Study Team. Bella Patel Uttekar Sandhya Barge Yashwant Deshpande Vasant Uttekar Jashoda Sharma Shweta Shahane

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2 Study Team Bella Patel Uttekar Sandhya Barge Yashwant Deshpande 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 Himachal Pradesh, Chamba, Shimla and Una. 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. Negi, Officer on Special Duty, Directorate of Health Services, NRHM and Mr. Mauhan Chauhan, NRHM Mission Director Himachal Pradesh, CMO of the selected districts 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 AWWs... 4 Interviews of beneficiaries of JSY... 4 Other stakeholders... 4 Community members... 5 Study tools... 5 Field operations... 5 Ethical considerations... 5 Data management and analysis... 6 Presentation of the report... 6 Chapter 2: Operationalization of ASHA Intervention and JSY in Himachal Pradesh State scenario... 7 Adaptation and operationalization of ASHA intervention... 8 Programme management processes... 9 Selection of ASHAs... 9 Training of ASHAs Compensation package for ASHAs Adaptation of JSY guidelines and its operationalization Linkages and integration Accreditation of private institutions Monitoring and supervision Community s perception about ASHA and JSY... 16

5 Chapter 3: Involvement of AWW in JSY Background characteristics of AWW...19 Awareness and opinion of AWW about ASHA Training of AWW...20 Quality of Training Knowledge of AWW about ANC and child care services...22 Knowledge of pregnancy and delivery complications and actions to be taken...22 Knowledge about newborn care...23 Knowledge about responsibilities of AWWs...23 Organization of work by AWWs...24 Availability and utilization of drug kits...25 AWWs role in JSY...25 AWWs awareness about cash assistance under JSY...26 Promoting JSY...26 Accompanying JSY cases and arranging for institutional delivery...27 Cooperation and cash assistance payment to JSY beneficiaries...27 Handling of delivery at natal place...28 AWW s views about preference for home delivery among women...28 AWW s clientele...29 Networking of AWW...30 The role of other stakeholders...31 Panchayati Raj Institute...31 NGOs/CBOs...32 Block officials...32 Incentives received as AWWs...32 Supervision and monitoring of AWW...33 Opinion about the JSY component...33 Difficulties and challenges faced by AWW...34 Chapter 4: Beneficiaries of JSY in Himachal Pradesh Background information of JSY beneficiaries...37 Awareness about JSY Process of registration under JSY Utilization of ANC services by JSY beneficiaries Role of health personnel in helping JSY beneficiaries...40 Role of health personnel in micro-birth planning...40 Intention versus actual place of delivery...41 Motivation and decision making for institutional delivery...41 Impact of JSY on institutional delivery...42 Process of arranging transport...42 Difficulties faced in reaching the place of delivery...43 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...44 Satisfaction with the services at the place of delivery...45

6 Suggestions for improvement of institutional facilities Decision making process of deciding for home delivery Persons who assisted delivery at home and views about TBA 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 Complications during delivery Child mortality Chapter 5: Evidences of Success, Challenges and Policy and Programme Implications Programme management ANM s contribution to JSY Cash assistance Increasing institutional delivery Community perceptions about ASHA and JSY Challenges Implementation of ASHA Involvement of AWW ANMs participation Accessibility of services Readiness of facilities Ensuring quality of service in the facility Cash assistance under the scheme Policy and Programme Implications Policy and programme implications Policy Programme management Demand generation Appendix 1: ASHAs tables Appendix 2: JSY tables

7 LIST OF TABLES Table 1.1: Table 2.1: Table 2.2: Sample covered for qualitative and quantitative components in Himachal Pradesh... 4 Number of JSY beneficiaries by place of delivery from service statistics in Himachal Pradesh up to March Mother s cash assistance package for JSY beneficiaries in Himachal Pradesh Table 4.1: Intention versus actual place of delivery, Himachal Pradesh Table 4.2: Shift in the place of delivery before and after JSY, Himachal Pradesh Table 5.1: Table 5.2: Motivational factors leading to institutional delivery as against intension, Himachal Pradesh Pregnancy expenditure as against the amount received by JSY beneficiaries, Himachal Pradesh... 57

8 LIST OF FIGURES Figure 3.1: Knowledge of AWWS ANC and child care in Himachal Pradesh Figure 3.2: AWW s awareness about her responsibilities Figure 3.3: Network of AWW with stakeholders Figure 4.1: Time when the beneficiary heard about the JSY Figure 4.2: Help provided by health personnel to JSY beneficiaries Figure 4.2: Sufficiency of cash incentives received by JSY beneficiary... 48

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

10 Table A24 Handling of women visiting natal place (other village) for delivery in Himachal Pradesh, Table A25: Reasons for preferring home delivery despite cash assistance for institutional delivery, Himachal Pradesh, Table A26: Brief details of AWW s interaction with her last client in Himachal Pradesh, Table A27: Details of AWWs when last accompanied women for delivery in Himachal Pradesh, Table A28: Networking of Anganwadi worker with other stakeholders in Himachal Pradesh, Table A29: The roles of other stakeholders in the implementation of AWWs in Himachal Pradesh, Table A30: Process of receiving cash incentive money as AWW in Himachal Pradesh, Table A31: Average amount received from government (other than training) by AWW in the last three months Table A32: Reported satisfaction with the cash incentive in Himachal Pradesh, Table A33: Supervision and monitoring of AWW in Himachal Pradesh, Table A34: Knowledge and opinion of AWWs about their work with the government in Himachal Pradesh, Table A35: Suggestions of AWW for further strengthening their work in Himachal Pradesh, Table A36: Difficulties and challenges faced by AWW in carrying out activities in Himachal Pradesh, Appendix 2: JSY Tables Coverage of sample in Himachal Pradesh 85 Table J1: Background information of JSY beneficiary, Himachal Pradesh, Table J2: Source and type of information heard about JSY in Himachal Pradesh, Table J3: Process of registration, Himachal Pradesh, Table J4: Awareness about index pregnancy, Himachal Pradesh, Table J5: Contacts with health personnel during index pregnancy, Himachal Pradesh, Table J6: Frequency and place of antenatal check-ups during index pregnancy, Himachal Pradesh, Table J7: Persons who motivated JSY beneficiaries for antenatal check-ups in Himachal Pradesh, Table J8: Persons who accompanied the beneficiary and cost incurred for ANC visits, Himachal Pradesh, Table J9: Reasons for not seeking ANC services, Himachal Pradesh, Table J10: Role of AWW to JSY beneficiary during index delivery in Himachal Pradesh, Table J11: Intentional and actual place of delivery among JSY beneficiaries, Himachal Pradesh, Table J12: Intention versus actual place of delivery, Himachal Pradesh,

11 Table J13: Rationale for choosing place of delivery, Himachal Pradesh, Table J14: Shift in the place of delivery before and after JSY, Himachal Pradesh, Table J15: Process of arranging transport to reach health institution, Himachal Pradesh, Table J16: Process of arranging money to pay for transport to reach the institution, Himachal Pradesh, Table J17: Difficulties faced in reaching the place of delivery, Himachal Pradesh, Table J18: Persons accompanying JSY beneficiaries to the health institution, Himachal Pradesh, Table J19: Quality of services available at the place of delivery, Himachal Pradesh, Table J20: Payments made for services at the health centre, Himachal Pradesh, Table J21: Satisfaction with the services at the place of delivery, Himachal Pradesh, Table J22: Improvement necessary at the institution in Himachal Pradesh, Table J23: Rationale for JSY beneficiaries to deliver at home and information they had regarding institutional delivery Table J24: Persons who assisted delivery at home, Himachal Pradesh, Table J25: Views about TBA, Himachal Pradesh, Table J26: Perceived reasons for women to deliver at home despite cash assistance paid under JSY for institutional delivery, Himachal Pradesh, Table J27: Background information of JSY beneficiaries, Himachal Pradesh, Table J28: Contact with health personnel during index pregnancy by place of delivery, Himachal Pradesh, Table J29: Utilization of ANC services during index pregnancy by place of delivery, Himachal Pradesh, Table J30: Payment made to JSY beneficiaries in Himachal Pradesh, Table J31: Difficulties faced by JSY beneficiaries in getting cash assistance for delivery in Himachal Pradesh, Table J32: Opinions on JSY among beneficiaries in Himachal Pradesh, Table J33: Complications during index pregnancy, Himachal Pradesh, Table J34: Profile of last and last but one child, Himachal Pradesh,

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 focused 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. In Himachal Pradesh, AWWs are responsible for these tasks until ASHAs are selected, trained and in position. 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 JSY for GTZ and the MoHFW to understand the process of implementation of the programme, involvement of AWWs and experiences of JSY beneficiaries. This report is based on the qualitative and quantitative assessment of JSY in Himachal Pradesh covering three districts of Chamba, Shimla and Una. Using semi-structured study tools, 150 AWWs and 237 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, Himachal Pradesh with 29 percent institutional deliveries as per NFHS-2 and 45 percent of institutional deliveries as per NFHS-3 is categorized as a high performing state. However, as per NFHS-2, the proportion of institutional deliveries among poor women is only 14 percent. As per the service statistics, only 16 percent of the deliveries among JSY beneficiaries were institutional deliveries. The GOI has approved the ASHA intervention on 15 th November The implementation of the ASHA intervention is taking place in a phased manner, while in phase 1, 40 out of 75 blocks would be covered by mid 2007 and the remaining 35 blocks by Considering the difficult terrain and sparsely located villages, the state has suggested engaging approximately 7,750 ASHAs, one for every 800 population. Until ASHAs are functional, Anganwadi workers are provided with the incentives of Rs 50 per case for the promotion of institutional deliveries and Rs. 25 for each immunization session that she attends.

13 Centre for Operations Research and Training, Vadodara At the state level, Mission Director, NRHM and an officer on special duty give directives to implement the programme. At the district level, Chief Medical Officers cum Nodal Officer and Block Medical Officer at the block level would implement the trainings and programme activities, as well as monitor the programme. At the village level, Gram Sabha, Panchayat, Palikas, PHC/SC staff, sarpanch, ANM, AWW and SHGs are to provide ANC and PNC services. Besides, Swasthya Parivaar Kalyan Salahkar Samiti would take all the decisions concerning spending of untied funds at the sub-centres. The state conducted three-day training of the state trainers by NIHFW and six days training of district trainers in Dec 06 Jan 07. Block trainers were to be trained during April-May The state JSY nodal officer administers JSY. CMO and BMO in-charge are responsible for JSY intervention at district and block level. The scheme was publicized through print and electronic media. Though 77 percent women in rural areas have access to TV, the poor women- the JSY target population, and people in the community were largely unaware of the programme details. As Himachal Pradesh is a high performing state, only BPL pregnant women and SC/ST women irrespective of their financial status aged 19 years or more were eligible to receive cash assistance up to two live births. The cash assistance includes Rs. 700 for women in rural area and Rs. 600 for those belonging to urban areas. Besides, for delivery at home only BPL women with same criteria receive Rs Currently, the untied funds are managed at Block and PHC level and process of decentralization of administration power was yet to start. The process of accreditation of private institutions was to be initiated. Monitoring and supervision is taking place at all the levels, with state officials playing a key role. Yet, there is a need to develop a simple and sustainable monitoring system. Involvement of AWW in JSY Most of the AWWs are middle-aged, educated and married staying in the same village where they were functioning. Thirty-five percent of the AWWs belonged to SC/ST or other backward classes and 65 percent belonged to high caste Hindus. Before JSY, 64 percent of the AWWs themselves delivered their child at home. On average, the respondents worked as AWW for months (9 years) and they received rupees monthly from working as AWW. Forty-one percent of the respondents first came to know about the ASHA from ANM and 14 percent from health personnel. Government doctors, TV, radio, hoardings, pamphlets, CDPO/ICDS office, and other anganwadi workers also informed them about ASHAs. A probing to AWWs about their thoughts of having ASHA as a co-worker at the village level revealed that 79 percent said ASHAs would be useful to the AWW and only one percent did say that ASHAs would not be useful to them. One-fifth of the AWWs did ii

14 Executive Summary not specify reasons for believing that ASHAs would be helpful or not, but majority (59 percent) said that ASHAs would help AWWs in health related work and immunization, and ASHAs can provide information to AWWs about the community and people s health needs. In Himachal Pradesh, training of AWWs was done, on average, 8 months ago. Majority (71 percent) of the AWWs attended trainings conducted at Anganwadi centre/ balbhavan and nursing training center. Logistic arrangements during training including sitting arrangements (13 percent), accommodation (22 percent), food arrangements (22 percent), and size of the room (24 percent) were rated as average by the AWWs. AWWs appreciated the training sessions including trainers and training methods feeling they were good and useful. On average they received Rs. 216 as training allowance. Fifty percent of the AWWs scored Grade A or O for answering 8-10 out of 10 questions correctly, while another 43 percent scored Grade B. Figure 3.1: Knowledge of AWWs - ANC & Child Care in Himachal Pradesh Grade B Grade A AWWs knew about the complications during pregnancy, but only 4 19 percent talked about abnormal position of foetus, weak or no foetal movement, high fever, 43% 49% Grade C Grade O feeling uneasy and body/back pain. In 7% 1% such situation, AWWs said that they would immediately refer the pregnant woman to the nearest functional FRU or to a government accredited hospital, while 17 percent said that they would ask the pregnant woman to consult the ANM the next day. As per AWWs, their main responsibilities were to help in immunization programme (82 percent), create awareness on health (59 percent), and registration of birth and death (45 percent), while 39 percent AWW mentioned about mobilizing community to utilize health services and create awareness about basic sanitation and hygiene. AWWs also promote good health practices, family planning, provide ANC care, preeducation for small children, and nutritious food to pregnant women and children. Only eight percent of AWWs mentioned about accompanying delivery cases. AWWs mentioned about house-to-house (92 percent), talk during VLCC meetings, besides attending immunization session (65 percent), organizing health days and attending camp (20 percent), and accompanying ANM for conducted their work (17 percent). AWWs 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 immunization (41 percent), registration of pregnancy (31 percent), for getting BPL card (21 percent), medicine for fever/vomiting/back pain (16 percent), nutrition (13 percent) and place of delivery (12 percent), sterilization (11 percent), ANC care (7 percent), and for receiving IFA tablets (6 percent). iii

15 Centre for Operations Research and Training, Vadodara Forty-three percent of the AWWs had accompanied an average of 2.8 JSY cases for institutional delivery, mainly to government hospitals, PHCs and CHCs. Anganwadi workers accompanied the last case around 109 days ago while only six percent of them stayed with JSY beneficiaries at the place of delivery. AWWs network with the various stakeholders in the village to implement JSY. All the AWWs met ANMs, followed by PRI (87 percent), SHG (82 percent), PHC staff (71 percent) and village mandals (50 percent). They also met block facilitators, Health and Sanitation Committee and NGO staff. Only 18 percent of the AWWs received some cash incentive money, mainly for immunization of children and attending JSY beneficiaries. Thirty-three percent AWWs were satisfied or somewhat satisfied with the cash incentives mainly because they were able to serve people and received payment. Sixty-three AWWs were unsatisfied with the cash assistance as it was too much of work and too little money (53 percent), or did not get JSY money from ANM (21 percent) and because of delay in payment (13 percent). AWWs spent on average 5.5 hours every week in preparing various registers while AWW s work was mostly monitored by anganwadi supervisors, ANMs and MO PHC. Beneficiaries of JSY in Himachal Pradesh The JSY beneficiaries were young (23.6 years) and mostly those who had schooling up to primary, middle or secondary level. Sixty percent of the JSY beneficiaries belonged to SC/SC and five percent to the other backward classes. The beneficiaries learnt about JSY during various stages of pregnancy, however, 27 percent learnt about the scheme only after their delivery from ANM (48 percent), Anganwadi centre (36 percent) and doctor (23 percent). Only one-fifth of the JSY beneficiaries got registered in the first trimester, and on average, women had 3.7 antenatal check-ups during their index (JSY) pregnancy. Husbands (72 percent), mother-in-law (36 percent) and sister-in-law (17 percent) accompanied the beneficiary for ANC visit(s). Thirty-four percent of the women received antenatal care at district/sub-district hospital, 32 percent at sub-centre and 16 percent each at PHC and home. Majority (55 68 percent) of the JSY beneficiary received advice about diet, delivery care and newborn care, breastfeeding, while 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 32.5 (77) 15.2 (36) 7.6 (18) 44.7 (106) 40.1 (95) 59.9 (142) advice regarding danger Total 47.7 (113) 52.3 (124) 10 (237) signs and family planning was mentioned by 44 percent each. Fifty-eight percent 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, eight percent (n=18) women iv

16 Executive Summary delivered at home though they intended to deliver at a hospital because of lack of time to reach the hospital, due to extreme poverty and opposition from family members. Only 15 percent (n=36) of those beneficiaries that intended to deliver at home finally opted institutional delivery due to complications (58 percent), safety of mother and child (14 percent), as per motivation provided by relatives to go for institutional delivery (11 percent) and non availability of TBA in the village (6 percent). Majority (34 percent) of the institutional deliveries took place in district/sub-district hospitals. Among all beneficiaries who opted for institutional deliveries safety of both mother and child (77 percent), better access to institutional delivery services (30 percent) and cash assistance (26 percent) were mentioned as motivating factors while only 12 percent named support provided by AWWs. Out of the 100 JSY beneficiaries who had two or more children, 57 percent of the previous deliveries were reported delivery at home. Twenty-four percent of the women with two or more children continued with institutional delivery and 46 percent with delivery at home. However, between two deliveries, 11 percent (n=11) of the beneficiaries shifted from home to institution due to complications and safety of the child. In Himachal Pradesh, JSY beneficiaries had to travel, on average, 22.4 kms to reach the ultimate place of delivery. Women spent approximately 1 hour and 8 minutes to arrange transport and reach the ultimate place of delivery and another 1 hour and 2 minutes after reaching the institution on registration and administrative process and as waiting time until someone attend them. Twenty-four percent of the JSY beneficiaries did not receive their cash assistance, while 90 percent of those who received cash got payment in one go (much before the delivery (26 percent) or much later after the delivery (28 percent)) from the ANM or CHC/PHC MO. 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 from the government as cash assistance. The study evidently reveals that the cash assistance is not enough to cover all expenses for institutional deliveries with women spending a substantial amount out of their own pockets. For those, who delivered at home, 17 percent had negative balance and others gained Rs. 175 on average. While in the case of institutional deliveries, 75 percent spent more than what they received, on average an additional Rs Forty-one percent of the JSY beneficiaries felt that the cash assistance received was not sufficient. It is encouraging that husbands (86 percent) and mother-in-laws (59 percent) as well as other family members (43 percent) accompanied women for delivery. Mothers, neighbours, AWW, ANM, dai and government doctor also accompanied the women. On average, after normal delivery (n=89) and assisted delivery (n=3) women were discharged after 24 hours and for caesarean (n=21) after 5 days. v

17 Centre for Operations Research and Training, Vadodara Most of the women were satisfied with JSY and would recommend relatives or friends/ neighbours to be a beneficiary under JSY, mainly due to cash assistance, safety of mothers, good services at hospital and because poor families receive help. JSY beneficiaries perceived that despite cash assistance paid under JSY, women still prefer to deliver at home because of extreme poverty, shyness, hospital expenses, fear of doctors, and clinics located far away. The process of programme implementation such as selection and training of ASHAs was yet to be initiated. In the absence of ASHA anganwadi centers are bridging the gap though the role of anganwadi workers in JSY is minimal. Seven percent of the interviewed beneficiaries said that AWWs actually decided for institutional delivery on behalf of the JSY beneficiary; five percent arranged transport and two percent AWWs accompanied women to the health institution. Besides, the quality of care and infrastructure at the facilities particularly PHCs and sub-centre needs to be improved to provide services for normal deliveries. 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. ASHA would be chosen by and would be accountable to the panchayat to 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 programmes. 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 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 transport to reach the institution. In case of complications, referral services are required. The scheme has considered all these

19 Centre for Operations Research and Training, Vadodara elements and has made provision for transport including referral and escort (by ASHAs) and at the same time invested in improving public health institutions and services through the Reproductive and Child Health (RCH) Programme interventions. Moreover, the states have flexibility to evolve public-private partnership (PPP) mechanism and accredit private health institutions for providing institutional delivery services. As stated earlier, for LPS, in both rural and urban areas, special dispensation is available and linked to the ASHA intervention. The LPS are states that have institutional delivery rates below 25 percent and include 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 were worked out in detail. The guidelines since inception of the scheme have undergone four revisions and certain clauses were 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 AWW who were promoting JSY till ASHAs are in place 2

20 Introduction 4. Study engagement of PRI, NGO, SHGs and other CBOs engagement in extending support to ASHA 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. Understand the factors responsible for home delivery over institutional delivery among JSY beneficiaries 4. Review engagement of private sector including accreditation and compensation 5. 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 Himachal Pradesh, one good, average and poor performing district, selected on the basis of performance in the context of number of JSY beneficiaries and percentage of institutional deliveries among those JSY beneficiaries. The NRHM Mission Director, Department of Health and Family Welfare, Himachal Pradesh provided data regarding the number of JSY beneficiaries in each district as well as information regarding the distribution of cash assistance to those beneficiaries. Based on this information the place of delivery (home or institutional) could be determined. Subsequently, districts were grouped as good, average and poor performing districts. The selection process was discussed with the State officials prior to finalization of study districts by GTZ. Likewise, a procedure of district-level consultation and secondary data review was undertaken in each of the districts to select two blocks by CORT. Thus, in all six blocks from three districts were covered in Himachal Pradesh. Study Area This report is based on the assessment study conducted in Himachal Pradesh covering Chamba, Shimla, and Una districts. The Sample The sample covered in the state included Anganwadi workers and beneficiaries of JSY. In the state of Himachal Pradesh, ASHAs are yet to be recruited and trained. Until then, Anganwadi workers have been engaged to 3

21 Centre for Operations Research and Training, Vadodara promote JSY. Several other people associated with the scheme such as state and district programme managers, block-level providers, Auxiliary Nurse Midwife (ANMs), members of Panchayati Raj Institutions (PRIs), Community Based Organizations (CBOs), and community members were interviewed and included in the study. Interviews of AWWs: In all, 150 AWWs interviewed from the state and included in the study. From each of the six study blocks, 30 AWWs were to be interviewed. However, several posts of AWW were vacant and we could identify only AWWs per block, except for Gagret Block in Una district. Therefore, in Una block 35 AWWs were interviewed. To cover 30 AWWs, nearly 30 villages/hills were visited in each of the study block, which included one CHC village, 2 PHC villages; 9 sub-centre villages (3 SCs within each selected PHC/CHC), and 18 remote villages (2 remote villages from each of the selected sub-centre). Interviews of beneficiaries of JSY: Altogether, 237 JSY beneficiaries who availed services under the scheme were interviewed. As per the proposal it was envisaged that the beneficiaries would be selected among those who had availed services in the six months prior to the survey, but to achieve the desired sample this could not be adhered to. It was further plan to include 40 percent (96 cases) institutional deliveries and 60 percent (144 cases) home deliveries from the study districts. From each of the study block, 40 JSY beneficiaries were planned to be interviewed. However, in Himachal Pradesh due to non-availability of JSY beneficiaries in the four blocks of Mashobara, Sunni, Amb, and Tissa fewer than 40 cases could be interviewed. To compensate for this, in Gagret and Pukhari block 46 and 51 JSY beneficiaries were interviewed respectively. List of JSY beneficiaries was availed from PHC and SC to select the name of the beneficiary. Given the number of JSY beneficiaries in each of the list, almost all were approached if available for the interview. ANMs and Anganwadi workers at times helped in locating the respondent. Given the nature of settlement pattern and geographical terrain of the area this was essential. Other stakeholders: In addition to quantitative survey of JSY beneficiaries, other people including state and district programme managers, blocklevel providers, nodal officers, Chief Medical Officers, State and District Accounts Manager, ANMs, PRIs, CBOs, and community members were also interviewed. In Himachal Pradesh, Mission Director, NRHM, an Officer on special duty, Table 1.1: Sample covered for qualitative component in Himachal Pradesh Type of stakeholders Number of stakeholders interviewed Qualitative study State officials 1 District level officers 7 Block level provider 10 PRI/NGO/SHGs 17 ANMs 58 Community members 15 Quantitative survey JSY Beneficiaries 237 Anganwadi workers 150 Directorate of Health Services and State nodal officer were interviewed by the GTZ representative. Specific questions related to the implementation of the scheme, processes involved and challenges faced were addressed to them. The state Nodal Officer 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, and 4

22 Introduction steps required for future improvement of the scheme. Again, at block level, Block Medical Officer of Health, members of Panchayati Raj Institutions, NGOs, self-help groups, CBOs, and ANMs were interviewed to assess the networking of ASHA its benefits and challenges. Community members: 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 the programmes, attitude, and utilization. In each of the study block, four key informants, two males and two females, were interviewed in-depth regarding various aspects of the scheme. 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. After the fieldwork in the first state of Rajasthan (done in collaboration with the UNFPA), based on the responses from Rajasthan, several open-ended questions were modified to close ended questions. Probing questions related to home deliveries were added for the states of Himachal Pradesh and West Bengal after the fieldwork in Assam was completed. 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, and community perceptions about JSY. Field Operations Experienced Field Manager and Field Coordinators from social sciences coordinated the entire fieldwork. Fourteen field investigators, males and females were trained at Shimla for six 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 conducted at site ensured consistency in the data thereby ensuring quality, validity and reliability. Fieldwork in Himachal Pradesh was carried out during March 10 th 2007 to April 15 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. 5

23 Centre for Operations Research and Training, Vadodara 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. Presentation of the Report The report has five main chapters, apart from Preface and Executive Summary. The present one 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 Himachal Pradesh. AWW 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 Himachal Pradesh The features and implementation of ASHA intervention and Janani Suraksha Yojana (JSY) are discussed in this chapter. It includes an 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 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 conducted with the Mission Director NRHM and an Officer on Special Duty, Directorate of Health Services, NRHM at the state level. Besides, at the district level, Chief Medical Officers cum Nodal Officer and Chief Medical Officers, Finance Officers (FOs), Block Medical Officer (BMO), Block Mo Finance of the three districts were interviewed to understand the implementation of JSY. State Scenario According to the National Family Health Survey (NFHS) 3, in 2006, in Himachal Pradesh 45 percent of births took place in health facilities as opposed to 29 percent during , while 61 percent of deliveries took place in the women s own and 10 percent in their parents homes. In rural areas, only 25 percent of the total deliveries took place in health institution. Though Himachal Pradesh is categorizing as a high performing state, the proportion of institutional Table 2.1: Number of JSY beneficiaries by place of delivery from service statistics in Himachal Pradesh up to March, 2007 Number of deliveries (April 06 Feb 07) Home Institutional deliveries delivery Total beneficiaries Percentage institution delivery Total number of 4185 JSY beneficiaries in Himachal Pradesh Chamba NA NA 596 NA Shimla Una NA : Not available deliveries among women from households with a low standard of living is only 14 percent. (Standard of living was measured through possession of durable goods in the household. In a range of 0 to 67 as the maximum score, those scoring 14 or below have been considered as low standard of living index.) NFHS-2 also reveals that amongst other backward class, only 20 percent of the deliveries took place in health facilities. As per the service statistics, during April 06 to February 07, only 16 percent of the deliveries among JSY beneficiaries were institutional deliveries. The Government of India has recently sanctioned the ASHA intervention for the state of Himachal Pradesh. Thereby, the Project Implementation Plan was prepared including the ASHA intervention and was approved by the GOI on 15 th November