC/SC level, besides academic inputs and planning, monitoring of number of JSY beneficiaries registered, institutional deliveries per institutions, payments made, number of home deliveries, persons who conducted home deliveries are monitored. ICDS, health, Panchayat, and other stakeholders are to attend this meeting. ASHAs are maintaining several records and registers along with helping in birth and death registration. While discussing with district officer, he said, We go to field to verify the records and check if the cash payment is made and beneficiaries have received the money without any hustle. Community s Perceptions about ASHA and JSY In all 24 community members including men and women were interviewed to understand their perceptions about ASHA and JSY. Majority (19 out of 24) of the members in the community who participated in in-depth interview had heard of ASHA and was aware about her selection process. They knew that a village meeting was held, and the village head and ANM selected one ASHA for 1000 population covered under a Gram Panchayat and sent the selected name to the health department. They came to know about ASHA from her work or as they (ASHAs) themselves told about the programme sometime ago. Most of the community members knew her by name and her roles in the village. They said, She suggests and even accompanies a pregnant woman to the hospital fo r delivery. She helps ANM and AWW for registering birth and death. She also participate s in health programmes and camps. The community members also knew about ASHA s role in immunization, nutrition, ANC care, promotion of sanitation and latrine, and creating health awareness by visiting house to house. They thought that having ASHA in the village is beneficial because she takes care of pregnant women and children and help women of BPL families. The males in the community said, Poor women in the community are benefited because they are getting remuneration after delivery because o f ASHA. She does immunization and informs all children in the village. She (ASHA) comes for antenatal and even post natal care. Several women got institutional delivery free at the civil hospital. They also got Rs Later on women started getting Rs. 1400, as the scheme changed. 16

34 Operationalization of ASHA Intervention and JSY in Assam According to villagers almost every one in the village knows ASHA, as she belongs to the village and pays door-to-door visit and they take her as a health worker. According to the community members in Assam, ASHAs get compensation of Rs. 600 for delivery and Rs. 150 for immunization but the money is not sufficient. They even suggested for monthly payment to ASHAs. Similarly, most of the members in the community had heard about JSY that it is for increasing deliveries at hospitals. A few had some vague idea that the scheme is for the benefit of poor family and they would get some money, transportation and some facilities. In their views, up to 40 percent of the people were aware of the JSY through meetings held at the village level, and through ASHAs, ANMs, and village leaders. The community members knew that the scheme provides for transportation. The villagers were satisfied with ASHA s work and suggested for a sub-centre in the village and transport for ASHA. The assessment thus shows that the Assam has adhered to the national guidelines and its subsequent modifications. ASHA mentoring group, NE Regional Resource Centre and State and District Programme Management Unit are engaged in implementing and monitoring JSY. PRI and Gram Sabha played an active role in selection of ASHAs and monitoring the financial aspect of JSY. In Assam, print and electronic media have been used to propagate the scheme and it will be interesting to assess its reach to the general masses. Accreditation of Tea Garden and Red Cross hospitals looks promising, but a sustainable partnership will have to be nurtured. 17

35 CHAPTER 3 INVOLVEMENT OF ASHA IN JSY A major component of the NRHM is to involve ASHA, a village-based women activist, who would be able to organise demand-side for effectively promoting JSY and timely utilisation of various health related interventions within the programme. It is further felt that ASHA would act as an interface between vulnerable communities, especially women and children, with the health care providers. As mentioned earlier, ASHAs have been trained for module 1 and would be further trained to enable them to perform their roles. Such schedule of trainings will help ASHAs to practice what ever they learned in earlier training and to come back for next training keeping in mind their own work environment in villages. In this context, It was expected that by training the ASHA s, would be able to facilitate implementation of the Village Health Plan along with Anganwadi worker (AWW), ANM, functionaries of other Departments, and Self Help Group (SHG) members under the leadership of the Village Health Committee of the Panchayat. In addition, ASHA guidelines proposed provision of a Drug Kit containing generic AYUSH and allopathic drugs for common ailments, oral pills and condoms so that they could provide general health care specifically for minor ailments and act as depot holder for oral pills and condoms as well. This chapter describes the socio-demographic profile of ASHAs, their motivation to be ASHA, selection process, training, and knowledge retention regarding antenatal and childcare. The Chapter also discusses their roles and responsibilities, and services provided to pregnant women by them under the JSY. Details about ASHA s last clientele (to understand the nature and range of interactions), networking with key stakeholders, cash assistance received by ASHA, their supervision and monitoring, challenges faced and their suggestions for improving the scheme are also presented. Background Characteristics of ASHA In all, 181 ASHAs were interviewed from the three districts of Assam. ASHAs interviewed were middle aged with the average age of 32. Two-thirds of the ASHAs were 30 years or above. On average, ASHAs have had 9 years of schooling. Majority (74 percent) of the ASHAs studied up to secondary or higher secondary level. Thirteen percent of the ASHAs who had studied below eighth class did not fulfil the eligibility criteria for ASHAs (Table A1). Most of the ASHAs interviewed were married, 4 percent were unmarried, while 9 percent were divorced, separated or widowed. Eighty-two percent ASHAs were Hindu, and 16 percent were Muslims. Forty-five percent of the ASHAs belonged to scheduled caste/scheduled tribe and 24 percent belonged to other backward classes.

36 Centre for Operations Research and Training, Vadodara It is encouraging to note that all the ASHAs stayed in the same village where they worked as ASHA (Table A2). The eligibility criteria for ASHAs are that she should be eighth class pass; should be between 25 and 45 years and preferably married in the village. Analysis of the data in the study shows that 25 percent of ASHAs did not fulfil one or the other criteria for becoming ASHA because they either were aged less than 25 years or more than 45 years, had not studied up to 8 th standard or were not resident of the village. Such proportion of ASHAs not fulfilling the eligibility criteria was the highest in Goalpara (33 percent) followed by Jorhat (30 percent) and Nalbari (16 percent). Regarding the number of living children of ASHAs, the study showed that only eight percent ASHAs had not experienced any childbirth, while, on average, the other ASHAs had 2.5 living children (Table A3). Majority of the ASHAs had 2 3 living children, and 15 percent had four or more living children. All the ASHAs who had children were asked about the place where their last child was delivered to understand their own practice and behavioural aspects regarding place of delivery. The study revealed that 68 percent of the ASHAs had delivered their last child at home, followed by 27 percent at the government institution, which was in line with the trends observed in the community in Assam and reflected community behaviour. This ensured that the selection of ASHAs represented the community and was done adequately as per the national guidelines. Thirty-seven percent of the ASHAs worked for earning cash or kind before being selected as an ASHA for an average of 6.7 years mainly as agricultural labour or helping on farm, as skilled workers, or assisting ANM/AWW. Twelve percent of the ASHAs undertook health related activities from home or worked in school. They also worked as daily wage labourers or had their small business. After becoming ASHA, 24 out of 67 (36 percent) ASHAs continued their cash earning activities (Table A3). Regarding duration of working as ASHA, on average, it was found that they worked as ASHA since 7.4 months ranging from 2 14 months. Seventy-three percent respondents worked as ASHA for seven months or more. The study revealed that 26 percent of ASHAs had not received any money from ASHA work till the date of survey, though most of them had been working for four months or more. Of the remaining ASHAs, 44 percent received up to rupees 250 per month. The average earnings were Rs per month. About ASHA: Their Selection and Motivation to Work ASHAs were asked about the source of information about ASHAs, method of their selection and about their motivation. Nearly 46 percent of the respondents first came to know about the ASHA from ANM and another 13 percent from Gram Panchayat. For 6 11 percent of the ASHAs hoardings kept at sub-centres, PHC or CHC, radio/tv or health personnel were source of information, while for five percent or less Anganwadi worker and Sugam workers as the source of information. A few of the respondents came to know about ASHA only at the time of training from their trainers or family members. 20

37 Involvement of ASHA in JSY The respondents were asked about the way they were selected as ASHAs and the role of gram sabha in approving their selection. Majority (71 percent) was selected through ANM. Forty-three percent mentioned about selection or approval by Gram Sabha. Some 9 percent or less were selected because they worked as Anganwadi Sahyogini, or due to political support from Sarpanch. Nearly 76 percent of the ASHAs said that Gram Sabha had approved their names (Table A4). The main motivation for the respondents to become an ASHA was to serve/help the community (90 percent), to save children (57 percent) and to earn money (56 percent). Respondents also appreciated that participating as ASHA gave them the opportunity to remove misconceptions in the community (24 percent), and help reducing the population growth. Training of ASHA As per the national guidelines, each ASHA should have attended seven days of induction training. The study shows that all the ASHAs had attended the training in the last one-year. According to the ASHAs, the topics covered during the ASHA training programme included women and health including FP, ANC, breast-feeding, and infant and childcare and immunization. Thirty to 43 percent, ASHAs talked about nutrition, sanitation, and HIV/AIDS. Only a quarter of the ASHAs mentioned about the eight tasks of ASHAs and supply of safe drinking water and a still lower proportion mentioned NRHM and organizing a group meeting as the topics covered during their training. Curative care, reproductive and sexual health problems and adolescent education were mentioned as topics covered by only a few ASHAs (Table A5). The training of ASHAs was done, on average, 7.2 months ago (July August 2006) and the duration of the training was 7 days. The training was mostly held at PHC and CHC. Regarding additional arrangement, every third ASHA responded for additional arrangements. Most of them (82 percent) needed proper food arrangements, more space in the training room, proper water facilities, proper beds/bed sheets, and latrine/ bathroom facilities. A few ASHAs put forth the need for having TV, transport arrangements, electricity, and fan during training (Table A5). Two-thirds of the ASHAs appreciated the arrangement for sitting and size of the room, and only one-third of them said that the accommodation and food facilities were good. One-third of the ASHAs complained about poor accommodation and food arrangements (Table A6). Quality of Training To assess the quality of training, training pedagogy, ASHAs were asked to comment upon the trainers and the process of training. Majority of the ASHAs found the trainers to be either very good (49 percent) or good (48 percent). Besides, ASHAs found the training to be participatory and said that the trainers encouraged them to ask questions (70 percent) and answered their questions properly (Table A7). 21

38 Centre for Operations Research and Training, Vadodara Majority (68 80 percent) of the ASHAs said that the trainers gave lectures and used books/modules, posters and models to explain the topics. Pamphlets, flip charts, TV/ video, and folksongs were also used as training aids. Most (89 percent) of the ASHAs found the training materials to be very good or good and useful (87 percent) or somewhat useful (12 percent). Thus, the study reveals that the logistic arrangements at the place of training were not proper, but ASHAs appreciated the training including trainers and training methods as good and useful. There were certain topics covered during training that are mentioned by only few ASHAs such as disposal of waste water, safe drinking water, organizing a group meeting and reproductive and sexual health problems or management of diarrhoea and pneumonia. These topics need to be readdressed in subsequent training for ASHA. Payments during training: The study reveals that only 77 percent of the ASHAs received their allowance during training. On average, they received Rs Only 14 percent of the ASHAs received amount due to them, that is, Rs. 100 X number of days attended training as DA + Rs. 100 for transportation. Fifty-eight percent ASHAs were given Rs for attending 6 days of training, while five percent ASHA was given more than due (Table A8). Certain batches of ASHAs were not paid, as advance money was not released but were told that they would be paid the money subsequently when the second round of training would be conducted. Use of reading materials: ASHAs were given reading materials/guidelines immediately after their training. Most (94 percent) of the ASHAs confirmed having received the reading materials for the implementation and promotion of JSY. In fifty percent of the cases, the field investigators saw the guidelines, while another 44 percent had the reading materials but could not show it to the team (Table A9). It is also encouraging that three-fourths of them were able to refer and follow the reading materials and the remaining one-fourth could follow it to some extent. ASHAs could not follow the reading material because they found it too extensive, followed only what they understood, and a few experienced lack of time as they had a small child to be looked after. One-sixth of the ASHAs practised only a part of the reading materials based on the facility/services available in the first referral unit, they were still fresher and hence were learning and/or waiting for their joining letter before they could adopt the guidelines. Knowledge of ASHA about ANC and Child Care Services To assess the knowledge of ASHAs, they were asked about various aspects of antenatal care taught to them during the training. In the survey, 10 questions related to ANC care and newborn care were asked to ASHAs and each question answered correctly was given one mark. Later, the scores achieved by a particular ASHA were added up to get total score to understand whether the ASHAs were having knowledge required for ANC care. 22

39 Involvement of ASHA in JSY The total score of all questions was categorized as Grade O (outstanding) for scoring 10 out of 10 points, Grade A for those who score 8-9, Grade B for those who score 6-7, andd Grade C for those who score 5 or less. Majority (70 percent) of the ASHAs scored Grade A or Grade O, and 25 percent of them scored Grade B (Table A10). Every fourth ASHA could answer all the 10 questions correctly (see Figure 3.1). Figure 3.1: Scoring knowledge of ASHAs in Assam Grade O 25% Grade A 45% Grade C 5% Grade B 25% Further analysis of the specific aspects shows that ASHAs had good knowledge about antenatal and newborn care (Table A11). For instance, majority (84 99 percent) of the ASHAs knew about the various aspects of safe motherhood and child care including number of antenatal checkups required during pregnancy, IFA tablets to be consumed, number of TT injections to be taken, minimum birth weight of baby, breast feeding and management of diarrhoea. Majority of the ASHAs (67 percent) knew about all the five cleans that need to be maintained during delivery. Knowledge of Pregnancy and Delivery Complications and Actions to be Taken ASHAs need to know about the complications women may experience during pregnancy for early identification and timely referral. Regarding complications during pregnancy, 53 to 74 percent of the ASHAs mentioned swelling of hands and feet, vomiting, paleness, and excessive bleeding. Forty-five percent of the ASHAs mentioned about convulsions, while one-third mentioned about abdomen or body pain, and high fever. Less than 5 percent mentioned about weak movement or abnormal position of foetus. The knowledge of ASHAs regarding complications during pregnancy and delivery was low and may be taken up in subsequent rounds of training (Table A12). If ASHAs recognize any signs of complications among women during pregnancy, the data shows that they could take varied actions depending on the type of complication the women suffered during pregnancy. Three out of four ASHAs said that they would immediately refer the pregnant woman to the nearest functional FRU including upgraded CHC, subdivision or district hospital. It is to be noted that 48 percent of the ASHAs said that they would ask the pregnant woman to consult the ANM the next day. This would further delay the process and timely referral. One-sixth of the ASHAs mentioned that they would take the woman with complication to the nearest functional FRU, or refer to a government hospital / private accredited hospital. A few (3 percent) ASHAs said that they would provide money for transportation to the women. ASHAs further said that common complications during pregnancy or delivery resulting in maternal death could be excessive bleeding (79 percent), weakness of the mother (72 percent), convulsions (44 percent), blood pressure problem (38 percent), or 23

40 Centre for Operations Research and Training, Vadodara abnormal position of the foetus. Other reasons for death could be fever, death of foetus in mother s womb, abdominal pain, tetanus, or headache (Table A13). Knowledge about Newborn Care Most (90 91 percent) of the ASHAs knew about BCG and DPT vaccines by names that are to be given to children as part of the Universal Immunization Programme. Majority (69-77 percent) of the ASHAs knew tetanus toxoid, OPV, and Measles vaccines by name. Moreover, 18 percent of the ASHAs knew about the booster dose. Most of the ASHAs said that newborns are most likely to die soon after birth (62 percent), within a week of birth (9 percent), or within a month of birth (9 percent). The study reveals that nearly 15 percent of the ASHAs did not know the period when newborns are most likely to die (Table A14). Knowledge about responsibilities of ASHAs According to the ASHAs, their main Figure 3.2: ASHAs' awareness about her responsibilities responsibilities are to help in immunization program (85 percent), accompany delivery Help in immunization program Accompanying delivery cases cases (82 percent), Registration of birth and death 51 ensure registration of birth and death (51 Provide ANC care 49 percent), provide Create awareness on health 48 antenatal care and Work with ANM/Anganwadi/dai 37 create health Create awareness on basic sanitation & awareness. One-third hygiene 35 of the ASHAs Motivating and mobilizing community 31 mentioned that their responsibilities include Counseling 23 working with ANM, Family planning 19 Anganwadi worker and dai, creating Village health planning 18 awareness about basic Provide basic curative care 9 sanitation and hygiene, Make timely referrals 6 and mobilizing community to utilize Promote good health practices 6 health services. Onefifth of the ASHAs mentioned Increase institutional delivery Other 1 2 counselling, family planning, village health planning, providing basic curative care and promoting good health practices as their responsibilities. Only 6 percent of the ASHAs mentioned about timely referrals as their responsibilities (Table A15). 24

41 Involvement of ASHA in JSY To increase utilization of the services of ASHAs, it is important that the community recognize ASHAs and know their role in the village. In two-thirds of the cases, ASHAs informed the villagers, or the respondents felt that people in the village recognize them because of their work in the community. Another 47 percent were introduced by the gram sabha/sarpanch or ANM, while 35 percent said that they attend meetings at the health centre so people could recognize them as ASHAs. The respondents felt that people in the village recognize ASHAs as Sahyogini working with Anganwadi, and because of their work in the community. People also knew that ASHA can get them money and that ASHAs are paid. Most (97 percent) of the respondents were happy being an ASHA, as they got the opportunity to serve the community (26 percent); received more money (22 percent), and learnt new things, which they pass on to the community. A few ASHAs complained about too many responsibilities, targets (informally assigned by the ANMs) or difficulty in working with ANM. ASHAs felt happy because they came to know about ANC (84 percent), and got respect and support from the villagers (49 percent). ASHAs said that they were happy being ASHAs as they like to serve the community and they got to know people and doctors in the village. A few ASHAs disliked the work because of targets and delayed payments. All the ASHAs were asked how the community felt about them. Most (95 percent) of the ASHAs thought that the community appreciated their work and consulted them for health problems (26 percent). Only two percent of the ASHAs said that the community did not interact with them. Organization of Work by ASHAs All the ASHAs were asked about the process of carrying out their work. Most (98 percent) of the ASHAs said that they visited house, and percent said that they attended immunization session and accompanied women for delivery. Another 55 percent of the ASHAs said that they accompanied ANMs, and every third ASHA organized health day at Anganwadi Centre (Table A16). All the ASHAs were asked about the advice and services given to a woman during antenatal and postnatal period. Most (93 percent) of the ASHAs said that they advised pregnant woman regarding diet, followed by ANC care (to have three check-ups and take IFA tables and TT injections) and delivery care. Two-thirds of the ASHAs mentioned giving advice related to institutional delivery and immunization, followed by newborn care, breast-feeding, danger signs, and personal hygiene. One in every five ASHAs advised pregnant women about breast care and family planning. As for the services to pregnant woman, 86 percent of the ASHAs mentioned that they gave advice for antenatal check-up, three-quarters each accompanied pregnant woman for TT and for ANC check-up and ensured that woman took IFA tablets. Only few ASHA talked about attending outreach day or identifying risk factor in antenatal mothers (Table A17). 25

42 Centre for Operations Research and Training, Vadodara Majority (82 84 percent) of the ASHAs said that during post partum period, they advised woman regarding immunization, breast-feeding, newborn care, and nutrition. Follow-up regime was explained by 46 percent of the ASHAs. Only few ASHAs (3 percent) mentioned childhood morbidity management. Availability and Utilization of Drug Kits It is proposed that ASHAs will be provided with drug kits to provide basic medicines to the people, if required. The study reveals that only four out of 181 ASHAs said that they received the drug kit, some days after training (n=3), while one ASHA received drug kit much later after her training. Thus, the drug kit is not available with most (98 percent) of ASHAs and hence not utilized. Since only four ASHAs received the drug kit, it is difficult to generalize any findings from this section on availability and utilization of drug kits. The drugs and materials mainly supplied in the drug kit to ASHAs are paracetamol, quinine tablets, IFA, Nirodh and Mala D, and ORS packets. Two out of four ASHAs who had reportedly received the drug kit mentioned needle, blade, scissor, bandage, cotton, and thread. All the four ASHAs who received the drug kit had used the medicines available in the kit about 93 days ago, on average. The last time when ASHAs used the drug kit, they dispensed paracetamol tablets, and Mala D. The medicines are mostly replenished at CHC/PHCs (Table A18). ASHA s Role in JSY ASHAs play a key role as an effective link between the Government and the poor pregnant women in the promotion and propagation of JSY. As expected, all the ASHAs, except one, had heard about JSY. Majority (62 percent) of them heard about JSY for the first time from ANM or other PHC staff, while 19 percent each said that they first heard about JSY during training or from Medical Officer of PHC/CHC. TV, radio and newspapers (11 percent), AWW (7 percent), village panchayat leader and women in the community also were the source of information about JSY. Posters / hoardings were almost absent in Assam and were mentioned by only one ASHA as their first source of information about JSY (Table A19). When ASHAs were asked about JSY, 78 and 74 percent respectively mentioned it as a scheme for promotion of institution delivery, and for benefit of mothers to take proper care of mother and newborn. Forty-six to 47 percent of the ASHAs said that the scheme was for immunizing children and poor families, while only 13 percent mentioned that JSY was to promote family planning. Some of the ASHAs understood JSY as taking nutritious food, for population stabilization and for getting cash assistance. Seventy-nine percent of the ASHAs said that all women during pregnancy could be the beneficiaries, while 56 percent believed that women from BPL families could be the beneficiaries. Few of the ASHAs mentioned women above 19 years of age, or those with less than two children, and from SC/ST families as beneficiaries. It appears that several ASHAs had confusion regarding the eligibility criteria of JSY beneficiaries. Besides, the ASHAs also mixed up the answers for beneficiaries to be eligible for JSY for institutional deliveries and for deliveries at home. 26

43 Involvement of ASHA in JSY Most (92 percent) of the ASHAs identify possible beneficiaries through home visits, 59 percent by contacting people and 42 percent said that if a woman felt uneasy or was vomiting, they took her to the hospital. One-fifth of the ASHAs said that pregnant women themselves came for check-ups or that ANM/AWWs informed ASHAs about the pregnant women. ASHA s Awareness about Cash Assistance under JSY Each of the ASHAs interviewed were asked about the cash assistance available to ASHA and JSY beneficiaries. Chapter 1 gave details of the payment package as propagated by the state. Majority (89 percent) of the ASHAs mentioned the cash incentive available to them mainly for attending delivery cases, immunization (61 percent), Rs. 200 as transportation money for escorting women for delivery (38 percent) and for accompanying women for delivery (24 percent). A few ASHAs said that they get encouragement from Sarpanch, ANM and villagers and support from the system or money for training (Table A20). Almost all the ASHAs mentioned that the benefits available to a beneficiary mother include Rs. 1,400 for institutional delivery. This was Rs. 700 before November One-third or less mentioned that beneficiaries get free treatment, delivery, immunization, followed by assistance of Rs. 500 for home delivery (29 percent). Twenty-two percent mentioned Rs. 400 for sterilization, free medicines and free transport to hospital (8 percent). Some of the ASHAs mentioned antenatal services, protection of mother and child health, nutritional supplement from Anganwadi, and quality services. Surprisingly low proportion of ASHAs mentioned cash assistance for home delivery and free transport to hospital. Informal discussion with the state officer revealed that ASHAs are given money for transport as part of 600 Rs. Package. However, travel expenses were free for the beneficiaries only if ASHA accompanied and paid for the transport right away; otherwise beneficiaries had to pay for transport. Promoting JSY As expected, most (96 percent) of the ASHAs said that they played a role in promoting JSY. To promote JSY, they talked to women (84 percent), their husbands (52 percent), and other family members (35 percent). Nearly 45 percent of the ASHAs mentioned door-to-door visit and another 41 percent said that they publicised JSY during immunization and health days. A few (three percent or less) mentioned distributing pamphlets/brochures. All the ASHAs considered the work under JSY as very important (62 percent) or important (38 percent) as compared to other tasks that they had to fulfil as ASHA (Table A21). All the ASHAs were invited to express their views about and suggest ways for further promotion of ASHA and JSY. Many of the ASHAs suggested organizing village level meetings (64 percent), door-to-door visits (60 percent), advertisement (43 percent), and giving more financial benefits to ASHA (32 percent) to strengthen their work as ASHAs in Assam. Nearly a quarter of the ASHAs thought that JSY could be promoted through satisfied beneficiaries. 27

44 Centre for Operations Research and Training, Vadodara Accompanying JSY Cases and Arranging for Institutional Delivery All the ASHAs were asked details about accompanying JYS cases, and arrangements made thereof. It was encouraging that 88 percent of the ASHAs had accompanied JSY cases for institutional delivery. On average, ASHAs had escorted 4.4 cases for institutional delivery ranging between one and twenty-five cases per ASHA. Majority (60 percent) had accompanied three or more women for institutional delivery. Majority (61 percent) of the cases were taken to PHC or government hospital (39 percent) and one-tenth to CHC. It is revealing that sub-centre is mentioned only by less than two percent of the ASHAs. As mentioned earlier sub-centres need to be upgraded and ANM need to stay there to provide services and motivate women to deliver at sub-centres. ASHA suggested private vehicles (79 percent) to transfer a case from village to health facility and 28 percent depended on public transportation (Table A22). ASHAs were asked how they usually arranged for transport. Nearly 54 percent ASHAs said that they called transporters over phone, while another 35 percent informed the transporters in advance. One-fifth each said they requested family members to identify a nearby transporter, when EDD was close, arranged transport as soon as possible, used private shuttle vehicle, or kept contact with transporters. Only 12 percent ASHAs said that families themselves arranged the transport. It is to be noted that in Assam, less than six percent of the ASHAs interviewed said that transport was easily available in their village or that they would contact ANM. Regarding the availability of transport, 77 percent of the ASHAs said that transport facility was available always, while it is crucial to note that 22 percent ASHAs said that transport was not always available. The average time taken to arrange for the transport was to be 33.4 minutes with maximum time taken up to 6 hours to arrange for the transport. Further, the average distance to the referral facility was 9.1 kms ranging between no distance and 60 kms. The study also reveals that it took 36.4 minutes, on average, and maximum of 6 hours to reach the institution. Depending on the distance to the facility from residence of JSY beneficiary, the time varied from an average of 17 minutes to 62 minutes (Table A23). Four to 7 percent of the ASHAs did not know the details about transportation or distance and time taken to reach the ultimate place of delivery. Cooperation and Cash Assistance Payment to JSY beneficiaries All the ASHAs interviewed were asked about the Cooperation at the institution and the process of paying cash assistance to JSY beneficiaries. Majority (87 percent) of the ASHAs said that the cooperation received at the institution was very good or good. However, 5 percent each said that the cooperation was neither good nor bad or that there was bad or no cooperation at the institution (Table A24). All the ASHAs were asked details about the process of disbursing cash assistance to the beneficiaries at the place of delivery. Ninety percent of the ASHAs were aware and mentioned that the beneficiary women were given cash assistance. Majority (54 percent) reported Rs 1400 and 32 percent mentioned Rs. 700 (that was given till November 2006) as the amount received by beneficiaries for institutional deliveries. 28

45 Involvement of ASHA in JSY Some 9 percent ASHAs mentioned about Rs , while another 2 percent mentioned Rs as cash assistance during delivery. According to the ASHAs, the MO CHC/PHC, civil hospital superintendent, or hospital in-charge (55 percent), doctor at the institute (26 percent), and accountant, clerk, or supervisor (24 percent) mostly paid the beneficiaries. ANM (14 percent) and ASHA themselves (2 percent) also made of the payment to the beneficiaries. Fifty percent ASHAs said that the payment of cash assistance to the beneficiary was done much later, and another 43 percent mentioned that cash assistance was given immediately or within a week after the delivery. Only two percent said that cash was given before delivery or at the time of registration, whereas the remaining five percent did not know about the timing of giving cash assistance. In most (93 percent) cases, the payment was done in one go at the PHC (51 percent), at the place of delivery (49 percent) or at CHC (7 percent). Five percent of the ASHAs said that payment was done at the sub-centre, within the village or at home. Two out of three ASHAs mentioned that there were delays in beneficiary receiving the money mainly because of lack of budget (59 percent), doctor s signature or long queue to collect money. On the one side, senior officials at the state level said that cash flow has never been a problem, while on the other side a substantial proportion of the beneficiaries did not receive cash assistance because of lack of budget at the centre. Handling of Delivery at Natal Place Each ASHA was asked about how they handle cases where a woman goes to her natal place for delivery in another village. In such situation, according to 31 percent of the ASHAs, they tried to convince women to deliver in the same village, or asked women to take proper care and go for institutional delivery at her natal place (25 percent). One-sixth of the ASHAs also said that if the natal place was nearby, they request women to call her at the time of delivery or accompany women to the place of delivery (11 percent). Less than 10 percent said they took care of immunization of the child, ASHA at woman s natal place took care, made sure that the woman gets the benefit. Eight percent said that women would receive the money at the place of delivery, hence there was no problem. Only 5 percent ASHAs mentioned that they would give JSY card from the village and referral slip. Nearly two-fifths of the ASHAs had no such case until now (Table A25). ASHA s views about Preference for Home Delivery among Women Despite cash assistance paid under JSY for institutional delivery, many women preferred to deliver at home. A probing was made to understand the reasons behind. As per 72 percent of the ASHAs, home delivery was cheaper and hospital delivery was costly. Another 36 percent of the ASHAs said that women did not understand the importance of institutional delivery because of illiteracy, and were afraid of going to hospital, of doctors/of injection, needle, equipment etc. (31 percent) and were afraid of nurses (28 percent). Other reasons put forth by up to a fifth of the ASHAs were related to better care at home, followed by unavailability of transport facility on time 29

46 Centre for Operations Research and Training, Vadodara (16 percent), not believing in ASHAs, and sense or shame in going to a doctor for delivery. Other factors contributing to home deliveries were lack of time, delivery before due date, and perception that hospital was for complications during delivery (Table A26). Beneficiaries of ASHAs ASHAs were asked about a brief description of their last case, to get an idea of the spectrum of services provided by them. On average, the last case availed services from ASHA 32 days ago. The average age of the last case of ASHA was 24.1 years with an average of 1.2 children. Almost half of the ASHA cases were schedule caste/schedule tribe, while 18 percent belonged to other backward caste group. The main reason for the interaction between ASHA and their last case was to get advice about place of delivery (54 percent), for immunization (48 percent), antenatal care/check-up (46 percent), registration of pregnancy (28 percent), IFA tablet distribution (20 percent) and for post natal care (19 percent). Another 6 7 percent of the ASHAs were contacted for procuring Mala D or condom, BPL card, information regarding sterilization, and to collect medicines for fever, back ache, or vomiting (Table A27). On average, it had been almost over a month (35 days) since ASHA last accompanied woman for delivery. One-fifth of the ASHA accompanied last case for delivery within 7 days, 10 percent between 8 15 days, and 25 percent between days. A quarter of the ASHAs accompanied women between 1 and 2 months, while 20 percent accompanied women 2 months to 6 months ago. Most (89 percent) of the ASHAs who accompanied a case, stayed with JSY beneficiary at the place of delivery for an average of 1.1 day. In 20 percent cases, ASHA stayed back at the place of delivery for less than one day, while another 20 percent stayed with the women for two days or more (Table A28). Networking of ASHA Under the NRHM, ASHAs network with various stakeholders, meet them Figure 3.3: Network of ASHA with stakeholders (Percent meeting the stakeholders) frequently and discuss/carry out ANM 100 several health related activities. 98 ASHAs were asked about the pattern of networking, activities carried out PHC staff 87 in collaboration and whether ASHAs 68 found the various stakeholders PRI 65 supportive. The results were interesting and revealing. As 43 presented in Figure 3.3, most ASHAs Village mandal 41 met ANMs and Anganwadi workers 23 ( percent), followed by PHC staff (87 percent), self-help group NGO staff 21 (68 percent) and panchayat members (65 percent). Two-fifths of the ASHAs each mentioned about meeting block facilitators and village mandals, while there 30

47 Involvement of ASHA in JSY seems to be hardly any interactions with village health and sanitation committee and NGO staff (23 and 21 percent respectively). As per frequency of meeting of ASHA with the stakeholders, percent of the ASHAs met ANM and/or AWW almost daily or at least once a week, and 9 12 percent ASHAs met fortnightly. The remaining 10 percent of the ASHAs met ANM/AWW monthly or less frequently. With other stakeholders, including village mandal, SHG members, PRI, PHC staff, percent ASHAs met at least once a week. In the case of health and sanitation committee, block facilitators, and NGOs, meetings were less frequent and weekly meetings were reported by only percent ASHAs (Table A29). The ASHAs were asked when they last met the stakeholders from the date of interview. The analysis reveals that among those who met the stakeholders, on average, ASHAs last met ANMs and AWWs 5 days ago; SHG members 6 days ago, village mandal and PHC staff (10 days ago), followed by Panchayat members, health and sanitation committee nearly days ago; and block facilitators and NGO staff before 23 days. ASHAs work in close collaboration with the Anganwadi worker and ANMs to enhance the utilization of immunization services, take care of antenatal women, motivate pregnant women for antenatal check ups, organize health days, ensure payment of cash assistance to JSY beneficiaries, and help in administration work. Together, they provide health awareness to the community, curative care, mobilize infants for nutritional supplements, and promote sanitation and hygiene. ASHAs also get guidance from ANMs to provide FP services. Similar activities are reported with the PHC staff, block facilitators, village Panchayat and NGO staff. ASHAs work with block facilitators, NGO staff, health and sanitation committee and self-help group to provide health information to the community, and organize health days/camp. They work with PHC staff and block facilitators to ensure payment of cash assistance, collaborate with SHG, NGO staff, village mandals, block facilitators to motivate people for saving money under saving scheme, and promote sanitation and hygiene with health and sanitation committee, village panchayat members, and village mandals. Thirteen to 18 percent of the ASHAs said that they got help in administration and registration work and guidance to overcome problems from the block facilitators and village panchayat. Almost all the ASHAs opined that the stakeholders except Health and Sanitation Committee, NGO staff, and SHG members were supportive. The Role of other Stakeholders Under the National Programme, officials of various levels including block officials, village panchayat, NGOs, SHG, health department, and CBOs have specific roles and responsibilities in the implementation of ASHA intervention. When asked, in most cases ASHAs were not aware about the role of these stakeholders. For instance, the 31

48 Centre for Operations Research and Training, Vadodara role of NGOs, CBOs, block officials and PRI in the execution of the ASHA component was not known to 47, 32, 28 and 21 percent of the ASHAs respectively (Table A30). It is encouraging to note that ASHAs knew about the role of Health Department in implementation of ASHA intervention. As per 36 percent of the ASHAs or less, the department was involved in various activities including providing medicines/drug kits, training of ASHAs, immunizing of children, arranging money, giving treatment to women, and selection of ASHAs. Besides, the health department motivated people for institutional delivery, birth and death registration, and organizing village health day. To some extent, health department propagated JSY, monitored work of ASHA, and maintained hygiene and sanitation in the village. Panchayati Raj Institute According to one-fifth of ASHAs, Panchayat served the village by building roads, drainage lines, and water facilities and 16 percent ASHAs said that PRI played a role in the selection of ASHA, and maintaining sanitation in the village. PRI members organized village health day, solved problems of ASHAs, created awareness of JSY among community, ensured payment of widow pension, and motivated people for institutional delivery. Out of the six Panchayat representatives that we interviewed, only half were aware of the JSY and ASHA. The Medical Officer of the area verbally told those who were aware about the scheme and the expected work with the ASHAs. In turn, Panchayat informed the community members during Panchayat meetings and most of them felt that regular discussions need to be held with the community were necessary to promote JSY and work of ASHA. A Panchayat member also explained his role in monitoring the work of ASHAs, saying, Weekly once I meet ASHA regularly and ask he r about the number of ANC women, delivery cases, JSY beneficiaries. I also ask her about the health camp and progress of work in immunization Talking about the ways to publicize the programme, PRI members had to say, In our villages people do not read newspaper o r see television. We listen to radio, but if you want to inform women about the scheme then you have to explain each of them individually. When they come to access services at the health camp. Yet another PRI member said, ASHA is doing very good work, and I try to solve any problem that she faces while working in the village. 32

49 Involvement of ASHA in JSY Appreciating her work, another PRI said, ASHA needs to be paid timely and her cash incentives should be increased. I would say a minimum amount should be further fixed for her on monthly basis. She would work with peace of mind. NGO/CBOs Out of the 20 NGOs/CBOs contacted by the field team, none of the NGO was involved in selection of ASHA, while only five CBOs confirmed that they participated in selection of ASHAs. These NGOs/CBOs were largely unaware about the selection criteria of ASHA, selection process, training, or roles and functions of ASHAs. None was actively involved in the implementation of JSY or ASHA intervention. Only one member said that they were asked to identify and suggest name of a good and honest woman in the village to work as ASHA. One of the CBO members said, We do not interact with ASHA regularly, but I saw her working in an ANC camp and on an immunization day. Another NGO staff commented, Community feel good about ASHA and appreciate her work. ASHA is a media through which poor women get Rs if they go for institutional delivery. Moreover, a CBO member suggested, To promote JSY and utilize the benefits of having ASHA, we need more advertisements, more meetings, and more discussions with the community about the functions of ASHA. A monthly general meeting about JSY could be thought about. Block Officials In Assam, the block officials were involved in arranging money, building roads/drainage lines/water facilities, and 10 percent each mentioned about solving ASHA s problems, running saving scheme/providing loans, followed by selection of ASHAs, ensuring payment of widow pension, help in training of ASHA, and creating awareness of JSY among community. The NGOs helped in organizing village health day (8 percent), running saving scheme (7 percent), maintaining hygiene / sanitation, solving problems of ASHA. The self-help groups and CBOs provided loans, were running saving scheme, and solving problems of ASHAs. The SHG members also motivated people for institutional delivery and helped in organizing village health day, and immunization of children. 33

50 Centre for Operations Research and Training, Vadodara Incentives Received as ASHAs All the ASHAs interviewed were asked details about the cash incentive money received by them. The study reveals that 80 percent of the respondents did receive some cash incentive money as ASHAs. Sixty-eight to 70 percent of the ASHAs each received money for attending JSY beneficiaries and for immunization of children. Only 19 percent ASHAs got money for antenatal care. ASHAs were asked about the amount they received for their last beneficiary case. Out of the 181 ASHAs, only 118 (65 percent) received money for their last beneficiary case. On average, ASHAs received Rs for their last beneficiary who could be JSY beneficiary or child s mother for immunization. Medical Officer of CHC/PHC (42 percent), ANM (33 percent), and doctor or staffs at the institute (26 percent) mainly gave the cash incentive money to the ASHA. Accountant and clerk also gave the cash incentive (Table A31). ASHAs got the payment for the last case at PHC (55 percent), place of delivery (21 percent), at sub-centre (9 percent), followed by the CHC, Anganwadi or at home (2 8 percent). The study reveals that nearly 28 percent of the ASHAs got the payment immediately, on the same day, or on giving the accounts, whereas the remaining got the payment within a month (37 percent) or after more than a month (35 percent) for the last case. Several ASHAs did not perceive (or reported) that they received some payment on monthly basis when asked earlier. Only 28 percent of the ASHAs said that they got the cash incentive on time. The main reasons for the delay in payment of cash incentive included lack of budget at the centre (71 percent), missing signature of the Sarpanch (10 percent), receiving total accumulated amount after 2 3 months (9 percent), or the approval for the payment. Some delay occurred because JSY had just started or because ANM did not make the payment. Only ASHAs received money for attending JSY beneficiary or for immunization of children. The mean amount received for attending JSY beneficiary was Rs (ranging between 100 and 2500) and for immunization of children, it was Rs (ranging between 20 and 800). Only one ASHA received payment for promoting sanitary latrine (Rs. 90) and for giving DOT treatment (Rs. 100) (Table A32). The study reveals that majority of the ASHAs were satisfied (26 percent) or somewhat satisfied (36 percent) with the cash incentive received under the scheme, because they served the community (29 percent), they received money (28 percent) and got the opportunity to learn many new things and work within the village. Thirty-eight percent of the ASHAs expressed that they were not satisfied with the cash assistance as the salary was not adequate for the work they did (53 percent), delayed payment (37 percent), or that some ASHAs were favoured and they got money even if activities were not done. Delay in payments and not receiving money from ANM or other officials caused dissatisfaction among the ASHAs (Table A33). 34

51 Involvement of ASHA in JSY Supervision and Monitoring of ASHA Each of the ASHAs was asked about the supervision and monitoring process. The study reveals that 92 percent of the ASHAs maintained records and registers, related to immunization of children (89 percent), delivery case record (83 percent), ANC (name, address, EDD, registration, weight) register (80 percent), and birth and death registration (52 percent). Thirty percent of the ASHAs maintained child registration, followed by household survey. Only some ASHAs maintained family planning, adolescent girl s registration (Table A34). Observations by the field staff showed that ASHAs maintained various types of registers, but not maintained properly. Besides, ASHAs were not trained or guided on record keeping, which is necessary. The average time taken to maintain and keep the records updated was 3.9 hours per week ranging between 1 hour and 24 hours. Majority (87 percent) of the 166 ASHAs submit records to the health department. Seventy-seven percent of the ASHAs said that they submitted the report to ANM followed by MO PHC (25 percent). Mainly ANMs (71 percent) and MO PHC (30 percent) checked records maintained by ASHAs. Anganwadi supervisor and LHV checked records of only a few ASHAs (2 percent or less). Majority (86 percent) of the ASHAs said that they did receive some feedback from the supervisors. All the ASHAs interviewed were asked if any district or block officials visited the place in the past 3 months. Majority (56 percent) of the ASHAs said that no one ever visited since they started working. Senior officials visited 32 percent of them (25 percent when ASHAs were present but 7 percent when ASHAs were not there). District or block officials visited 13 percent of the ASHAs more than 3 months back. The study also reveals that, only 29 percent of the ASHAs visited by senior officials were informed in advance about the visit of block or district officials. ASHAs need to be informed in advance about officials visit. Such visits with prior intimation are more productive in enhancing the quality of work. Opinion about the ASHA Component All the ASHAs were asked about their understanding of the objectives of government in involving village level Accredited Social Health Activities (ASHA), and about their views regarding future training needs. The study shows that three quarters of the ASHAs knew that the objective of the government in focusing on the ASHA component was to promote institutional delivery and one-half of the ASHAs mentioned providing benefits to poor people. Forty-three to 44 percent of the ASHAs mentioned improving immunization coverage, safe delivery to save the child, and to reduce the maternal and child mortality followed by improving mother s health through ANCs. Others (less than 20 percent) mentioned improving community health, creating awareness about health in the community and to bring about social development (Table A35). All the ASHAs interviewed opined that involvement of ASHA was useful and most of them thought that overall their knowledge and skills as ASHA worker were well utilized (70 percent) or at least somewhat utilized (28 percent). Ninety-two percent of the ASHAs thought that they required more training. 35

52 Centre for Operations Research and Training, Vadodara Additional services In addition, 59 percent mentioned that they would like to provide additional services that they did not provide. Of the 107 women who suggested additional services, said that they would like to further ensure that home deliveries were stopped and medicines were made available to poor women (38 percent), ensured advance money to ANC mothers (31 percent), and first aid services. Some percent ASHAs suggested that specialist doctor should check all the women coming for ANCs, give BPL card to all the eligible and ensure that women got money in time. A few of the ASHAs (8 percent or less) suggested that they would like to have vehicles to transport women, ensure benefits for widows and orphans, promote sanitary latrines, and propagate JSY (Table A35). Eighty-two percent of the ASHAs gave suggestion for improving JSY and the ASHA component. They suggested that cash assistance should be increased (48 percent), and more information provided to JSY beneficiaries (41 percent) and for making monthly payment to the ASHAs (40 percent) followed by visit of officials/ doctors/ nurse to explain JSY to people in the village, and practical training (like internship). Talking about the low payment in relation to their workload, ASHAs did say, We go for house-to-house visit, motivate women for 10 months and immunize child when we get some 100s of Rupees. Women in our area demand that we go with them and stay with them at the hospital. I tell you our remunerations are very low and need to be increased. Senior officials should visit and see how difficult is our work. Others (10 19 percent) suggested dress code for ASHAs, improved institutional facilities, arrangement of van/transport, good behaviour with women at the place of delivery, and using role-play, etc. to train ASHAs. One-tenth of the ASHAs suggested that people should recognize ASHAs in the village, and be given joining letters; the scheme should be propagated on TV, in newspapers, camps and rallies and availability of female doctor. A few other suggestions were related to providing dai kit for ASHAs, more incentives for sterilization cases, IEC campaign to deal with myths and misconceptions, dai training, and timely payment of cash assistance (Table A36). Difficulties and Challenges Faced by ASHA Nearly 55 percent of the ASHAs said that they have no problem in implementing JSY. The main difficulties faced by other ASHAs include JSY beneficiaries who did not receive payment on time, complained to the ASHAs (44 percent), people not willing to go for institutional delivery (38 percent), or opposition from community/ illiterate people and family members of the women (26 30 percent). Other challenges like women not willing to take IFA tablets or not ready to weigh the baby or immunize the child, or ANM not allowing to work without joining letter and bad behaviour of the hospital staff were also put forth by ASHAs. A few ASHAs complained that their husband/ family disliked the job, seniors did not allow them to work, and that cases motivated by them were being registered by ANM. It was disturbing that in few cases doctors refused to handle complicated cases or told ASHAs that if the women died, it would be ASHA s responsibility (Table A37). 36

53 Involvement of ASHA in JSY To sum up, ASHAs were middle aged, educated and representative of the community. The study reveals that 25 percent of the ASHAs did not fulfil at least one of the eligibility criteria. Thirty-seven percent of the ASHAs had been working before being selected as an ASHA and now, on average, for 7.4 months were working as ASHAs. It is a matter of concern that a quarter of the ASHAs who had been carrying out some responsibilities for several months had not received any payment. Among those who received payment, received, on average, Rs /- per month. The first source of information about the ASHA intervention was ANMs and Gram Panchayat who also had a major role in their selection. Training of ASHAs was of 7 days and was mostly held at PHC and CHC, where the logistic arrangements were not proper, but ASHAs appreciated the training, the trainers and training methods as good and useful. Majority of the ASHAs had better knowledge about ANC and newborn care and they scored eight or more out of 10 points. ASHAs go house to house, besides attending immunization session and accompanying ANM and women for delivery. ASHAs need to put into practice their knowledge about ANC care and give complete information/advice and services. Drug kits were not available with ASHAs in Assam. ASHAs came to know about the JSY for the first time from ANM, other PHC staff, medical officer and electronic and print media. ASHAs and AWWs along with the community need to be prepared for arranging prompt referral services and transferring a woman quickly to the place of delivery. On average, the time taken to arrange for the transport and reach the institution is 70 minutes. There is no clear guideline regarding the ways to handle cases where a woman goes to her natal place for delivery in another village. The study reveals that each ASHA has worked out her own way to handle the cases. According to ASHAs, women preferred home deliveries, as these were cheaper, because of lack of understanding about the importance of institutional delivery, etc. ASHAs do provide constellation of services and network with the various stakeholders including ANMs, Anganwadi workers, PHC staff, self-help group, Panchayat members, block facilitators, village mandals, village health and sanitation committee and NGO staff in the village to implement JSY. ASHAs also spend 4 hours every week in preparing and updating various registers. The ANMs and MO PHC mostly monitor ASHA s work. 37

54 CHAPTER 4 BENEFICIARIES OF JSY IN ASSAM In the rapid assessment of JSY, beneficiaries were interviewed to understand their background, their source of information and awareness about JSY, and the kind of support received from ASHA, Anganwadi workers and ANM. The study also tried to examine if the process of claiming benefits under JSY was simple, nature of difficulties faced in availing services/benefits, and satisfaction of JSY beneficiary with the implementation of the scheme and cash assistance. Chapter 4 presents the findings from interviews with 240 JSY beneficiaries from three districts of Assam. The study meant to cover at least 40 JSY beneficiaries from each of the six study blocks. Due to non availability of JSY beneficiaries, in Kamalabari block 39 JSY beneficiaries could be interviewed, while in Agia block 41 JSY beneficiaries were interviewed. Out of 240 JSY beneficiaries, 32 had delivered at home and the remaining 208 had institutional delivery. Due to small sample size, it was not possible to compare the characteristics of women who delivered at home vs. institution. In the changing state scenario, it was pointed out that the sample was not only small for valid analysis, but also not representative of the local situation. Background information of JSY Beneficiaries The profile of JSY beneficiaries shows that the mean age of the women was 23.8 years. Seventy-seven percent of the women were aged years, and nearly 9 percent were aged 19 years or less. Majority of JSY beneficiaries in Assam had received formal education (78 percent) and had studied up to middle or secondary level (56 percent). Six percent had studied above higher secondary level. Majority of the beneficiaries were Hindus (81 percent) and 18 percent were Muslims. Further, the study found that half of the beneficiaries belonged to scheduled caste and scheduled tribe and 14 percent belonged to other backward classes. The beneficiaries represent lower middle-income group with mean family income to be Rs. 2,205 per month. On average, the beneficiaries had 1.6 children (on average 0.8 son and 0.8 daughter) (Table J1). Awareness about JSY All JSY beneficiaries were asked about their awareness. The study shows that half of the beneficiaries heard about the scheme during pregnancy and 9 percent after their delivery. Nearly 41 percent knew about the scheme before being pregnant. Figure 4.1: Time when the beneficiary heard about the JSY During pregnancy 50% After delivery 9% Before pregnancy 41%

55 Centre for Operations Research and Training, Vadodara ASHAs were the main source of information about JSY (93 percent), followed by ANMs (41 percent), radio/tv (39 percent), and relatives (31 percent). Whereas Anganwadi workers, other users of JSY, hoardings at SC/PHC, doctors, pamphlets were other sources of information for 10 percent or less of JSY beneficiaries. Each of JSY beneficiaries was asked about what they heard about JSY. Analysis of their responses shows a mix response and that women were not very clear about the scheme. Half (52 percent) of the beneficiaries heard that JSY was for poor women, for benefit of mothers (47 percent), provided free institutional delivery services with some financial assistance (38 percent). Thirty-seven percent of JSY beneficiaries had heard that the scheme was for promotion of institution delivery and that they would get some money (25 percent). Others understood JSY as one for intake of nutritious food, for family planning to stabilize population growth, and for benefit of newborn child (Table J2). Process of Registration under JSY Registration under JSY is essential to avail the benefits, and more so for monitoring of the activities. The data shows that health functionaries approached 71 percent of the beneficiaries, while 29 percent beneficiaries had themselves approached somebody in the health department for JSY registration. ASHA (66 percent), ANM/FHW (30 percent), and doctor (3 percent) registered the JSY beneficiaries (Table J3). Thirty percent of JSY beneficiaries were registered in 1 st trimester, 46 percent got registered in the second trimester, 15 percent in 3 rd trimester, whereas 6 percent were registered under JSY after delivery. Three percent, however, did not remember when they got registered for availing benefits of JSY. Regarding the place of registration, 43 percent were registered at PHC, one-third at the sub-centre, 16 percent got registered at the District / sub-district hospital and 7 percent at CHC. The study showed that JSY cards were not provided to the JSY beneficiaries yet. Informal discussions with the state officials revealed that the state distributed the cards to the districts and that they were available at PHC level. However, an official at the district level said that the JSY cards were being printed. Utilization of ANC Services by JSY Beneficiaries The beneficiaries were asked about the antenatal services utilized by them under JSY. The study reveals that (96 percent) of the women realized that they were pregnant within first trimester and most of them (83 percent) confirmed pregnancy through testing (Table J4). In 54 percent of the cases, health personnel contacted the women, while in 41 percent, the beneficiary themselves contacted somebody from the health department. The first contact with the health institution was during 1 st trimester (79 percent) or 2 nd trimester (21 percent). On average, the first contact was made This woman's weight at first ANC was 38 kg by 2.8 months of pregnancy upto a maximum of 8 months and with median value of 3 months. For majority of the antenatal women, the first 40

56 Beneficiaries of JSY in Assam contact was with the doctor (62 percent) followed by ANM/FHW (25 percent). Nearly 13 percent of the women had their first contact during pregnancy with the ASHA. Health personnel advised most (98 percent) of the women for antenatal check-up (Table J5). The study reveals that 32 percent of the women had antenatal check-up done during the index pregnancy within 2 months and 53 percent within 3 4 months of pregnancy. The women were influenced by the ASHAs (90 percent), husband (50 percent), self (36 percent) or by ANM/LHV (33 percent) to go for antenatal check-up. The study further reveals that, on average, JSY beneficiaries had antenatal check-ups done for 3.3 times. Most (85 percent) of the women had antenatal check-ups done for 3 times or more. Majority of the women received antenatal care at the PHC/subcentre (75 percent), district hospital/ CHC (33 percent), and private hospital (5 percent) (Table J6). ASHAs (71 percent), husbands (50 percent), mother-in-law/sister-in-law (22 percent) accompanied the beneficiary for ANC visit(s). Other family members including mother, sister, father-in-law, father and brother-in-law also accompanied the women for ANC visits. Twenty-four percent of the women incurred some expenses for receiving antenatal checkups. The average amount spent during ANC period among those who have incurred expenses including doctors fees, laboratory test worked out to be Rs approximately. Only four percent of JSY beneficiaries said that the received cash assistance for antenatal care (Table J8). In all, 13 women did not avail any antenatal care services during index pregnancy as they found antenatal care to be costly, did not feel it necessary, or it was not customary to go for antenatal check-ups. Others had no transport to visit far off place, had no time, faced family opposition, or lacked knowledge about the various aspects of antenatal care (Table J9). Role of ASHAs in Micro-Birth Planning Micro-birth planning includes discussion and deciding the date of next check-up, place of next check-up, place of delivery, expected date of delivery, and place of referral, in case of complications. Prompting on each aspect of micro-birth planning showed that majority of the ASHAs discussed the date (92 percent) and place (90 percent) of next antenatal check-up, and 83 percent discussed the expected date of delivery and 71 percent the place of delivery. However, only 55 percent talked about the place of referral, if complications arise (Table J10). Nearly 65 percent were told by ASHAs about four or more aspects of micro-birth planning, 22 percent were given half of the information, while another 10 percent were told either only one or two aspects of micro-birth planning. Three percent of the JSY beneficiaries said that no aspect of micro birth planning was ever discussed. It is clear that the process of micro-birth planning has begun but there is a long way to go for pre-planning institutional delivery. 41

57 Centre for Operations Research and Training, Vadodara Intention versus Actual Place of Delivery The respondents were asked about the place where they intended to deliver and about the ultimate place of delivery. Three-quarters of the respondents intended to deliver in government hospital and the remaining one-quarter preferred delivery at home. Talking about the actual place of delivery, majority of the deliveries took place in PHC/CHC, and district/ sub-district hospital. Table 4.1: Intention vs. actual place of delivery, Assam Place where last delivery of JSY Thirteen percent had beneficiary took place delivery at home as Institutional At home Total against 25 percent who Intended place for last delivery Institutional 70.4 (169) 5.0 (12) 75.4 (181) intended to deliver at At home 16.3 (39) 8.3 (20) 24.6 (59) home (Table J11). A Total 86.7 (208) 13.3 (32) 10 (240) statistically significant shift can be noticed among 16 percent of the total JSY beneficiaries interviewed who intended to deliver at home but shifted to institution. The analysis reveals that 8 percent of JSY beneficiaries insisted upon delivering at home. The main reasons for preferring institutional delivery for the 39 JSY beneficiaries who intended to deliver at home but had institutional delivery were support provided by ASHA (n=30, 77 percent), and safety of mother and child (n=14, 36 percent). Onefourth (n=10) changed their intention as they had health problem, one fifth (n=8) as they had better access to institutional deliveries. Money available under JSY was not the main motivating factor and was mentioned by 18 percent (n=7) of the women. Impact of JSY on Institutional Delivery To check the influence of JSY on women, each JSY beneficiary was asked about their place of delivery for the last but one child. Out of the total 240 JSY beneficiaries interviewed, only 106 had two or more children. In other words, for the balance 134 mothers this was the first delivery. Nearly 57 Table 4.2: Shift in the place of delivery before and after JSY, Assam Place of delivery for last (JSY) child Institutional Home Total Place of delivery for last but one child Institutional Home 42.5 (45) 38.7 (41) 0.9 (1) 17.9 (19) 43.4 (46) 56.6 (60) Total 81.1 (86) 18.9 (20) 10 (106) percent of the previous deliveries were at home. Of the total, 43 percent continued with institutional delivery and 18 percent continued to deliver at home. One percent shifted from institution to home. Interestingly and encouragingly, a major shift from home to institution delivery has been noticed among 39 percent (N 41) of the JSY beneficiaries who had more than two or more children. This shift is statistically significant. 42

58 Beneficiaries of JSY in Assam Motivation and Decision Making for Institutional Delivery The support provided by ASHA (81 percent), followed by safety of both mother and child (38 percent), money available under JSY (31 percent), and better access to institutional delivery within the area (25 percent) were the motivations for opting for institutional delivery. Twelve percent of the beneficiaries opted for institutional delivery because of complications and other health problems, 11 percent because of support provided by health personnel and 6 percent because of previous experience of institutional delivery (Table J11). Husbands (89 percent) and ASHAs (59 percent) along with women themselves were the persons who finally decided for institutional delivery. Relatives/ neighbours or users of the scheme, ANMs, mother-in-law and father-in-law also played a role in motivating for institutional delivery. Process of Arranging Transport Some of the major delays in accessing health services during delivery are related to time taken in recognizing the problem, arranging for the transport, travelling time and delay in getting services after reaching the ultimate place of delivery. All the beneficiaries reached the ultimate place of delivery directly from home travelling an average distance of 6.6 kms from residence to the institution ranging from no distance to 100 kms. Three-fourths of the women travelled up to 10 kms, while another 10 percent had to travel kms. The modes of transport used to reach the ultimate place of delivery were auto rickshaw (44 percent), car or jeep (37 percent) and tempo or tractor (14 percent). Only a few (less than 2 percent) used motor cycle, bus, bullock/camel cart or chakda, three wheel cycle, ambulance among other modes of transport. Family members (87 percent) and ASHA workers (37 percent) facilitated the beneficiaries in arranging the transport. ANM / health worker, panchayat members, self-help group, and Anganwadi workers also played a role in arranging the transport facilities. Despite the programme interventions and ASHA, only 20 percent of JSY beneficiaries mentioned that the arrangements were pre-planned (Table J14). The average time taken to arrange the transport after deciding to visit the ultimate place of delivery was to be 33.6 minutes ranging between 1 minute (to make a call) and 3 hours. Again, it took on average more than half an hour (35.1 minutes) to reach the ultimate place of delivery from the time the transport facility reached the respondent. The time taken to travel to the place of delivery ranged between 2 minutes to 3 hours. Overall, percent respondents did not know details about the distance travelled, or time taken in arranging the transport and reaching the place of delivery. The study reveals that on average, the beneficiaries spent Rs on transport to reach the ultimate place of delivery. Majority (89 percent) of the respondents had money on hand to pay for the transport expenses and most of them paid money themselves. Only six percent women said that they received money for transport. 43

59 Centre for Operations Research and Training, Vadodara Those women said that they received Rs on average ranging between Rs. 60 and 600 Difficulties Faced in Reaching the Place of Delivery Under JSY, it is provided that ASHAs would accompany women to the institution for delivery and if the women went to her mother s place for delivery or to other areas (rural to urban) ANM/ASHA would provide a referral slip to the women for their easy access to place of delivery and help in case of complications during delivery. JSY beneficiaries were asked about the details of their transport to the place of delivery, role of key stakeholders in arranging for transport and difficulties faced. The study reveals that one-third of JSY beneficiaries were given a referral slip by ASHA or other health personnel to help them access services. The study also reveals that 11 percent (n=22) of the beneficiaries, who had institutional delivery, had some difficulties in reaching the health institution. The respondent did not have sufficient money to pay for the transport (n=10), transport was not available immediately (n=9), or it was too late in the night (n=4), whereas in one or two cases, the beneficiaries complained that ASHA was not available, or it rained heavily in the night and male members were not present in the household. In these cases (n=10), ASHAs totally missed out their responsibilities of arranging transport and giving advance cash assistance for transport (Table J15). As mentioned in the next paragraph, 83 percent of the JSY beneficiaries were accompanied by ASHAs to the health institution. Informal discussions with various stakeholders revealed that ASHAs did not have any money in advance (which she is supposed to have). Persons Accompanying JSY Beneficiaries to the Health Institution The study found that 9 percent of the beneficiaries reached the place of delivery in the night between midnight and early morning. Their husbands and ASHA each accompanied most (83 percent) of the women, followed by other family members (51 percent) and mother-in-law or mothers who accompanied one-fourth of JSY beneficiaries. Neighbours accompanied nearly one-sixth of the women to the health institution for delivery, while ANM, government doctor and Anganwadi worker or dai each accompanied less than 3 percent of the women (Table J16). The presence of ASHAs facilitated in obtaining services at the place of delivery in 94 percent of the 172 JSY beneficiaries accompanied by ASHA. They mainly spoke to the medical personnel (95 percent), helped in expediting registration and other administrative activities (62 percent), provided psychological and moral support (48 percent) and helped in getting JSY cash assistance (38 percent). Quality of Services Available at the Place of Delivery An attempt was made to assess the quality of services at the place of delivery in terms of promptness in attending the delivery case, waiting time, person attending the delivery and average stay in the hospital. While 24 percent of the women did not know about the time taken to complete the registration process, others said that, on average, it took 20.5 minutes ranging between one minute and three hours to complete the administrative process at the ultimate place of delivery. It took another 44

60 Beneficiaries of JSY in Assam 19.4 minutes, on average, as waiting time at the facility, ranging between 1 minute and 2 hours, until someone attended JSY beneficiary. Most (91 percent) of the deliveries were normal, 3 percent were caesarean, and 6 percent were assisted deliveries. Three-fourths of the deliveries at the institution were conducted by the doctor and 18 percent by the ANM, nurse or LHV. Seven percent women did not know who conducted their delivery. On average, women were discharged within 28.8 hours after delivery. Further analysis showed that for normal delivery women were discharged in 23.7 hours (a day), for assisted delivery in 35.8 hours (1½ day) and for caesarean by nearly 6 days (172.3 hours) (Table J17). Payments Incurred for Services at the Health Centre It is important to understand the expenses incurred by women to avail certain services at the health institution. The study shows that most of the women (89 percent) had to pay for services at the health centre, mostly for medicines and fluids (94 percent), delivery, caesarean or operation charges (45 percent) and percent paid for food and accommodation. Others, less than 18 percent, paid for paediatric care, laboratory test and diagnostic or sonography test (Table J18). On average, JSY beneficiary spent Rs for the index delivery. Eleven percent of the women did not know about the expenses incurred. It may be pointed out here that the expenses for the previous delivery were on average Rs ( for institutional delivery and for home delivery). Satisfaction with the Services at the Place of Delivery Most (93 percent) of JSY beneficiaries were satisfied with the services available at the place of delivery because of the good behaviour of the health staff and doctors, cleanliness maintained at the health facility, and counselling about breast feeding, immunization, follow-up visit, newborn care, diarrhoea management, and family planning. A few others expressed dissatisfaction with the services as the staff was rude (n=7), facilities were not clean or adequate (n=12), and poor quality of services. A few ASHA were not satisfied with the place of delivery as the staff or doctor demanded money from ASHA or did not provide JSY cash assistance (Table J19). Persons who Assisted Delivery at Home and Views about TBA Of the 32 home deliveries, the TBA conducted two-thirds of them, while friends or relatives conducted two-fifths of the home deliveries. Doctor, ANM/nurse and ASHA assisted 6 9 percent of the deliveries at home (Table J20). All the JSY beneficiaries were asked to give opinion about the role of TBA in providing all necessary midwifery services. Thirty-eight percent of the beneficiaries opined that TBA/dai can provide all the necessary midwifery services, as they know about the cultural practices, charge less money, have been traditionally conducting deliveries, TBAs are easily accessible, and women feel more comfortable with TBA (than doctor or nurse). Forty-three percent of those who delivered at home said that TBAs charge less money (Table J21). 45

61 Centre for Operations Research and Training, Vadodara Child mortality Nine (3.8 percent) out of 240 JSY mothers reported that the newborn child died and one of the last but one child was reported dead. While two children died on the day of birth, 3, 2, and 1 child(ren) died one day, 3 days and 4 days after birth respectively. In one case, the mother did not know the age of the newborn at death. All the mothers were young aged and educated except one. Three of the mothers were Muslim while the rest belonged to Hindus. Seven of the 9 mothers had their first ANC check-up in first trimester, while the remaining two had it in 5 th month of pregnancy and had three A 27 year old Kayasth Hindu women belonging to Rayagora took all the care during pregnancy, got registered herself as soon as she learnt in the first month of pregnancy and went every month for ANC care. When she experienced excessive labour pain, she took an auto and travelled half a kilometre to the PHC along with ASHA worker. She was attended to within 5 minutes by the ANM and had a normal delivery. But unfortunately she had a still birth. or more ANC check-ups. It is revealing that all of these children who died were born in an institution. None of them reported problem in reaching the institution that was within 12 kilometers from their residence. They easily got auto rickshaw, tempo, tractor or car and were accompanied by ASHA, female worker, or SHG member (one case). Travelling time was less than half an hour in case of 9 women, while it was 1 1½ hour in case of women who had to travel 7, 9, and 12 kms. A 25 year old educated Hindu women belonging to Kaliapur, lost her baby immediately after her delivery. She could not mention any cause for the death of her child but with tears in her eyes said, If there was a doctor, I think the child could have been saved. I do not know why my child died. She went to the PHC 7 kms from her residence in tractor and had a normal delivery. ANM conducted her delivery. She took all the care during pregnancy, got registered herself as soon as she learnt in the third month of pregnancy and went thrice for ANC care. She travelled in a tractor seven kilometres to the PHC along with ASHA worker and female worker. It took her one hour to arrange for the transport and another one hour to reach the PHC. She was attended to within 5 minutes by the ANM and had a normal delivery. But unfortunately her baby boy died on the first day of birth. According to the mothers, two newborns each died because of cold, cough, and pneumonia, or negligence of doctor giving treatment (one was born as blue baby). In one case each, the newborn was born dead (still birth), or due to abnormal position of the foetus. In yet another case, mother had a fall and experienced excessive bleeding. Dynamics of Delivery at Home All JSY beneficiaries interviewed were asked about reasons why women prefer to deliver at home despite cash assistance paid under JSY. The major reason for not preferring institutional delivery was poverty and expenses for the delivery at hospital put forth by a quarter of the women. Fear of doctors, nurses, hospitals, injections, needles, equipments, dai, stitches, surgery or bad omen was yet another factors. Ten 46

62 Beneficiaries of JSY in Assam to 12 percent each did not understand the importance of institutional delivery and this was associated with illiteracy, felt that they got better care at home, or lacked transport facility. Some women (3 percent or less) felt shy in going to a doctor for delivery, faced opposition from family members, clinics were located in far off places, and had a notion that dais take better care while assisting delivery. Some 12 percent were not aware of the reasons why women prefer to deliver at home (Table J22). Who Prefers Delivery at Home? Further analysis was undertaken to ascertain the reach of health functionaries, particularly ASHA, AWW, and ANM to the beneficiaries, and utilization of ANC services and JSY by women who delivered at home versus those who delivered at an institution. The study showed that ASHA, ANM, AWW and LHVs made serious efforts to contact women, who delivered at home, during various stages of pregnancy: First to register them, then to motivate them for antenatal check-up and to register them for JSY. For instance, ANM/LHV/Anganwadi worker influenced or motivated 39 percent of women who had institutional delivery and 79 percent of those who delivered at home to go for antenatal check-up. Proportion of ASHAs accompanying women who delivered at home for ANC visits was low (Table J24). Regarding utilization of services, the women who registered at home were from remote rural areas, had limited access to PHC/ CHC/ sub-district hospital. The sources of services for women who delivered at home were the sub-centre, Anganwadi centre and home. It is therefore important to upgrade the service component and facilities (particularly sub-centre) in the more remote rural areas to attract women to opt for institutional care. The study reveals that though health department reached the women at home, they did not come forward for institutional care. Some other factors including cost, culture and social aspects need to be probed further (Table J25). Mode of Payment and Difficulties Faced The study reveals that only 63 percent of JSY beneficiaries received JSY cash assistance for delivery. Seventy-two percent of the women who delivered at home as against only 62 percent of those who delivered at institution received JSY cash assistance. Thus, the money gets disbursed only after delivery, and often much later or not at all. All JSY beneficiaries who received the cash assistance received payment in one go, but much later after delivery (60 percent). Nearly 65 percent of the women who delivered at home received payment much later as compared to 47 percent of their counterparts who delivered at institution. Another 46 percent said that they received the money immediately or within a week after the delivery. In majority of the cases, medical officer at the CHC/PHC (42 percent), gave the cash assistance to JSY beneficiary, whereas one-fifth each received money from accountant or ANM, 7 percent or less received cash assistance from ASHA, block/bank official (Table J26). 47

63 Centre for Operations Research and Training, Vadodara Nearly 44 percent of the women received cash assistance at the place of delivery, and another 49 percent received at CHC, PHC, or sub-centre. Some 5 percent or less also mentioned that they received money at home, from block office or through banks. A JSY beneficiary received, on average, approximately Rs. 796 during their last delivery ranging between Rs. 300 and Rs The study reveals that the process of Figure 4.2: Sufficiency of cash receiving cash assistance was simple incentives as perceived by JSY for 91 percent of the beneficiaries. beneficiary Thirteen out of 152 (9 percent) JSY beneficiaries who received incentive Sufficient for delivery reported that they faced 31% difficulty in getting money. They did Not not get their payment when they sufficient needed and had to make several 46% Somewhat visits to get the money. They sufficient reported that process of getting 23% cash assistance was cumbersome. Forty-five percent of the total beneficiaries mentioned that the cash assistance received was not sufficient to meet the expenses of delivery. Others thought that it was sufficient (31 percent) or somewhat sufficient (23 percent) (Table J27). Qualitative interviews reveal that in order to get the incentives, the ANMs and ASHAs made it mandatory that full ANC care was availed. Use of Cash Assistance Received for Delivery To assess the utilization of money by the women, they were asked how did they use the money received under JSY? The analysis shows that about 58 percent of them bought medicines/tonics for self and child, while 21 percent used money for medical expenses for delivery. One-sixth of each said that they used for the purchases of consumables for the family, saved it or used for self nutrition and fruits. In few cases (less than 3 percent), husband took away the cash incentive. Appreciation of JSY by the Beneficiaries All the JSY beneficiaries were asked if they would recommend their relatives, friends or neighbours to be a JSY beneficiary. Most (95 percent) of the women were satisfied with JSY and answered in affirmative. They would recommend to relatives or friends/neighbours to be beneficiaries under JSY, because JSY was good. They received cash immediately on filling up form to meet expenses incurred at hospital, and they had safe delivery in the hospital, where staff and nurses were good. Receiving nutritious food, free medicines, and less costly or free institutional delivery were the other reasons for recommending JSY. A few women (n=4) had apprehensions that they would not receive cash assistance and hence did not appreciate JSY (Table J28). 48

64 Beneficiaries of JSY in Assam Role of ASHAs in Helping JSY Beneficiary JSY beneficiaries were asked and prompted about the help provided and advice given by ASHA, particularly for micro birth planning. The study shows Figure 4.3 Role of ASHAs in Helping JSY Beneficiaries that ASHAs registered birth of Registration of birth of the newborn 90 the newborn (90 percent), helped in immunizing the Helped in immunizing the newborn 85 newborn (85 percent), gave IFA tablets (83 percent), accompanied women to ANM Providing IFA tablets Accompanied to ANM for check-up for antenatal check-up (76 Accompanied to hospital for delivery 73 percent), and also accompanied women to hospital for delivery (73 percent). For percent Visited in post-partum period Did follow-up of the JSY cases, ASHAs paid Arranged transport 23 post partum visit and did follow-up. The study shows that ASHAs arranged transport for only every fourth JSY beneficiary Gave money for transport and further, only provided transport money to every sixth beneficiary. This clearly reveals that ASHAs have not been fulfilling their requirements in terms of prearranging transport and providing financial support to avail of it, one of the crucial factors in minimising a delay in seeking care. Most of the ASHAs advised JSY beneficiaries about diet (92 percent), delivery care (86 percent), newborn care (86 percent), breast-feeding (83 percent), and danger signs (71 percent). There was opportunity to talk about family planning during and after pregnancy but was mentioned by only 48 percent of the ASHAs (Table J10). Complications during Delivery Out of 208 beneficiaries who had institutional delivery, 71 (34 percent) faced complications just before or during delivery. Nearly half of the women who had complications perceived that they had excessive labour pain, followed by 30 percent who complained of obstructed or prolonged labour. Women also complained about various gynaecological problems (Table J29). To sum up, JSY beneficiaries are young and mostly those who had no formal education or had schooling up to middle level. One-third of JSY beneficiaries belonged to SC/ST and one-half to the other backward classes. It can be said that JSY reached the socio-economically lower strata women covering poor segment of the society. As per the utilization of JSY, 68 percent reported their first contact during first trimester, and on average, women had 4.0 antenatal check-ups during their index (JSY) pregnancy. Since ANC card showing that the women had taken full ANC is required for claiming payment of cash assistance, women make sure that they go for 3 or more ANC check-ups at CHC or PHC. One-tenth received antenatal care at home. The beneficiaries learnt about JSY during various stages of pregnancy, or even after the delivery, from ANM, ASHA, doctor or AWW and got themselves registered under JSY with the health personnel. 49

65 Centre for Operations Research and Training, Vadodara Health functionaries have started discussing about micro-birth planning, but only 40 percent told about 4 or more aspects (out of 5) of micro-birth planning. Nine percent JSY had no discussions on any aspect of the micro-birth planning. Fifteen percent changed their intension from delivering at home to institutional delivery. It is challenge to change the mindset of the women (and their families) who intended to deliver at home and did so. While discussing her workload, an ASHA said, Then, there are women in our community and thei r family who would not listen to us. We even visit them more often to explain them the benefits of delivery in hospital and motivate them for the same, but the y would just not listen. They prefe r to deliver at home, that s their custom. In Assam, JSY beneficiaries had to travel, on average, 11.6 kms to reach the ultimate place of delivery. Women spent approximately one hour to arrange transport and reach the ultimate place of delivery and another 25 minutes after reaching the institution on registration administrative process and as waiting time until someone attended them. Nearly 85 percent of the beneficiaries got payment in one go (but much later) from the ANM or PHC /CHC doctor. JSY beneficiaries spent an average of Rs during the ANC period, Rs for transportation to the place of delivery and Rs for delivery, against which they received an average of Rs from the government as cash assistance. Please see chapter 5 for a more in-depth illustration of this scenario. 50

66 CHAPTER 5 EVIDENCES OF SUCCESS, CHALLENGES AND POLICY AND PROGRAMME IMPLICATIONS This study has attempted to understand the status of implementation of Janani Suraksha Yojana and the processes adopted for its operationalization in the state of Assam. It also assessed the involvement of ASHAs in promoting JSY. JSY beneficiaries were interviewed to assess the awareness and utilization of JSY, and adequacy and simplicity of the processes of claiming benefits. In addition to the program specific results and findings, the research study as a whole yielded a richer understanding of the implementation of ASHA and JSY and some ways to improve the program. The overarching themes as crucial to the successful implementation of the programme activities and its outcome are: 1) adherence to the national guidelines and programme management processes, 2) ASHA s contribution, 3) Cash assistance, 4) Increasing institutional (safe) deliveries, and 5) Community perceptions about ASHA and JSY. Programme Management Part of assessing the effectiveness of a program is to understand the various steps taken in implementing the programme. Findings suggest that Assam has made serious efforts to operationalize ASHA intervention and JSY. National guidelines of ASHA and JSY were adapted and translated to suit the local context. State has implemented the scheme through ASHA mentoring group, NE Regional Resource Centre and State and District Programme Management Units that manages and monitors JSY. Assam has involved local NGOs, Panchayat and Gram Sabha at the grassroots level that played an active role in selection of ASHAs and monitoring the activities and financial aspect of JSY. The process of decentralization of administration of power has begun, as per the national guidelines, and district, block and village level stakeholders are actively participating in putting JSY into action. Assam has progressed well in selection of ASHAs and has selected 98 percent of the required number of ASHAs at the state level as per the selection process envisaged in the national guidelines. Following a cascade model of training, the state has completed the first round of 7 days training of Module 1 for 93 percent of the ASHAs. Training of 9,000 plus ASHAs in six months, through engagement of senior medical officers, NGOs and supervisory staff has given satisfactory results. ASHAs were happy with the training pedagogy. The drug kits were not available with the ASHAs and need to be immediately made available since a demand for such services has been created. The process for accreditation of Tea Garden and Red Cross hospitals has just begun and looks promising, but a sustainable partnership will have to be nurtured. While discussing about the programme management, a senior state level official said that

67 Centre for Operations Research and Training, Vadodara he would like to learn from the current study underway and identify gaps to further rectify and strengthen the program. He said, I look forward to this independent assessment of the scheme, where we are going wrong. We try our best to rectify everything that comes to our notice. So maybe an independent assessment will help us. ASHA s Contribution ASHAs are enthusiastic and motivated to serve the community and save women and children while earning some money. They also got the opportunity to learn new things, move out of the village and meet many people. This is an important opportunity in a situation where women usually do not get such opportunities. Majority of the ASHAs knew about the antenatal care, immunization and breastfeeding, but they lost scores for their knowledge on various types of complication during pregnancy and delivery and its management. ASHAs have explained microbirth planning aspects partially to the beneficiaries, but only about half of them discussed about the place of referral, if complications arise. ASHAs have been able to generate demand and mobilize clients for reproductive and child health services. ASHAs have also started accompanying a few beneficiaries for institutional deliveries. ASHAs network with various stakeholders besides Anganwadi worker or ANM and community has started recognizing them for their work. It was observed that ASHAs were briefed during training and accordingly were expected to make home visits on a regular basis, which is not in line with the ASHA guidelines. Cash Assistance It can be said that a proportion of the JSY beneficiaries opted for institutional delivery because of cash assistance available under JSY. Women who received cash were satisfied and did say that they would recommend others to avail the benefits of JSY. However, many did not get any cash or did not get their due amount. It is necessary that PRIs who are involved in the payment of cash ensure that women at least get their due payment including cash assistance for delivery and transportation. Besides, as mentioned later in this chapter, in the section on challenges, many paid out of their pocket Increasing Institutional Delivery The main aim of the JSY is to reducing maternal and infant mortality by promoting institutional deliveries, particularly amongst the poorest of poor. There are evidences that institutional deliveries are increasing. From 40 percent of institutional deliveries in National Family Health Surveys 3, the service statistics showed that 72 percent of the deliveries among JSY beneficiaries were institutional. In the selected district of Nalbari this was as high as 92 percent as against 67 percent in Jorhat and 56 percent in Goalpara. On the whole, the major triggering factors for availing institutional delivery facility were support of ASHA, safe delivery, the cash incentive, accessibility, availability of health staff and complications, while the reasons for not availing institutional delivery 52

68 Evidences of Success, Challenges and Policy & Programme Implications services despite the cash assistance were fear of visiting hospital and various other kinds, expenses in the hospitals, behaviour of doctors and other staff. The main motivation for going for institutional deliveries is support provided by ASHAs and hence ASHAs need to be further supported through support mechanism in able to take the agenda forward. Thirteen cases changed their intention to deliver at home as they had health problem or had previous experience of institutional delivery. Table 5.1: Motivational factors leading to institutional delivery as against intension, Assam Intended and delivered at Institution Intended to deliver at home but delivered in institution Total institutional deliveries N % N % N % Support provided by ASHA For safety of the child Money available under JSY Better access to institutional delivery Had health problem Support provided by health personnel Previous child was born in an institution Availability of transport assistance Previous complicated delivery Others Total Nonetheless, most of the JSY beneficiaries were satisfied with the services at the institution, as the staff members were courteous and hospitals were clean. They would also recommend institutional deliveries under JSY to their relatives and friends. Community Perceptions about ASHA and JSY Majority of the community members are aware of ASHA and JSY and also knew about the details of the scheme with respect to selection of ASHA, role of ASHA, payment to JSY beneficiaries, and also had several suggestions to further strengthen the scheme. ANMs and ASHA were the sources from whom they became aware of JSY and its benefits. Reach of other media was limited. The programme has been widely publicized through various media channels, however, state need to reach out poor women most of whom had no formal education through folk media and other means of communication including one-to-one communication. It can be inferred that JSY has been able to reach the poor and socially disadvantaged population to promote institutional delivery. It is encouraging that in Assam, husbands, ASHAs and other family members accompanied women to the institution for delivery. They appreciated the work of ASHAs and also felt that the payment made to ASHAs is not sufficient. 53

69 Centre for Operations Research and Training, Vadodara CHALLENGES Assam implemented ASHA component and JSY as per the national guidelines, but had problems in getting the required number of ASHAs with 8 th class pass in the tribal areas. In these areas, the state government modified the guidelines and selected ASHAs educated up to 5 th class. From gender perspective, female panchayat members should have been more involved in the selection procedure of ASHAs, whereas the study suggests that the female members of Panchayat were not even aware of the ASHA component. While the state completed its selection target, it compromised on the eligibility criteria. The study shows that 25 percent of the selected ASHAs that were included in the study did not fulfill the eligibility criteria as per the national norm. The state also faced some problem in identifying qualified and capable trainers at the block level who could give proper training to ASHAs. The national guidelines suggest that the block trainers need to undergo the training for same days as planned for ASHAs. It is recommended that the state should ensure that the block level trainers undergo training for requisite number of days. That is, since all the subsequent rounds of ASHAs would be of 4 days, block trainers should also undergo 4 days training for each round. The state has completed the first round of training for 93 percent of the ASHAs. The state now needs to plan for the second and subsequent rounds of training. However, logistical and training arrangements at PHCs where most of the trainings were conducted need to be improved, especially in relation to accommodation and food arrangements. Competency of ASHA One of the main actions expected from ASHA is to identify high-risk signs during pregnancy and childbirth and arrange for timely referral. The study, however, shows that her knowledge is poor about complications during pregnancy and delivery and its management including prompt actions. Similarly, their understanding about the non- RCH components such as disposal of wastewater, safe drinking water, organizing a group meeting and management of diarrhoea and pneumonia is also poor. Moreover, ASHAs did not know about the period when newborns are most likely to die. Another major concern is that apparently ASHA as well as JSY beneficiaries rarely mentioned about family planning advice, services or acceptance. It is necessary that ASHAs are reoriented and re-trained on detection and prompt action in the context of danger signs/complications as well as family planning advice as they are in an excellent position to explain women about the importance of adopting family planning during post partum period. In subsequent trainings, danger sign during pregnancy, newborn care and family planning need to be re-emphasized. However, reading materials provided to ASHAs during training are too extensive to follow while providing services. 54

70 Evidences of Success, Challenges and Policy & Programme Implications Moreover, despite the programme interventions, ASHAs missed out on several aspects of micro-birth planning, particularly pre-planning transport arrangements and advancing cash assistance for transportation. Informal discussion with the state officer revealed that travel expenses are free for JSY beneficiaries only if ASHA accompanies and pays for the transport right away; otherwise beneficiaries have to pay for transport. Theoretical knowledge of ASHAs seems to be quite good, but they need to put it into practice and provide women with services. For instance, 97 percent of ASHAs knew that a woman should receive three ANCs, but one-fourth of the beneficiaries still received less than three ANCs. Further analysis of these cases showed that ASHA did try to motivate them but they did not come forward. It is required that the health system including ANM, LHV and other staff including PRI member come forward to support ASHAs and motivate these women to go for antenatal check-up. Increasing Institutional Deliveries In spite of JSY, according to a district official, institutional deliveries are only 98,000 or there are still 66 percent of the people out of the net who do not deliver in an institution. Despite cash assistance paid under JSY for institutional delivery, many women prefer to deliver at home. A major reason is that for the poor women living below poverty line home deliveries are cheaper, as there are expenses for hospital delivery. The study shows that 70 percent of the women who delivered at an institution paid out of pocket an average of 1018 Rs, which is a major amount for them. On the contrary, if they deliver at home they would gain some cash as 500 Rs are provided for home delivery (see Table 5.2. below). Several women had fear of going to hospital due to fear of injections, needles and equipment at the hospital. They also feared of doctor/ nurse. Those fears need to be taken seriously and alleviated as they prevent many women from visiting a health facility. There is a need for psychosocial analysis of these factors and involvement of users to come forward and talk about their experiences at the hospitals. It also brings out that the staff behaviour needs to be courteous and they need to cajole women instead of being harsh to them. A challenge put forth by two out of five ASHAs in Assam was that people are not willing to go for institutional delivery. With all the efforts from the providers, still there are some people in the village who are not willing to go for institutional delivery. It is a challenge to bring all those people in to the institutions for delivery, and have functional facilities. In their words, This is a very good scheme. The incentives are also very good and we got a good response. People are coming forward. Now the challenge is that we have to ensure facilities for conducting institutional deliveries at every institution that we have. 55

71 Centre for Operations Research and Training, Vadodara Lack of Facilities Increasing institutional deliver is a challenge, especially when functional facilities are sparse; this applies specifically to remote areas. Both state and district officers raised their concerns that district hospitals are overflowing while PHCs and sub-centers are under-utilized. Moreover, sub-centers, PHCs and CHCs are not equipped for institutional delivery. There is a need to upgrade and ensure facilities for conducting institutional deliveries in the rural areas up to the PHC level. Facilities including labour rooms, wards, trained manpower, water and toilet facilities need to be available to meet the demand created for institutional deliveries. In support to the challenges mentioned by state and district officers, the picture clearly illustrates the present state of one of the sub-centre in the study area. Sub-centre We have the nurses, we have PHCs, but now what we are visualizing is that every sub-centre should have two ANMs and a labour room there. We want institutional delivery to start from the sub-centre level. The sub-centre just like any other institution should have a delivery facility. So if we can ensure that, this scheme can really help people. But today the bottleneck is that we have created and have a critical demand, but there are very few institutions to provide the service s. Now the challenge is that we have to increase the institutions that provide this. PHC Another official at the state level said, Wherever institutional deliveries are taking place we are providing the facilities labour room, water, toilet facilities and so on. Now what is happening is that the districts are asking for more money. They say that they are running short of money because the demand has gone up. We got 18 crores and the money is almost over now. ASHAs work needs to be appreciated instead of giving her false assurances and promising her a Government job. Besides, ASHAs are seen to have increased the workload at the hospitals for both the medical and paramedical staff. Explaining this, an officer said, They treat her as if she was a commission agent. They treat ASHA like that because they feel she makes thei r life miserable and get money for it while they do not get any. We ask them why they should get an incentive when they are on duty. The y don t want to work and now their workload has gone up. So when a pregnant woman comes they don t provide her services. 56

72 Evidences of Success, Challenges and Policy & Programme Implications A senior state official raised his concerns regarding the overflowing district hospitals due to lack of facilities at the block level. In this context he said, instead of considering ASHA as a facilitator, the officers at district hospital mistreat ASHA at the place of referral. Cash Assistance Both ASHA and JSY are given cash assistance but several ASHAs have not received their due payments while in other cases there were delays in payment. Three out of four ASHAs have been able to earn money while several of them are yet to start earning despite working for several months. Besides, their clientele is also low. On an average, the last client availed services from ASHA around a month ago. This has emerged as a serious concern, because in the absence of remuneration, it would be difficult to sustain interest of ASHAs. On average, ASHAs received only Rs. 234 as monthly income from ASHA work though 73 percent of them had been working as ASHA for more than 7 months. Though the state officials claim that the process of making payment is simple and women are paid immediately and in one go, field realities provided a different picture. While 20 percent ASHAs did not receive any amount till now, 35 percent had not received any payment for the last beneficiary case they had attended to. The delay is mostly due to lack of budget at the centre. One in every five ASHAs said that while we are satisfied with the services we need to provide, though it is more work, it would be bette r if we receive more payment. The beneficiaries paid the transport cost for reaching the facility in majority of the cases and only a few were reimbursed later. While state authorities thought that the payment to beneficiaries is done right after delivery at the institution, the study shows that beneficiaries received payments much later. There is a need to mention here that this is an area of concern where further explanation has to be sought as to the reasons for delay of payment. On average, women actually spent more on transport than what they received. Out of 240 JSY beneficiaries, 17 had neither any expense during pregnancy/delivery nor did they gain any amount. Another five beneficiaries received the exact amount that they spend. So the net gain/loss was balanced in case of these nine percent beneficiaries. However, 61 percent of the beneficiaries spent more than what they received under JSY. In case of 30 percent beneficiaries the expenses were less than the amount they received under JSY. For those, who delivered at home, only six percent have negative balance and on average they gained Rs. 300, while in the case of institutional delivery, 70 percent spent Rs more than what they received. A beneficiary illuminates the setback by explaining, It i s better to deliver at home as we get Rs. 500 against no expense, whereas in the case of institutional delivery we spend more than what we get. 57

73 Centre for Operations Research and Training, Vadodara Table 5.2: Pregnancy expenditure including costs incurred during ANC period, transport and delivery as against the amount received by JSY beneficiaries, Assam Place of delivery Institution At Home Total Total to to to to to to to to to to to to or more Mean amount It needs to be pointed out here that in Assam the cost of both transport and hospital delivery were very high which should be taken into consideration by the state. Yet another woman expressed, I think it is still good that government is giving as Rs so that it takes care of some of ou r expenses, otherwise we would have to bear all the expense s. In that case, I would have not gone for intuitional delivery. While for this woman the cash assistance was the decisive factor for institutional delivery it can be assumed that for the poorest of the poor, the underserved, the most vulnerable women in terms of socio-economic status, the cash assistance does not cover the cost of institutional delivery. Hence, no matter their attitude towards institutional delivery they will not go to a hospital for delivery simply because they cannot afford it. Under the given circumstances, JSY fails to reach out to its key target group. Furthermore, cash assistance to the beneficiaries for institutional delivery was mainly given within a week of delivery or much later. This implies that the families have to bear all costs until they are reimbursed. This further illustrates that the economically weakest strata in society cannot take advantage of JSY as they do not have the financial resources to advance such a high amount. Further, beneficiaries tend to blame ASHAs if they do not receive the payment (on time). This is one of the major challenges faced by ASHAs who then have to explain to beneficiaries why they have not received any payment or why their payment is delayed. Due to this, there are oppositions to ASHA from the community and family members of the women, which is a counterproductive trend. 58

74 Evidences of Success, Challenges and Policy & Programme Implications POLICY AND PROGRAMME IMPLICATIONS In the following paragraphs, an attempt has been made to present recommendations for improving JSY. These recommendations are based on the analysis of the findings and discussions with stakeholders. Findings are organized in three clusters such as policy; programme related and demand side issues. Policy The state implements NRHM through SPMU and DPMU with the technical inputs from NE Regional Resource Centre. They are: 1. The present structure of SPMU and DPMU depicts direct monitoring of ASHAs by DPMU while the national guideline has stressed the role of block facilitators in monitoring, supervising and providing mentoring support to ASHAs. There is a need to look into the existing structure and involve block facilitators more in accordance with the national guidelines. 2. The findings from the study clearly suggest need for effective engagement of PRIs in implementation of ASHA and JSY. District and block officials should ensure active participation of PRIs at different levels. An orientation training of the PRI members and reading material for them need to be developed to facilitate their engagement at different levels. This should also take into account PRIs role in formulation of village health plans, use of untied funds, monitoring of the performance of ASHAs and other health personnel at grass roots level. 3. Another new addition in the JSY guideline is the provision of Rs. 1,500/- to a private practitioner attending complicated deliveries in public health setting. So far, no money has been expended under this provision. The state needs to expedite the process of accreditation of private institutions and alternatively also utilize the services of private doctors to provide services through public institutions (PPP). Programme Management 1. State should plan for 2 nd and subsequent rounds of training to reorient ASHAs and motivate them further to provide services. Books number 2, 3 and 4 have been finalized and disseminated. SPMU should develop detailed state work plan for ASHA, and DPMUs should develop district plans. 2. The state and district health action plans should have detailed planning on ASHA and JSY interventions including activities and financial requirements to facilitate results based management. Since the blocks need to take a major role block level planning for implementation of the ASHA scheme is required. 3. The study clearly brings out that now that ASHAs are in action and have started catering to the pregnant women, each aspect of pregnancy including 59

75 Centre for Operations Research and Training, Vadodara complications, danger signs, actions to be taken, referral etc. needs to be re-emphasized 4. Promotion of family planning through ASHAs needs to be emphasized and focused. ANMs should play a significant role in mentoring ASHAs towards family planning activities. 5. Regular meetings with ASHAs at the block or PHC/CHC level for assessing performance and planning future activities need to be organized. These meetings need to be utilized by the ANMs/LHVs and medical officers for reinforcing knowledge and learning in key areas. 6. Issues related to timely payments after training and ensuring availability of drug kits during training need immediate attention. Drug kits are yet to be supplied. Drug kits need to be provided, and during 2 nd round of training, ASHAs need to be explained about the contents of kit and their use. 7. Timely payments to ASHAs and JSY beneficiaries are critical components to sustain interests of ASHAs and for mobilizing women to seek institutional delivery services. The study found that payment to both JSY and ASHAs has been delayed in several instances, despite clear instructions for immediate payment in the guidelines. While payment is made in one go, it is done much later. The guidelines suggest for payment to be made immediately at the place of delivery itself to JSY beneficiaries. State should clearly spell out guidelines for making payments, which need to be widely publicized in terms of entitlements. Further, necessary funds need to be provided to the institution. Delays in payment impede the success of JSY. 8. The support mechanism to ASHA as designed by GoI should make available a block facilitator for every 10 ASHAs who would be responsible for providing support in her functioning and facilitating the continuation of her learning. The involvement of block officials, and PRIs in monitoring should be ensured. Any implementation related issues should be deliberated and resolved with intervention of grievance redressal cell in each district under the DPMU. 9. Some people give false assurances to ASHAs regarding job security and working with government subsequently. Such false assurances create confusion and affect sustainability of ASHAs. Clarity on such issues should be ensured by the SPMU. 10. One of the areas where very little work has been done is involvement of private sector in providing institutional delivery services. Assam has initiated accrediting private sector facilities in the districts by involving tea garden hospitals and Red Cross Hospitals. As of now amount of money for cash assistance has been increased substantially and given the prevailing charges for a normal delivery, which is to the tune of Rs s, in a sub- 60

76 Evidences of Success, Challenges and Policy & Programme Implications district private facility, there is a good scope of increasing number of institutional deliveries through the private sector. 11. There is a need to upgrade the facilities at PHC/CHC and increase the number of functional sub-centres and institutions to meet the critical demand created for institutional deliveries. Normal deliveries can take place at PHCs and sub-centres, to lessen the caseload at the district and subdistrict hospitals. ANMs need to stay at the sub-centre. At times, ASHAs are not treated well at the hospital, as the doctors and nurses feel that their workload has increased because of ASHAs. 12. State may consider organizing exposure visits of ASHAs to neighbouring districts, so as to learn from each other and also build a network. Block facilitators/ngos can be identified for organizing such activities. Demand Generation Need for proper programme related communication has been observed at various levels: providers and stakeholders including community. The state government had introduced the ASHA intervention and JSY and has followed the routine track of publicity without getting into the nitty-gritty s of how the communication strategies could be made effective. Communication interventions are limited to disseminate guidelines in forms of circulars and some mass media activities in the form of wall paintings and hoardings. Radio and TV channels have also been utilized to propagate the scheme. However, key stakeholders such as PRIs, SHGs and others and the community have incomplete knowledge of roles and responsibilities of ASHA or further details of JSY. Overall, there was no Behavioural Change Communication (BCC) plan while publicizing ASHA intervention and JSY. Moreover, there was no conscious effort for disseminating messages during Village Health and Nutrition Day, Immunization Sessions or RCH Camps. Hence, following is recommended: 1. Prepare a comprehensive BCC annual plan for ASHA intervention and JSY spelling out BCC objectives, key messages, target audience, use of different communication media, periodicity of undertaking it, at what levels and by whom. In doing so, the State may consider seeking professional inputs in formulating the communication strategy. Unless the community is aware of the roles of ASHAs and avails services from them, it will be difficult to sustain interest of ASHAs, if she is not able to make any regular and reasonable income. 2. Study findings indicate women having apprehensions about deliveries in hospitals for several reasons. The communication strategy should attempt to address myths and misconceptions about hospitals/health centres. Previous users of JSY could function as peer educators and work towards reducing fears. 61

77 Centre for Operations Research and Training, Vadodara 3. The study found that husbands and ASHAs played a major role in motivating, deciding and accompanying women for ANC care as well as institutional delivery. The positive role of husbands needs to be tapped in JSY for increasing and meeting the demand for institutional delivery. 4. To ensure consistency in messages delivered through different information sources, state should develop appropriate media briefing kits, and orientation packages for different stakeholders in the form of Frequently Asked Questions (FAQs), preferably in local language. The information package should also detail out the role envisaged for different stakeholders in ASHA and JSY. This package should be readily available and widely distributed. 5. Conduct orientation programmes for medical and health department, PRI members and other stakeholders for effective dissemination of both ASHA and JSY activities. Civil society groups and networks of NGOs can be engaged to reach out to vast number of stakeholders. 62

78 Appendix Tables

79 Appendix 1 ASHAS Tables ASHAs interviewed in Assam, 2007 N % Total number of ASHAs contacted District name Jorhat Goalpara Nalbari Block name Baghchung Kamalabari Agia Ranguli Ghogharapra Tamulpur Table A1: Profile of ASHAs in Assam, 2007 Profile Percentage Total number of ASHAs interviewed 181 Age of ASHA (in completed years) < 19 years years years years 35 years or more Mean (in years) Years of schooling completed No formal education Below 8 th std 8 th std Secondary (9 10 std) Higher secondary (11 12 std) Mean (years of schooling) Marital status of ASHA Unmarried Married Separated/divorced/widowed Religion Hindu Muslim Christian Caste/tribe of ASHA Scheduled caste Scheduled tribe Other backward classes High caste Hindus Others/do not know

80 Centre for Operations Research and Training, Vadodara Table A2: Work history of ASHAs in Assam, 2007 Percentage Total number of ASHAs interviewed 181 Place of residence In this village/town 10 ASHAs that worked for earning cash or kind before being selected as an ASHA 37.0 (67) Mean duration of time for which ASHA worked for cash or kind before working as ASHA (in years) 6.7 Nature of previous job Agriculture labour/help on farm Skill worker Assisting ANM / AWW Health related work from home Working in school Daily wage labour Business Others Percent currently continuing with other job 35.8 (24) Duration of ASHA work Less than 3 months 4 6 months 7 9 months 10 months or more Mean (in months) 7.4 Approximate monthly income from ASHA work (in rupees) No amount received 26.0 Rupees 250 or less rupees rupees rupees or more 1.7 Do not know/cannot say 16.0 Mean (in rupees among those who received amount) Table A3: Number of living children and place of previous delivery for ASHAs in Assam, 2007 Percentage Total number of ASHAs interviewed 181 ASHAs with children 92.3 (167) Number of living children of ASHA None One Two Three Four or more Mean Place where last child of ASHA was delivered Home Government/Municipal hospital/dispensary Private hospital/clinic Primary Health Centre

81 Appendix 1 Table A4: Sources of information and selection of ASHA in Assam, 2007 Percentage Total number of ASHAs interviewed 181 Ways potential ASHA FIRST came to know about ASHAs ANM 45.7 Gram Panchayat 13.3 Phamphlets/Hoardings at SC/PHC/CHC etc Radio / TV 8.9 Health personnel 6.1 Anganwadi worker 5.0 Sugam worker 3.3 Trainers/during training Bal Vatika, Bal bhavan) 2.8 Family member/relative/village women/village people of the locality/husband 2.2 Government doctor 1.7 Reasons for wanting to be an ASHA* Serving/helping the community Save children / For the benefit of children Earning money To remove misconception Reducing population growth Others Ways ASHAs got selected* ANM Selected/approved by gram sabha Was working as an Anganwadi Sahyogini Because of netaji / politician / sarpanch Because of my good nature Mahila Samiti/through PHC member/aww/sugam worker Others Percent mentioned that Gram Sabha approved their name 75.7 * Multiple responses

82 Centre for Operations Research and Training, Vadodara Table A5: Topics covered and arrangements made in the training of ASHAs in Assam, 2007 Percentage ASHAs attended any training programme in the last one year 10 (181) Topics covered during training program for ASHA* Women and health (FP, ANC, breastfeeding) Infant and child care (immunization) Nutrition Disposal of waste water/clean drainage HIV and AIDS ASHA (my eight tasks) Water supply at home /safe drinking water National Rural Health Mission (NRHM) Organising a group meeting Management of diarrhoea and pneumonia Curative care Anganwadi centres Reproductive and sexual health problems Adolescent education Others Mean duration of time when ASHA training was held (months ago) 7.2 Mean number of training days attended by ASHA (in days) Range Place where the training was held PHC CHC Other hall (Dharamshala, balvatika, balbhavan) ASHAs that suggested for additional arrangements at training centre 30.9 (56) Additional arrangements needed at training centre* Food arrangements should be proper Charts/practical demonstrations should be there Lack of space/training room should be larger Water problem should be tackled Beds/bed sheets should be provided Better if there was a TV facility Arrangement for transportation Latrine/bathroom facilities Electricity/fan is required Inadequate money Others * Multiple responses Table A6: ASHAs views on logistic arrangements at the place of training, Assam, 2007 Percentage Good Average ASHAs views on logistic arrangements Sitting arrangement Size of the room Accommodation facilities Arrangement for food Poor

83 Appendix 1 Table A7: Views about the training among ASHAs in Assam, 2007 Percentage Number of ASHAs attended training 181 Perception about the trainers Trainers were very good Trainers were good Trainers were okay ASHAs mentioning that the training was participatory in nature Trainers encouraged to ask questions Trainers answered questions properly Training was not participatory ASHAs who said that the trainer used charts/models to explain the topics 77.9 (141) Training aids* Lectures Book / handbooks Posters Models/blackboards Pamphlets Flip charts TV/video/CD Folk songs Others Training materials Very good Good OK Not at all good Usefulness of the training Useful Somewhat useful Not useful * Multiple responses Table A8: Payments received during training by ASHA in Assam, 2007 Percentage Number of ASHAs attended training 181 Amount received during training No amount received Received amount due (Rs. 100 x number of days attended training as DA + Rs. 100 transportation) Received amount less than due Received amount more than due Mean (Rupees among those who have received )

84 Centre for Operations Research and Training, Vadodara Table A9: Utilization of guidelines by ASHAs in Assam, 2007 Percentage Number of ASHAs interviewed 181 ASHAs who stated that they had received guidelines for JSY 93.9 (170) Field investigator saw the guideline Guideline was not shown ASHA did not have guidelines Extent to which respondent is able to follow the guidelines To a great extent To some extent Never utilized the guideline Number of ASHAs not being able to follow the guidelines at all or only to some extent 25.3 (43) Reasons for not being able to follow the guidelines to a great extent* ASHA does not have time to follow all guidelines as it is too time consuming ASHA follows only what she could understand Lack of time due to small child(ren) ASHA follows only according to the facility available in the hospital ASHA is still a fresher and hence learning to follow the guidelines Because ASHA still does not have the joining letter Others * Multiple responses Table A10: Scoring of knowledge of ASHAs in Assam, 2007 Number Percentage Total number of ASHAs interviewed Grade O (10 out of 10) Grade A (8 9 out of 10) Grade B (6 7 out of 10) Grade C (3 5 out of 10) Table A11: Knowledge of ASHAs about ANC care in Assam, 2007 Percentage Total number of ASHAs interviewed 181 ASHAs that know that A pregnant woman should take two TT injections 99.4 A woman should undergo a minimum of three antenatal checkups during pregnancy 97.3 During diarrhoea a child should be given increased quantity of fluids 97.2 The mother should continue breastfeeding her child during diarrhoea 9 Recommended to exclusively breastfeed child for 6 months 88.4 A woman should consume a minimum of 100 IFA tablets during pregnancy 85.2 The minimum birth weight of the newborn child should be 2500 grams 84.6 All five cleans that need to be maintained during delivery 66.9 * Multiple responses 68

85 Appendix 1 Table A12: Knowledge about complications during pregnancy among ASHAs in Assam, 2007 Percentage Total number of ASHAs interviewed 181 Knowledge about type of complications women can experience during pregnancy* Swelling of hands and feet Vomiting Paleness/Anaemia Excessive bleeding Convulsion Abdominal pain Body pain/backache High fever Visual disturbance Feeling uneasy Weak or no movement of foetus Abnormal position of foetus Others Do not know Actions ASHA feels needs to be taken upon recognition of any signs of complications in a pregnant woman* Immediately refer her to the nearest functional FRU (Upgraded CHC, Sub division/district hospital) Ask her to consult the ANM the next day Take her to the nearest functional FRU Refer her to a government accredited hospital Provide money for transportation Refer her to a private accredited hospital Others * Multiple responses Table A13: Knowledge about common complications during pregnancy / delivery that can result into death of a woman among ASHAs in Assam, 2007 Percentage Total number of ASHAs interviewed 181 Common complications during pregnancy /delivery that can result into death of a woman* Excessive bleeding Weakness of the mother Convulsions / fit Blood pressure problem Abnormal position of the foetus Fever Foetus dies in mother s womb Abdominal pain Tetanus Headache Home delivery Others Do not know * Multiple responses

86 Centre for Operations Research and Training, Vadodara Table A14: Knowledge about immunization and child care among ASHAs in Assam, 2007 Percentage Total number of ASHAs interviewed 181 Vaccines named that are to be given to children as part of the Universal Immunization Programme* BCG (TB) 91.2 DPT 90.1 TT 76.8 OPV 75.7 Measles 69.1 Booster dose 17.7 Do not know 2.8 ASHAs knowledge of period when newborns are most likely to die Soon after birth Within 1 week of birth Between 1 to 2 weeks of birth Between 3 4 weeks of birth Within 6 months Within 1 year Within 2 years Others Do not know/cannot say * Multiple responses

87 Appendix 1 Table A15: Responsibilities, recognition and feelings about being an ASHA in Assam, 2007 Percentage Total number of ASHAs interviewed 181 Responsibilities as an ASHA* Help in immunization program 85.1 Accompanying delivery cases 82.3 Registration of birth and death 51.4 Provide ANC care 49.2 Create awareness on health 47.5 Work with ANM/Anganwadi/dai 37.0 Create awareness on basic sanitation & hygiene 34.8 Motivating and mobilizing community 30.9 Counseling 23.2 Family planning 19.3 Village health planning 18.2 Provide basic curative care 9.4 Promote good health practices 6.1 Make timely referrals 6.1 Increase institutional delivery 1.1 Others 1.7 Ways one can recognize ASHA in the village* I informed the villagers Because of my work Gram sabha/sarpanch introduced me to the village I attend meetings at the health centre As one working with ANM People know that I can get them money In the role of Anganwadi/Sahyogini As a well-wisher/good worker Others Ways respondent feels about being an ASHA* Feels good I get the opportunity to serve the community Better if I received more money I like that I get information which I can pass on to the community I get to know more about health I have too many responsibilities Everything is good, except working with ANM Others Reasons for feeling good about being an ASHA* I know about antenatal and natal care Villagers respect/support me/acknowledge my work Like to serve the community, but it is a lot of work People in the village now recognize me I know all the families in the village I get to know the doctor Keeping myself engaged in work Others Do not know Reasons for not feeling good about being an ASHA I still do not get money/i cannot maintain my family Because of my cases being claimed by ANM Ways the community feels about the ASHA (from the ASHAs perspective)* Appreciate the work Consider me for health problems No interaction Does not accept me Does not consult me for health questions Cannot say/do not know * Multiple responses

88 Centre for Operations Research and Training, Vadodara Table A16: Functioning of ASHAs in Assam, 2007 Percentage Total number of ASHAs interviewed 181 Ways ASHAs carry out their work* Go house to house Attend immunization session Accompany for delivery Accompany ANM Organize health days at AWW Others/ work has not started/ collecting data * Multiple responses Table A17: Knowledge about care for pregnant women, Assam, 2007 Percentage Total number of ASHAs interviewed 181 Advices given to a pregnant woman by respondent* Diet ANC care (check up, IFA tablets, TT) Delivery care Institutional delivery Immunization Newborn care Breastfeeding Danger signs Personal hygiene Breast care Family planning Others No advice given/no ANC case till now Services provided to a pregnant woman by respondent* Advise for antenatal check-up Accompany for TT Accompany for antenatal check-up Ensure IFA consumption Provide nutritious food Attend outreach day Identify risk factor in antenatal mothers Others No services given/no ANC case till now Advice given to a woman during postnatal period* Immunization Breastfeeding New born care Nutrition Follow-up advice Childhood morbidity management Others * Multiple responses

89 Appendix 1 Table A18: Availability and utilization of drug kits by ASHAs in Assam, 2007 Percentage Total number of ASHAs interviewed 181 Percent received the drug kit 2.2 (4) Time when received the drug kit Some days after training Much (months) after training Materials supplied in the drug kit* Paracetamol tablets I. P. Chloroquine Phosphate tablets IFA Nirodh/condom Mala D Needle, blade, scissor Soap ORS Bandage, cotton, thread Percent ever used the medicines available in the kit 10 (4) Average number of days ag,o when the last time drug kit was used Range Things dispensed the last time ASHA used the drug kit* Paracetamol tablets I. P. Mala D Others Ways medicines are being replenished* Get supplies from CHC/PHC Others * Multiple responses

90 Centre for Operations Research and Training, Vadodara Table A19: Awareness about JSY and its benefits among ASHAs in Assam, 2007 Percentage Total number of ASHAs interviewed 181 ASHAs who had heard about JSY 99.4 (180) Source from where FIRST heard about JSY ANM/ PHC field officer 62.2 During training 19.4 MO PHC/CHC government doctor 18.9 TV/paper/radio 11.1 AWW 7.2 Village panchayat leader/ from sarpanch 2.2 Women in the community 1.1 Health worker/lhv/compounder 1.1 Poster/hoardings Understanding the purpose of JSY* Promotion of institution delivery Benefit of mother / proper care of mother and newborn Immunizing children For poor family Registration of birth/death Family planning Intake of nutritious food Population stabilization Get cash incentives Do not know/cannot say Persons eligible for JSY* All women during pregnancy Women from BPL families Women above 19 years of age Women with less than 2 children Women from SC/ST families Others Ways followed to identify possible beneficiaries* Through home visits By contacting people If a woman feels uneasy or is vomiting I take her to hospital When women come for check-ups ANM/AWW tell me about which woman is pregnant Visit BPL families/through the BPL card * Multiple responses

91 Appendix 1 Table A20: Cash assistance available under different schemes for ASHAs and JSY beneficiaries in Assam, 2007 Percentage Number of ASHAs who have heard of JSY 180 Cash assistance available under different schemes for an ASHA* Get money for delivery Get money for immunization Get money for transport Get money for accompanying women for delivery An encouragement and support from sarpanch, ANM, villagers I get support from the system I do not get anything Get money for training Do not know Assistance available to beneficiary mothers* Get money (Rs. 700 Rs 1400) for institutional delivery Free treatment/delivery/immunization Get money (Rs. 500) for home delivery Receive Rs. 400 for sterilization Free medicines No expense for transportation to hospital Get services during antenatal period Protection of mother and child health Gets nutritional supplement from Anganwadi Receive good quality services * Multiple responses Table A21: ASHA s role in promoting JSY in Assam, 2007 Percentage Number of ASHAs who have heard of JSY 180 Percent ASHA playing a role in promoting JSY 96.1 Ways followed to promote JSY* Talk to women Talk to husband Door to door visit Publicity during immunization/health days Talk to other family members Distribute pamphlets/brochures Help in getting BPL card Others Importance of the work under JSY as compared to other tasks ASHA has to fulfil Very important Important Total number of ASHAs interviewed 181 Suggested ways to further promote (propagate) ASHA* Village meeting Door to door visit Advertisement More financial benefits Satisfied clients Others Do not know * Multiple responses

92 Centre for Operations Research and Training, Vadodara Table A22: Role of ASHAs in accompanying JSY cases and arranging for institutional delivery, Assam, 2007 Percentage Total number of ASHAs interviewed 181 Number of JSY cases ASHA has accompanied for institutional delivery so far None or more cases Mean (number of cases) Place where ASHAs usually take women for delivery* PHC Government hospital CHC Sub-centre No case till now Transport facility usually suggested to transfer a case from the village to the health facility* Private vehicle/clients own vehicle/motorcycle/tractor/bullock cart Public transportation Ambulance/hand puller NGO vehicle No case till now Arrangements made for transport* If transport facility is available, I call from the village Tell them (transporters) in advance When EDD is approaching, tell family members to identify a nearby transporters Arrange transport as soon as possible Arrange private shuttle vehicle standing near the bus stand I keep in contact with transporters Till now I have not arranged any transport Beneficiaries themselves arrange the transport Transport is easily available in our village I contact ANM Call transporters over phone We walk to the health centre within the village I have my own vehicle Do not know Availability of transport facility Always available Not available always Do not know Average time taken to arrange for transport (in minutes) Range (in minutes) Do not know/cannot say (% of ASHAs) Average distance of the facility where the JSY beneficiary is usually referred to (in kms) Range (in kms) Do not know (% of ASHAs) Average time it takes to reach the institution (in minutes) Range (in minutes) Do not know/cannot say * Multiple responses Table A23: Average time taken to reach the institution by distance of the facility from residence of JSY beneficiary, Assam, 2007 (Percentages) Number of ASHAs mentioning about the distance to referral unit Mean time taken to reach the institution (in minute) Mean distance of the facility where JSY beneficiary is usually referred to (km) 1 Km 2 Km 3-5 Km 6-10 Km Km 16+ Km Do not know Total 5.0 (9) 13.2 (24) (64) 22.1 (40) 5.5 (10) 14.9 (27) 3.9 (7) 10 (181)

93 Appendix 1 Table A24: Cooperation and cash assistance received at the place of delivery as perceived by ASHA, Assam, 2007 Percentage Number of ASHAs interviewed 181 Cooperation with health personnel at the institution Cooperation is very good 49.2 Cooperation is good 37.6 Neither good nor bad 5.5 Cooperation is bad 4.4 No cooperation No case attained 2.2 Do not know Percent mentioning that the beneficiary women are given any cash assistance 9 (164) Amount ASHA states as being disbursed to the beneficiary (in rupees) Mean (among those who received cash assistance) Range Persons who makes the payments to the beneficiary* MO CHC/PHC, civil hospital superintendent, hospital in-charge 54.9 Doctor at the institute 25.6 Accountant, clerk, babu, supervisor 23.8 ANM/nurse/LHV 14.0 Myself (ASHA) 1.8 Do not know 3.7 Time when the cash assistance is given to the beneficiary Much later 5 Within a week after the delivery 29.9 Immediately after the delivery 12.8 At the time of registration 1.8 Much before the delivery Not received yet 3.0 Do not know 1.8 Mode of payment for cash assistance Entire cash in given in one go 93.3 Cash assistance is given in instalments 1.8 I do not know 4.9 Place where beneficiaries get the payment* At the PHC 51.2 At the institution (place of delivery) 49.4 At the CHC 6.7 At the SC 3.0 At home/within the village/aww/panchayat office, in AWW institution 1.2 Superintendent 1.2 Others Do not know 2.4 ASHAs mentioning that there are delays in beneficiaries receiving the money 66.5 (109) Reasons for the delay in receiving the money* Lack of budget at the centre 58.7 Doctor s signature is missing 7.3 Child is not completely immunized 7.3 There are long queues to collect cash assistance 6.4 Others 10.1 Do not know 22.9 * Multiple responses

94 Centre for Operations Research and Training, Vadodara Table A25: Handling of women visiting natal place (other village) for delivery, Assam, 2007 Percentage Total number of ASHAs interviewed 181 Ways followed to handle a case where a woman goes to her maternal home for delivery/to a different village where the respondent is not responsible* Try to convince her to deliver in this village (for money reasons) 30.9 Ask her to take proper care/go for institutional delivery 25.4 If nearby, I ask to call at the time of delivery 16.6 I will still accompany her to the place of delivery and take total care 11.0 Take care of immunization of child 9.4 ASHA at woman s natal place takes care 6.6 I make sure she gets the benefit 6.6 Women receive the money at the place of delivery/at her natal place, so there is no problem 8.3 Give JSY card from the village and referral slip 5.0 Do not know, have no such case till now 39.8 I do not know, I have not started to work as an ASHA 1.1 Do not know 2.2 * Multiple responses Table A26: Reasons for preferring home delivery despite cash assistance for institutional delivery in Assam, 2007 Percentage Total number of ASHAs interviewed 181 Reasons for women to deliver at home despite cash assistance paid under JSY for institutional delivery* There are expenses in the hospital/home delivery is cheaper Illiteracy and lack of understanding of the importance of institutional delivery Fear of going to hospital/needle/injection/equipments Fear of doctor/nurse Women believe they get better care at home Unavailability of transport facility on time Women do not believe us (ASHAs) Shy of going to a doctor for delivery No time to go to hospital/delivery before due date If there is any complication they go to hospital or contact us Staff is not cooperative/rude Others Do not know * Multiple responses

95 Appendix 1 Table A27: Brief details of ASHA s interaction with her last client in Assam, 2007 Percentage Number of ASHAs who had handled a case 172 Time when the last client availed services from ASHA (days before) Mean days ago (among those who had handled a case) No case served by ASHA (%) Average age of the last client (in years) 24.1 Caste of the client Schedule caste Schedule tribe OBC General Reasons for the interaction* Delivery/to get advice about place of delivery Immunization Antenatal care/check-up Registration of pregnancy IFA tablet distribution Post natal care Procuring Mala D or condom For BPL card Information regarding sterilization Collect medicines for fever, back pain, vomiting Pain in lower abdomen Did not get money after delivery, hence came to me * Multiple responses Table A28: Details of ASHAs when last accompanied women for delivery in Assam, 2007 Mean duration of days ago when ASHA last accompanied a woman for delivery (in days among those ASHAs who accompanied) Percentage and means 35.4 ASHAs who stayed with JSY beneficiary at the place of delivery 89.0 (153) Number of days ASHA stayed with JSY beneficiary at the place of delivery Less than one day One day Two days Three or more days Average number of days (among those who stayed with JSY beneficiary at the place of delivery)

96 Centre for Operations Research and Training, Vadodara Table A29: Networking of ASHA with other stakeholders in Assam, 2007 Stakeholders AWW ANM Block facilitator ASHAs who met the following 98.3 (178) Frequency of meeting the stakeholders Daily Weekly once Fortnightly Once a month Less frequently Time when last met the stakeholders 1 2 days ago 3 7 days ago 8 15 days ago days ago days ago Do not know/cannot say (181) (77) PHC staff 87.3 (158) NGO staff 21.0 (38) (Percentage) SHG PRI Health and sanitation committee 68.0 (123) (118) (42) Village mandal 40.9 (74) Mean number of days ago when met last Activities done by ASHA in collaboration with the stakeholders* Enhance utilization of immunization services Take care of antenatal mothers Motivate pregnant women for check ups Organizing health days/camp Ensure payment of assistance to benef. Help in administration/registration work Provide health awareness to community Provide curative care Mobilize infant for nutritional supplements Guidance to overcome problems Promote sanitation and hygiene Advice/provide family planning services Motivate for saving/give loan Get medicines supply Nothing Others ASHAs experience in terms of support from stakeholders Yes, they support They somewhat support No support/cannot say * Multiple responses 80

97 Appendix 1 Table A30: The roles of other stakeholders in the implementation of ASHA in Assam, 2007 Block officials Panchayati Raj Institutions Non Government Organizations Total number of ASHAs interviewed 181 Support from/roles of other stakeholders* Arrange for money Selection of ASHA Training of ASHA Advice ASHA Give treatment to women Create awareness of JSY among community Serve the village by building roads/drainage lines/ water facilities Maintain hygiene/sanitation Motivate people for institutional delivery Birth and death registration Immunization of children Provide medicines/drug kits Organize health camp/village health day Motivate me from time to time Provide supplies Check registers/records/ performance of ASHA Runs saving scheme/provide loans Ensures widow pension Solve problem No one visits Others Do not know * Multiple responses Self help group Community Based Organization (Percentage) Health department

98 Centre for Operations Research and Training, Vadodara Table A31: Process of receiving cash incentive money as ASHA in Assam, 2007 Percentage Total number of ASHAs interviewed 181 ASHAs who have received any cash incentive till now 80.1 (145) Services for which ASHA received cash incentive money* Attending JSY beneficiary Antenatal care Immunization of children DOTS treatment Person who usually disburses the cash incentive* ANM Doctor/staff at the institute MO CHC/PHC Account/clerk ASHAs who received money for their last beneficiary case 65.2 (118) Average amount received for last beneficiary case (in rupees among those who receive money) Place where ASHA got the payment for her last case At the institution (place of delivery) At the CHC At the PHC At the sub-centre At home Anganwadi Centre Time when ASHA got the payment for her last case Same day/immediately after delivery On giving the accounts Within a month More than a month after delivery ASHAs who did not get the cash incentive on time 72.4 (105) Reasons for the delay in payment of cash incentive* Lack of budget at the centre Surpanch s signature is missing ASHA gets the total amount after 2 3 months JSY has just started hence there is some delay Did not get total amount due as per entitlement Have to fill up form, which has to go for approval before making the payment ANM does not give me money Others Do not know * Multiple responses Table A32: Average amount received from government (other than training) by ASHA in the last three months in Assam, 2007 Months of payments Attending JSY beneficiary (n=30) Mean amount received Range b. Immunization of children (n=38) Mean amount received Range October 06 (Amount in Rs) November 06 (Amount in Rs) December 06 (Amount in Rs) C. Sanitary latrine promotion (n=1) Mean amount received D. DOTS treatment (n=1) Mean amount received

99 Appendix 1 Table A33: Reported satisfaction with the cash incentive in Assam, 2007 Percentage ASHAs that received any cash incentive money till now 80.1 (145) Percent satisfied with the cash incentive received under the JSY Satisfied Somewhat satisfied Unsatisfied Reasons for satisfaction with the cash incentives* Able to serve the community We get money I also get to learn many things Working within the village so it is ok Reasons for dissatisfaction with the cash incentives* Too much work and too little money Delay in getting payment Money should be available timely Did not get JSY money from ANM/other officials Get money even if activities are not done/ some ASHA are not working but favoured and paid Get money only if activities are done Sometime need to stay at hospital * Multiple responses

100 Centre for Operations Research and Training, Vadodara Table A34: Supervision and monitoring of ASHA in Assam, 2007 Percentage Number of ASHA interviewed 181 ASHAs maintaining any records or registers 91.7 (166) Types of records maintained as an ASHA* Immunization Delivery case record ANC register (name, address, DoD, registration, weight) Birth and death registration Child registration, nutrition Household survey Family planning Adolescent girl s register Sanitation (spraying of bleaching powder) Drug register ASHAs submitting the records/registers of those maintaining them to health department 87.3 (145) Mean number of hours per week taken to maintain/update the records by ASHA Range in hours (Minimum - Maximum) Person to whom ASHA submit the records to* ANM MO PHC Anganwadi supervisor/anganwadi worker No one Person who checks/supervises the records/registers that are maintained by ASHA* ANM MO PHC LHV Anganwadi supervisor/anganwadi worker I do not know Nobody ASHAs who receive feedback from supervisor on the data maintained or provided by ASHA 85.5 (124) Total number of ASHAs interviewed 181 Visits by district or block officials in the past 3 months Yes, visited while I was present Yes, visited but I was not there No, did not visit in past 3 months No, visited more than 3 months back Never visited since I started working here Percent of ASHAs visited by district/block officials in the past 3 months 44.2 (80) Percent informed in advance about the last visit of block/district officials 28.8 (23) * Multiple responses 84

101 Appendix 1 Table A35: Knowledge and opinion of ASHAs about their work with the government in Assam, 2007 Percentage Total number of ASHAs interviewed 181 Knowledge about the objective of Government in implementing ASHA* To promote institutional delivery To provide benefits for poor people Immunization coverage Safe delivery to save the child Reduce maternal and child mortality Improve mother s health Improve mother s health through ANCs Improve community health Create awareness on health in the community Population control Social development Tuberculosis control program Others Do not know ASHAs perception on the utilization of their knowledge Well utilized Somewhat utilized Not utilized at all Respondents that felt that they require more training to be a good ASHA 91.7 Percent of ASHAs who thought that involvement of them is useful 10 Respondents mentioning services that they as ASHA would like to provide but not providing currently Type of services ASHAs would like to provide* Ensure that home deliveries are stopped/motivate for institutional delivery Give necessary aids/medicine to poor women Ensure advance money for ANCs to mother First aid services Specialist doctor should check all the women coming for ANCs Give BPL card to all eligible Ensure that women get money quickly Should have a vehicle Benefits for widows/orphans Build latrine in poor people s houses Propagate about the JSY Others * Multiple responses 59.1 (107)

102 Centre for Operations Research and Training, Vadodara Table A36: Suggestions of ASHA for further strengthening their work in Assam, 2007 Percentage Total number of ASHAs interviewed 181 Respondents that provided suggestion for improving the JSY and ASHA 82.3 (149) Suggestions made by ASHAs for improving their work and JSY* Cash assistance should be more Should give complete information Should get monthly payment Some officials/doctors/nurse should come and talk to the village people to explain JSY Should get good/practical training for ASHA ASHA should have a dress code Facilities should be improved Arrangement of transportation/van Good behaviour with women at the place of delivery Should use posters/role play/drama for training ASHA People should recognize me as ASHA Should get joining letter soon More propagation/advertise on television/newspaper/camp/rally Lady doctor should be there Should get dai kit More incentive for sterilization Health system should deal with myths and misconceptions Dai should be trained Cash assistance should be given timely/doctors should not demand money Others * Multiple responses Table A37: Difficulties and challenges faced by ASHA in carrying out activities in Assam, 2007 Percentage Total number of ASHAs interviewed 181 ASHAs voicing challenges faced by them 44.8 (81) Challenges faced by ASHA* I do not get money on time so I have to listen to complains from the community Village people are not ready for institutional delivery Opposition from community/illiterate people Opposition by family members of the women Women are not ready to take IFA tablets Women do not listen regarding weighing the baby/immunizing the child ANM does not allow to work without joining letter Hospital staff is not cooperative/their behaviour is very bad My husband/family does not like my job Seniors at work do not allow us to work/move forward Cases motivated by us are registered by ANM Doctor says if the women dies it will be ASHA s responsibility Other ASHAs take away my cases Problems from hospital staff Others Do not know * Multiple responses

103 Appendix 2 JSY Tables Coverage of sample in Assam, 2007 Place of delivery Total Institution At home N % N % N % JSY beneficiaries interviewed District name Block name Jorhat Baghchung Kamalabari Goalpara Agia Ranguli Nalbari Ghogharapra Tamulpur Table J1: Background information of JSY beneficiary, Assam, 2007 (Percentages) Institution At home Total Total number of JSY beneficiaries interviewed Age of JSY beneficiary in completed years 19 years years years years years Mean (age in years) Years of schooling completed No formal education Up to primary (5 th std) Middle (6 8 std) Secondary (9 10 std) Higher secondary (11 12 std) Undergraduate and above Mean (years of completed education) Religion Hindu Muslim Christian Others Caste Scheduled caste Scheduled tribe Other backward classes General No caste Do not know Average monthly family income (In Rs.) Mean number of living sons and daughters Living sons Living daughters Living children

104 Centre for Operations Research and Training, Vadodara Table J2: Source and type of information regarding JSY, Assam, 2007 (Percentages) Institution At home Total Total number of JSY beneficiaries interviewed Time when JSY beneficiary heard about the JSY Before pregnancy During pregnancy After delivery Source of information about JSY* ASHA ANM Relatives Radio TV Anganwadi Centre/Worker Others users of JSY Hoardings at SC/PHC etc. Doctor Pamphlets Non-government organization/shgs Neighbour Gram Panchayat Newspaper Information about the nature of services of JSY* For poor family For the benefit of the mother Free institutional delivery services for poor women with financial assistance Promotion of institution delivery Get/receive money Advice for intake of nutritious food Do not know/cannot say Discouraging home delivery Family planning Population stabilization Benefit of child/to take care of newborn child Others * Multiple responses

105 Appendix 2 Table J3: Process of registration, Assam, 2007 (Percentages) Institution At home Total Total number of JSY beneficiaries interviewed Percent JSY beneficiary approached someone or someone approached her for JSY registration Yes, I approached someone Yes, someone approached me Person who registered respondent for JSY Doctor ANM/FHW ASHA Stage of pregnancy when woman got registered for JSY First trimester Second trimester Third trimester After delivery Do not know Mean (in months) Place where respondent was registered PHC Subcentre District/sub-district hospital Community Health Centre Anganwadi centre At home Others Do not know * Multiple responses Table J4: Awareness about index pregnancy, Assam, 2007 (Percentages) Place of delivery Institution At home Total Total number of JSY beneficiaries interviewed Month of index pregnancy when mother realized that she was pregnant 2 months 3 rd month 4 th month or later Mean (in months) Percent who confirmed pregnancy through testing

106 Centre for Operations Research and Training, Vadodara Table J5: Contacts with health personnel during index pregnancy, Assam, 2007 (Percentages) Institution At home Total Total number of JSY beneficiaries interviewed Percent contacted by someone (from health department) or self contacted health personnel during last pregnancy Somebody from health department contacted JSY beneficiary contacted somebody No contact made Number of JSY beneficiary who had contact with health personnel 95.7 (199) Stage of pregnancy when first contact was made 2 months 3 rd month 4 th month 5 th month or later (29) 95.0 (228) Mean (in months) Person with whom first contact was made Doctor ANM/FHW ASHA Percent advised by the health personnel for antenatal check-up Yes, advised for ANC No, not advised Do not know/cannot say Note: Figures in bracket represents numbers Table J6: Frequency and place of antenatal check-ups during index pregnancy, Assam, 2007 (Percentages) Institution At home Total Total number of JSY beneficiaries interviewed Women who availed any antenatal check-up during index pregnancy 95.2 (198) Month of pregnancy when availed antenatal care services for the first time 2 months 3 4 months 5 6 months 7 th month or later (29) 94.6 (227) Mean (in months) Number of times mother underwent antenatal check-ups 1 time 2 times 3 times 4 or more I do not remember Mean (number of times) Place from where she received antenatal care services* District/sub-district hospital Community Health Centre PHC Subcentre Private hospital At home Anganwadi centre Others * Multiple responses

107 Appendix 2 Table J7: Persons who motivated JSY beneficiaries for antenatal check-ups, Assam, 2007 (Percentages) Institution At home Total Total number of JSY beneficiaries interviewed Percent influenced or motivated by someone to avail antenatal check-up 96.5 (191) Persons who influenced or motivated respondent s decision to go for antenatal check-up* ASHA Husband Self motivated LHV/ANM/FHW Mother-in-law Anganwadi worker Doctor Other family members/relatives/friends * Multiple responses (29) (220) Table J8: Persons who accompanied the beneficiary and cost incurred for ANC visits, Assam, 2007 (Percentages) Institution At home Total Number of JSY beneficiaries who availed any antenatal check-up Persons who accompanied JSY beneficiary for ANC visit(s)* ASHA Husband Sister-in-law Mother-in-law Mother Sister Brother/father/other males Neighbour Anganwadi worker/anganwadi Sahyogini Dai Others No one Cost incurred (including fees, laboratory test) during ANC period No expense < 100 rupees rupees rupees rupees 1001 or more rupees Do not know Mean (in rupees among those who incurred expenses) Percent received cash assistance for antenatal care 4.2 (2) (0) 3.8 (2) * Multiple responses 91

108 Centre for Operations Research and Training, Vadodara Table J9: Reasons for not seeking ANC services, Assam, 2007 (Percentages) Institution At home Total Total number of JSY beneficiaries interviewed JSY beneficiaries who did not avail antenatal care services during index pregnancy 4.8 (10) 9.4 (3) 5.4 (13) Reasons for not seeking any antenatal care services* A high cost Not necessary Not customary Facilities are too far/no transport No time to go Family did not allow Lack of knowledge Others * Multiple responses Table J10: Role of ASHA to JSY beneficiary during index delivery, Assam, 2007 (Percentages) Institution At home Total Total number of JSY beneficiaries interviewed Type of help provided by ASHA to JSY beneficiary* Registration of birth of the newborn Helped in immunizing the newborn Providing IFA tablets Accompanied to ANM for check-up Accompanied to hospital for delivery Visited in post-partum period Did follow-up Arranged transport Gave money for transport Percent who received advice from ASHA at least once during the index pregnancy * Diet Delivery care Newborn care Breastfeeding Danger signs Family planning Others Percent who informed about the following during the antenatal period* Date of next check-up Place of next check-up Place of delivery Date of expected delivery Place of referral, if complications arise * Multiple responses

109 Appendix 2 Table J11: Intentional and actual place of delivery of JSY beneficiaries, Assam, 2007 (Percentages) Total Total number of JSY beneficiaries interviewed 240 Place where respondent intended to deliver the index child PHC District/sub-district hospital At home Community Health Centre Sub-centre Place where delivery took place PHC District/sub-district hospital At home Community Health Centre Sub-centre Private hospital accredited by the government Percent who delivered at an institution 86.7 (208) Motivation for opting for institutional delivery* Support provided by ASHA Safe delivery of child/safety of both mother and child Money available under JSY Better access to institutional delivery services in the area Complicated delivery/health problem, white discharge Support provided by health personnel A institutional birth of previous child Availability of transport assistance Previous history of child is not surviving/miscarriage/caesarian section Others Person who finally decided for institutional delivery* Husband ASHA Self Relatives/neighbours/users of the ANM Mother-in-law Father-in-law Friends Anganwadi worker/anganwadi helper/shg member Dai * Multiple responses Table J12: Intention vs. actual place of delivery, Assam, 2007 (Percentages) Place where last delivery of JSY beneficiary took place Institutional At home Total Intended place for last delivery Institutional At home 70.4 (169) 16.3 (39) 5.0 (12) 8.3 (20) 75.4 (181) 24.6 (59) Total 86.7 (208) 13.3 (32) 10 (240) Table J13: Shift in the place of delivery before and after JSY, Assam, 2007 (Percentages) Place of delivery for last (JSY) child Institutional Home Total Place of delivery for last but one child Institutional Home 42.5 (45) 38.7 (41) 0.9 (1) 17.9 (19) 43.4 (46) 56.6 (60) Total 81.1 (86) 18.9 (20) 10 (106) 93

110 Centre for Operations Research and Training, Vadodara Table J14: Process of arranging transport to reach health institution, Assam, 2007 (Percentages) Total Number of JSY beneficiaries who delivered in an institution 208 Percent who directly came from home to the ultimate place of delivery 10 Average distance to the ultimate place of delivery from respondent s residence (in kms) Range (in km) (Minimum - Maximum) Do not know (%) Mode of transport used to reach the ultimate place of delivery* Auto rickshaw Car/Jeep Tempo/tractor Motorcycle/scooter Bus Bullock/Camel cart/chakda Three wheel cycle / hand cart Ambulance Walking Bicycle Others Persons who facilitated in arranging transport* Family members ASHA ANM/Health worker Panchayat members/shgs Anganwadi worker Relatives / neighbours / cousin brother Others Average time taken to arrange the transport since respondent decided to visit the ultimate place of delivery (in minutes) Range (Minimum - Maximum) Do not know/cannot say (%) Percent mentioning that arrangement for transport was pre-planned 20.3 Average travel time taken to reach the ultimate place of delivery (From the time the transport facility reached the respondent) (in minutes) Range (Minimum - Maximum) Do not know/cannot say (%) Average cost incurred for transport to reach the ultimate place of delivery (in rupees) Range (Minimum - Maximum) Do not know (%) Percent who said they had private funds to pay for the transport expenses 64.7 Percent given advanced money for transport expenses or reimbursed by ASHA/health personnel* Advance money for transport given Reimbursed later Paid by self * Multiple responses

111 Appendix 2 Table J15: Difficulties faced in reaching the place of delivery, Assam, 2007 (Percentages) Total Number of JSY beneficiaries who delivered in an institution 208 Percent given a referral slip to help them access delivery services by ASHA or health personnel 33.2 Percent who had any difficulty in reaching the health institution 1 (22) Types of difficulties faced in reaching the health institution* Did not have sufficient money Transport was not immediately available It was late in the night ASHA was not readily available Rainy night/heavy rain Male members in household were not present Others * Multiple responses Table J16: Persons accompanying JSY beneficiaries to the health institution, Assam, 2007 (Percentages) Total Number of JSY beneficiaries that delivered in an institution 208 Timing of the day when JSY beneficiary reached the place of delivery 6 AM 12 PM 12 PM 6 PM 6 PM 12 AM 12 AM 6 AM Persons who accompanied the JSY beneficiary to the health institution* Husband ASHA Other family members Mother-in-law Mother Neighbour or other ANM/Health worker Government doctor Anganwadi worker Dai/TBA Number of JSY beneficiaries accompanied by ASHA 172 JSY cases where ASHA facilitated in obtaining services on accompanying them 94.2 (162) Kind of facilitation done by ASHA* Spoke to the medical personnel Helped in expediting registration and other administrative activities Provided psychological and moral support Helped in getting the JSY cash assistance * Multiple responses

112 Centre for Operations Research and Training, Vadodara Table J17: Quality of services available at the place of delivery, Assam, 2007 (Percentages) Total Number of JSY beneficiary that delivered in an institution 208 Average time taken to complete the administrative or registration process at the ultimate place of delivery (in minutes) Range (Minimum - Maximum) Do not know/cannot say (%) Average waiting time at the facility until someone attended the JSY beneficiary (in minutes) Range (Minimum - Maximum) Do not know/cannot say (%) Type of delivery Normal Assisted (Forceps, Ventouse, Vacuum) Caesarean Person who conducted the delivery Doctor ANM/nurse/LHV Do not know Average (and range) hours after delivery when woman was discharged Normal delivery (n=186) Assisted (forcep, ventouse, vacuum) (n=13) Caesarean (n=6) (1-420) 35.8 (1-112) (1-170) Table J18: Payments made for services at the health center, Assam, 2007 (Percentages) Total Number of JSY beneficiaries who delivered in an institution 208 Percent who had to pay for services at the health centre 88.9 (185) Specific services for which beneficiaries were charged Medicines/IV fluids Delivery/caesarean /Operation charge Food charges Accommodation charge Paediatric care Laboratory test Diagnostic/sonography Average amount spent for the index delivery (in rupees) Range (Minimum - Maximum) Do not know Table J19: Satisfaction with the services at the place of delivery, Assam, 2007 (Percentages) Total Number of JSY beneficiaries that delivered in an institution 208 Percent satisfied with the services available at the place of delivery 93.3 (194) Nature of satisfaction/dissatisfaction expressed* Health staff and doctors were courteous Health facility was clean Counselled for breastfeeding/immunization Counselled about follow-up visit Counselled for newborn care, diarrhoea management Counselled for family planning Safety of mother and child/hospital is good, provided better and sufficient services Staff was rude Facility was not clean/adequate Staff asks for money from JSY beneficiaries /staff/doctor demanded money from us forcefully Staff did not provide JSY assistance/they give money only if we give them some Others * Multiple responses

113 Appendix 2 Table J20: Persons who assisted delivery at home, Assam, 2007 (Percentages) Total Number of JSY beneficiaries who delivered at home 32 Persons who assisted the delivery* TBA Friends/Relatives Doctor LHV/ANM/Nurse ASHA Others * Multiple responses Table J21: Views about TBA, Assam, 2007 (Percentages) Institution At home Total Total number of JSY beneficiaries interviewed Percent opined that TBA can provide all necessary midwifery services 34.1 (71) 65.6 (21) 38.3 (92) Reasons for saying that TBA can provide necessary midwifery services* TBA has better knowledge of the cultural practices and follows it TBA charges less money By tradition TBA has been conducting deliveries in the family TBA is easily accessible Better comfort level with TBA Others * Multiple responses Table J22: Perceived reasons for women to deliver at home despite cash assistance paid under JSY for institutional delivery, Assam, 2007 (Percentages) Institution At Total home Total number of JSY beneficiaries interviewed Reasons for preferring home delivery* Because of poverty There are expenses in the hospital / Home delivery is cheaper Fear of doctor/nurse Illiteracy and lack of understanding of the importance of institutional delivery Women believe they get better care at home Unavailability of transport facility on time Fear of going to hospital/needles/injection, equipments Shy of going to a doctor for delivery Opposition from family members Clinic far away/long distance Dai (TBA) takes better care while assisting delivery Prefer home delivery by dai Do not get time to go to hospital Most go to hospital Women do not believe in institutional delivery Because of stitches/fear of caesarean Unaware about JSY Hospital staff is not cooperative/rude Others Do not know * Multiple responses

114 Centre for Operations Research and Training, Vadodara Table J23: Background information of JSY beneficiaries, Assam, 2007 Education No formal education or up to primary Middle level or more Percent belonged to Scheduled caste / Scheduled tribe Other backward classes General No caste Do not know (Percentages) Institution At home Total N Average monthly family income (In Rs.) Table J24: Contact with health personnel during index pregnancy by place of delivery, Assam, 2007 (Percentages) Institution At home Total Percent contacted by someone from health department during last pregnancy Among those contacted during pregnancy, person first contacted by LHV/ANM/FHW Percent of respondents who were influenced or motivated to go for antenatal check-up by ASHA LHV/ANM/FHW/Anganwadi worker Percent JSY beneficiaries accompanied by ASHA for ANC visit(s)* Percent JSY beneficiaries approached by someone for JSY registration Percent registered by health personnel for JSY LHV/ANM/FHW/Anganwadi worker ASHAs Total number of JSY beneficiaries interviewed Table J25: Utilization of ANC services during index pregnancy by place of delivery, Assam, 2007 (Percentages) Institution At home Total Percent first contacted in 1 st trimester Percent who had 3 or more antenatal check-ups Percent incurred any expenses for receiving antenatal check-ups Average amount spent during ANC period including fees, laboratory test Percent heard about the JSY after delivery Total number of JSY beneficiaries interviewed Place where received antenatal care* District/sub-district hospital/chc/phc Sub-centre/Anganwadi centre Private hospital Others Place where respondent was registered District/sub-district hospital/chc/phc Sub-centre/Anganwadi centre/at home/ Others Do not know

115 Appendix 2 Table J26: Payment made to JSY beneficiaries, Assam, 2007 (Percentages) Institution At home Total Total number of JSY beneficiaries interviewed Percent received JSY cash assistance for delivery 62.0 (129) 71.9 (23) 63.3(152) Instalment of payment for JSY cash assistance In one go Time when JSY beneficiary received the money Much later A week after the delivery Immediately after the delivery At the time of registration Much before the delivery Within a week before the EDD Person who gave the cash assistance to JSY beneficiary CHC/PHC MO Accountant ANM ASHA Staff at health centre Block official Bank official Do not know Place where received cash assistance Place of delivery At the CHC/PHC Sub-center At home Block office Bank Average amount received by JSY beneficiary (in rupees) Range (Minimum - Maximum) No money received Table J27: Difficulties faced by JSY beneficiaries in getting cash assistance for delivery, Assam, 2007 (Percentages) Total Number of JSY beneficiaries who received JSY cash assistance for delivery 152 Percent faced difficulty in getting money (of those who received JSY assistance) 8.6 (13) Type of difficulties faced in getting money* Payment not received when needed/untimely Several visits to get the money Cumbersome processes Percent mentioning that the cash assistance received was sufficient to meet delivery expenses Sufficient Somewhat sufficient Not sufficient Type of utilization of money received under the JSY * Bought medicines/tonics for self and child Used for medical expenses for delivery Purchased consumables for the family Have not spent any money so far Used on self nutrition/fruit Husband took it away Others Do not know * Multiple responses

116 Centre for Operations Research and Training, Vadodara Table J28: Opinions of beneficiaries about JSY, Assam, 2007 (Percentages) Institution At home Total Total number of JSY beneficiaries interviewed Percent who would recommend relatives or friends/neighbours to be a beneficiary under JSY Reasons for recommending/not recommending to relatives or friends/neighbours to be a beneficiary under JSY* Received money / received cash immediately on filling up form/received expenses incurred in hospital JSY is beneficial and provides safety to mothers so all should use Good for safe delivery in the hospital, and hospital staff and nurse are also good Poor women receive help and nutritious food Get free medicines, having delivery in less amount or free of charge I have not received money, so I do not advice others Do not know / cannot say * Multiple responses 94.7 (197) (32) (229) Table J29: Complications during index pregnancy, Assam, 2007 (Percentages) Total Number of JSY beneficiaries who delivered in an institution 208 Percent who had any complications just before or during delivery 34.1 (71) Type of complications faced before or during delivery* Excessive labour Prolonged labour Health problems/vomiting/feeling uneasy/physically weak Premature labour Excessive white discharge Excessive bleeding/vaginal bleeding Obstructed labour Swelling of hands and feet Fever * Multiple responses

117 Appendix 2 Table J30: Profile of last and last but one child, Assam, 2007 Percentage and mean Last child Last but one child Number of mothers Average age of child (in months) Sex of the child Male Female Place of delivery District/sub-district hospital Community Health Centre PHC Subcentre Private hospital Private hospital accredited by Government At home Do not know Mothers who incurred expense on the last but one delivery Institutional Home Total Average expense on the last but one delivery (in rupees) Institutional Home Total (48) (11) (59) Percent of mothers reporting that the newborn died 3.8 (9) 1.9 (2) Number of days child died after birth (number) Immediately after birth / day of delivery One day after birth 3 days after birth Four days after birth After 36 days Do not remember Place of delivery Institution Home Causes of death (number) High fever Still birth Cold cough and pneumonia Abnormal position of the child / (bacha ulta paida hua tha) Mother fell down and had excessive bleeding Due to negligence of doctor/wrong treatment Don t know the cause of death but the baby was born blue Do not know