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

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

PREFACE JSY, Janani Suraksha Yojana, is an integral component of the National Rural Health Mission, launched in April 2005. 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 Bihar, the United Nations Children s Fund (UNICEF) commissioned 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 JBSY (Janani Avam Bal Suraksha Yojana in Bihar) in three districts of Bihar, namely Gopalgunj, Jamui and Samastipur. The districts were chosen based on the various levels of performance in consultation with the State Health Society, Bihar. The present report documents the process of implementation of the ASHA intervention and JBSY, involvement of ASHA s, and services and payments received by the JBSY beneficiaries, and highlights program implications that need to be addressed in order to further improve JBSY. 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. At the outset, we take this opportunity to thank the UNICEF for having entrusted the work of conducting the assessment to CORT. Our sincere thanks are due to Dr. James Patterson, Project Officer Child Survival, UNICEF for the cooperation extended to us during the various stages of the study. We appreciate his inputs in helping us in administering the study in the field and analysis. We also appreciate and thank Dr. Sherin Varkey, and Dr. Samaresh SenGupta, Project Officers from the UNICEF office in Patna for all the support extended. We are also 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, Assistant Commissioner (Trg.) and Dr. K. P. Ramaiah, IAS, Executive Director NRHM, Bihar, Dr. Mona Gupta, State Programme Manager-cum-State Nodal Officer-ASHA, Dr. Varsha Singh, State Nodal Officer-JSBY and CMOs of the selected districts and Managers of DPMU for all the support extended by them. We thank our respondents officers at the district and block levels, trainers of ASHAs, PRI/NGO/SHGs/AWW, ANMs, community members, ASHAs 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

CONTENTS Executive Summary... i-vi Chapter 1: Introduction The background... 1 Objectives of the study... 2 Study design... 3 Study area... 3 The Sample... 3 Interviews of ASHAs... 4 Interviews of beneficiaries of JBSY... 4 Other stakeholders... 4 Community members... 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 JBSY in Bihar Project implementation... 7 Selection and recruitment of ASHAs... 7 Training of ASHAs... 9 Functioning of ASHAs... 10 Involvement of PRIs... 11 Working with ANM/AWW... 12 Accrediting of private institutions... 12 Compensation package... 13 Adoption of Jajani avam Bal Suraksha Yojana (JBSY)... 13 Propagation of the JBSY... 14 Cash assistance... 15 Monitoring of JBSY... 16 Challenges... 17 Chapter 3: Engagement of ASHA in the National Programmes Background characteristics of ASHA... 19 About ASHA: Their selection and motivation to work... 21 Training of ASHAs... 21 Quality of training... 22 Use of reading materials... 23 Knowledge of ASHAs... 23 Antenatal and child care services... 23 Pregnancy, delivery complications and action/s... 24 Knowledge about newborn care... 25 Knowledge about tasks to be performed by ASHAs... 25 Organization of work by ASHAs... 26

Care for pregnant woman... 27 Availability and utilization of drug kits... 27 ASHAs clientele... 27 Cash remuneration received by ASHAs... 28 Monitoring system... 29 Support mechanisms and networking of ASHAs... 29 PRIs... 30 ANM... 32 Anganwadi workers... 33 Community perception... 34 Strengthening of ASHA intervention as perceived by ASHA... 34 Chapter 4: Beneficiaries of JBSY in Bihar Background information of JBSY beneficiaries... 37 Awareness about JBSY... 38 Process of registration under JBSY... 38 Utilization of ANC services by JBSY beneficiaries... 39 Role of ASHA in micro-birth planning... 41 Intention versus actual place of delivery... 41 Impact of JBSY on institutional delivery... 42 Motivation and decision making for institutional delivery... 42 Process of arranging transport... 42 Difficulties faced in reaching the place of delivery... 44 Persons accompanying JBSY beneficiaries to the health institution... 44 Quality of services available at the place of delivery... 45 Payments incurred for services at the health centre... 45 Satisfaction with the services at the place of delivery... 46 Views about TBA... 46 Child mortality... 47 Dynamics of delivery at home... 47 Mode of payment and difficulties faced... 48 Use of cash assistance received for delivery... 49 Appreciation of JBSY by the beneficiaries... 49 Role of ASHAs in helping JBSY beneficiaries... 49 Complications during delivery... 50 Chapter 5: Policy and Programme Implications Programme management... 51 ASHA intervention... 51 Recommendations... 52 Policy... 53 Programme management... 53 Demand generation... 54 Appendix: Tables based on background characteristics of the JBSY beneficiaries... 55-65

LIST OF TABLES Table 1.1: Sample covered for qualitative and quantitative survey in Bihar... 4 Table 2.1: Status of ASHA training as on June, 2007... 10 Table 2.2: Cash assistance package for JBSY beneficiaries in Bihar, 2007... 15 Table 3.1: Profile of ASHA worker in Bihar, 2007... 20 Table 3.2: Duration of work and earning of ASHA in Bihar, 2007... 20 Table 3.3: Motivation for being an ASHA in Bihar, 2007... 21 Table 3.4: Topics covered in the training of ASHA in Bihar, 2007... 22 Table 3.5: Teaching aids used for training of ASHAs in Bihar, 2007... 22 Table 3.6: Payments received during training by ASHA in Bihar, 2007... 23 Table 3.7: Knowledge of ASHAs about complications during pregnancy & delivery and their management, Bihar, 2007... 24 Table 3.8: Knowledge about likelihood of neonates dying after birth in Bihar, 2007... 25 Table 3.9: Feeling of working as ASHA in Bihar, 2007... 26 Table 3.10: Brief details of ASHAs interaction with her last client in Bihar, 2007... 27 Table 3.11: Details of ASHAs when last accompanied women for delivery in Bihar, 2007... 28 Table 3.12: Cash remuneration received by ASHA in Bihar, 2007... 28 Table 3.13: Networking of ASHA with other stakeholders in Bihar, 2007... 30 Table 3.14: Suggestions for further strengthening their work as ASHAs in Bihar, 2007... 34 Table 3.15: Difficulties and challenges faced by ASHA in carrying out the activities in Bihar, 2007... 35 Table 4.1: Background information of JBSY beneficiaries in Bihar, 2007... 37 Table 4.2: Source and type of information heard about JBSY in Bihar, 2007... 38 Table 4.3: Process of registration in Bihar, 2007... 39 Table 4.4: Contact with health personnel during index pregnancy, Bihar, 2007... 39 Table 4.5: Frequency of antenatal check-ups during index pregnancy, Bihar, 2007.. 40 Table 4.6: Cost incurred for ANC visits, Bihar, 2007... 40 Table 4.7: Role of ASHA to JBSY beneficiaries during index delivery in Bihar, 2007... 41 Table 4.8: Intention and actual place of delivery among JBSY beneficiaries in Bihar, 2007... 41 Table 4.9 Motivation for institution delivery among JBSY beneficiaries who had institution delivery, Bihar, 2007... 42 Table 4.10: Process of arranging transport to reach health institution, Bihar, 2007... 43 Table 4.11: Duration of time to arrange transport and travel to place of delivery, Bihar, 2007... 43

Table 4.12: Persons accompanying JBSY beneficiaries to the health institution, Bihar, 2007... 44 Table 4.13: Quality of services available at the place of delivery, Bihar, 2007... 45 Table 4.14: Payments made for services at the health centre, Bihar, 2007... 45 Table 4.15: Satisfaction with the services at the place of delivery, Bihar, 2007... 46 Table 4.16: Views about TBA, Bihar, 2007... 46 Table 4.17: Perceived reasons for women to deliver at home despite cash assistance being paid under JBSY for institutional delivery, Bihar, 2007... 47 Table 4.18: Payment made to JBSY beneficiaries in Bihar, 2007... 48

LIST OF FIGURES Figure 3.1 : Scoring knowledge of ASHAs in Bihar... 23 Figure 3.2 : ASHAs awareness about her responsibilities... 25 Figure 3.3 : Networking of ASHA with stakeholders... 29 Figure 4.1 : Time when the beneficiary heard about the JBSY... 38 Figure 4.2 : Sufficiency of cash incentives as perceived by JBSY beneficiary... 48 Figure 4.3 : Role of ASHAs in helping JBSY beneficiaries... 49

EXECUTIVE SUMMARY Janani Suraksha Yojana was launched in April 2005 to promote institutional deliveries particularly among the below poverty line population through provision of referral, transport and escort services for achieving the objectives of the National Rural Health Mission (NRHM). 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 village-based 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 (renamed as JBSY- Janani avam Bal Suraksha Yojana in Bihar) and ASHA component. The Centre for Operations Research and Training, CORT, based at Vadodara conducted this assessment of the JBSY for UNICEF and the MoHFW to understand the process of implementation of the programme, involvement of ASHAs and experiences of JBSY beneficiaries. This report is based on the qualitative and quantitative assessment of JBSY in Bihar covering three districts of Gopalganj, Jamui, Samastipur. Using semi-structured study tools, 183 ASHAs and 241 JBSY beneficiaries were interviewed through a quantitative survey. In-depth interviews were conducted with key persons associated with the implementation of JBSY. Implementation of ASHA Intervention and JBSY As per the national guidelines, with 15 percent institutional deliveries according to NFHS-2, Bihar is categorized as a low performing state. The implementation of the ASHA intervention is taking place all over the state covering 40 percent of the ASHAs from all the districts first and the remaining 60 percent subsequently. Around 74,313 ASHAs, one for every 1,000 population, are required. By June 2007, all the districts were covered, 83 percent of the required number of ASHAs was selected and 60 percent (73 percent of the selected) were trained. At the state level, the State Health Society (SHS, Bihar) administers the programme. At the district level, District Health Society (DHS) implemented the trainings and programme activities, monitored the selection process and programme. At the village level, ANMs, AWWs and ASHAs worked together to provide ANC and PNC services. ASHAs are paid performance-based payment of Rs. 600 under JBSY by the ANM and PRI. Besides, they are paid under the respective national programme as per the services provided by them including immunization, pulse polio, family planning, management of tuberculosis and filaria, and conducting community meetings. The CMO and BMO in-charge are responsible for JBSY intervention at district and block

Centre for Operations Research and Training, Vadodara level respectively. The schemes were publicized through print and electronic media; however, the messages have not reached the target population. Panchayat, ANMs, AWWs and ASHAs worked for creating awareness about the scheme. All women delivering in Government health centres like sub-centres, PHC, CHC, FRU and general wards of District and state hospitals or accredited private institutions were eligible for getting JBSY 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. 500. Untied fund of Rs. 10,000 were mainly managed by the MOIC and ANMs, while PRIs were yet not involved in managing this funds. Monitoring and supervision is planned at all levels, with DHSs playing a key role. Yet, there is a need to develop a simple and sustainable monitoring system like reviewing performance on ASHA Diwas. ASHA Diwas is when around 100 ASHAs would meet at the PHC along with key stake holders to discuss the performance, collect payment and get guidance/ appreciation. Involvement of ASHA in JBSY The ASHAs interviewed were around 29.6 years of age on average and had 9.5 years of schooling. Seventy percent of the ASHAs belonged to scheduled caste or other backward classes. Of the 183 ASHAs interviewed, 17 percent did not fulfill one or the other eligibility criteria. Before JBSY, 75 percent of the ASHAs had themselves opted to deliver their child at home. On average, the respondents worked as ASHA for 10.2 months. The study reveals that 20 percent of the ASHAs did not receive any payment until the date of survey. On average, ASHAs who were paid received only Rs. 143.3 monthly from working as ASHA. Fifty-three percent of the respondents first came to know about the ASHA from Gram panchayat, 12 percent from pamphlets or hoardings at SC/PHC/CHC and11 percent from ANM. Other sources included radio, anganwadi worker, government doctor, private doctor, NGO, health personnel, trainers during training, family members/ husband/ relatives/ village people. Gram sabha, ANMs and political leaders played a major role in selection of ASHAs and approving their names. The main motivation for being an ASHA was to earn money (78 percent), serve the community (74 percent), save children (58 percent) and remove misconception (10 percent). In Bihar, the induction training of ASHAs was done for 7 days mainly conducted at PHCs and schools. Accommodation, food arrangements, size of rooms and sitting arrangements need to be further improved. However, ASHAs appreciated the training sessions, trainers and training methods as good and useful. All the ASHAs received their allowances for training, and on average, they got Rs. 987. Ninety-two percent of the ASHAs received reading materials/guidelines while 76 percent of them were largely able to follow the materials. Fifty-three percent of the ASHAs scored Grade A or O for answering 8-10 out of 10 questions correctly. ii

Executive Summary Majority of the ASHAs knew about Scoring knowledge of ASHAs in complications during pregnancy such as Bihar swelling of hands and feet, vomiting, body pain/backache, while one-third mentioned Grade A 43% about abdominal pain, anaemia, and weak or no foetal movement. ASHAs also knew about Grade 'O' 10% feeling uneasy, visual disturbance, convulsion, excessive bleeding, fever and abnormal position of foetus. In such Grade C situations, 75 percent ASHAs said that they 17% Grade B would immediately refer the pregnant 30% woman to the nearest functional FRU, while 49 percent said that they would ask the pregnant woman to consult the ANM the next day. Only nine percent would actually take her to the nearest functional FRU. As for newborn care, 53 percent of the ASHAs said that newborns are most likely to die soon after birth, while 15 percent ASHAs did not know when newborns are most likely to die. Their knowledge about specifics of child immunization and schedule needs to be strengthened in the next round of training. ASHAs mentioned that their main responsibilities were to support the immunization programme (60 percent), create awareness on health (55 percent), accompany delivery cases (44 percent), motivate and mobilize community (43 percent) and motivating and mobilizing community. ASHAs also mentioned about registration of birth and death, family planning, creating awareness regarding basic sanitation and hygiene, providing ANC care, counseling and promote good health practices among others as their responsibilities. ASHAs visited house to house (96 percent), besides accompanying women for delivery, attending immunization session, accompanying ANM and organizing health days. It is encouraging to know that ASHAs provided constellation of services and played a potential role in providing primary medical care as their last client came seeking advice or services related to place of delivery, immunization, ANC care, receiving IFA tablets and collecting basic medicines. Eighty percent of the ASHAs had accompanied at least one JBSY case for institutional delivery, and on an average they had accompanied 5.3 such cases mainly to PHC. ASHA accompanied the last case around 23 days ago and most of them stayed with JBSY beneficiaries at the place of delivery. ASHAs network with the various stakeholders in the village to implement JBSY. Almost all ASHAs met ANMs, majority (86 87 percent) met PHC staff and AWW, while 30 34 percent met block facilitators, and PRI members. They also met NGO staff, village mandals and SHG members. Eighty-five percent of the ASHAs received some incentive money, mainly for attending JBSY beneficiaries (83 percent), immunization of children (59 percent) and family planning (17 percent). The mean monthly amount received for attending JBSY iii

Centre for Operations Research and Training, Vadodara beneficiary in three months varied between Rs. 235 525 (ranging between 100-4800) and for immunization of children between Rs. 244 283 (ranging between 10-900). Fifty-five percent of the ASHAs were satisfied with the cash incentives mainly because they got some money. Besides, ASHAs appreciated that they were able to learn many new things while serving the community. Forty percent ASHAs were unsatisfied with the cash assistance as it was too much work and too little money (33 percent), or because of no/delayed payment (26 percent). ASHAs spent on average 2.9 hours every week in preparing various registers while their work was mostly monitored by the ANMs and MO PHC. Nearly 61 percent of ASHAs submitted records to ANMs or MO PHC every month. Supervisory support from other officials was lacking. Beneficiaries of JBSY in Bihar The JBSY beneficiaries were young (mean age, 24.8) and mostly those who had no schooling (70 percent) or had schooling up to primary and middle level (12 percent). Twenty-nine percent of the JBSY beneficiaries belonged to SC/SC and 60 percent to the other backward classes. The average monthly family income of the JBSY beneficiaries is only Rs. 2239.8. It can be said that JBSY reached to the socioeconomically lower strata women covering poor segment of the society, as at least 80 percent of the JBSY beneficiaries earned less than Rs. 2,500/- per month. The beneficiaries learnt about JBSY during (75 percent) or before (21 percent) pregnancy, however, 4 percent learnt about the scheme only after delivery. Nearly 62 percent of the beneficiaries got registered in the first or second trimester, and on average, women had 2.6 antenatal check-ups during their index (JBSY) pregnancy. Husbands (47 percent), mother-in-law (41 percent), ASHAs (34 percent) and mothers (16 percent) accompanied the beneficiary for ANC visit(s). Sixty-one percent of the women received antenatal care at PHC and 8 percent at sub-centre. One-sixth of the women availed antenatal services from private hospital. Only one-third of JBSY beneficiary received advice about diet, 20-27 percent about delivery care, breast-feeding and newborn care, but advice regarding danger signs and family planning was mentioned by only 8 and 15 percent respectively. Nineteen percent of the beneficiaries were told about four or more aspects (out of 5) of microbirth planning including date of next check-up, place of next check-up, place of delivery, date of expected delivery, and place of referral, if complications arise. Of the total JBSY beneficiaries interviewed, fourteen percent women intended to deliver at home but delivered institutionally. In Bihar, the study team did not find any case of home delivery. Institutional deliveries mainly took place in PHC (93 percent). Motivating factors among all the beneficiaries who opted institutional deliveries were money available under JBSY (87 percent), better facilities for delivery (52 percent), safety of child (32 percent), and support received from health personnel (18 percent). iv

Executive Summary Out of the 171 JBSY beneficiaries who had two or more children, 19 percent delivered last but one baby at the institution while 81 percent preferred home delivery. Nevertheless, between two deliveries, all of these beneficiaries shifted from home to institution due to cash assistance available and better facilities at the institution. It shall be pointed out here that at the state level, as per the services statistics for April 06 March 07, institutional deliveries are increasing. The demand for institutional delivery calls for upgrading of the public health infrastructure to provide quality care, especially in the context of sub-centres and PHCs. In Bihar, JBSY beneficiaries were asked details about the distance traveled, mode of travel and average time taken in arranging for the transport, traveling to the institution, and time taken after reaching the institution. The study reveals that the beneficiaries had to travel an average of 5.1 kms to reach the ultimate place of delivery. Women spent above one hour to arrange transport and reach the ultimate place of delivery and another 43 minutes on average after reaching the institution on registration and administrative processes as well as waiting time until someone attend to them. Ten percent of the JBSY beneficiaries did not receive their cash assistance, while remaining who received cash got payment in one go before (11 percent) or within a week (64 percent) after the delivery) from the accountant, ANM, or CHC/PHC MO. The JBSY beneficiaries spent an average of Rs. 427.6 during ANC period, Rs. 185.6 for transportation to the place of delivery and Rs. 508.5 for delivery, against which they received an average of Rs. 1339 from the government as cash assistance. The study evidently shows that among those who had difficulty in reaching the health institution, 62 percent did not have sufficient money. Moreover, 17 percent of the JBSY beneficiaries felt that the cash assistance received was not sufficient. It is encouraging that ASHAs (86 percent), mothers-in-law (52 percent), husbands (47 percent), other family members (39 percent), and mothers (18 percent) accompanied the women for delivery. On average, after normal delivery (n=226) women were discharged within 13 hours, for assisted delivery (n=14) after 20 hours and for caesarean (n=1) after 3 days. Most of the women were satisfied with JBSY and would recommend relatives or friends/neighbours (98 percent) to benefit from it, mainly because of money received, safe delivery, poor women receive help, and free or subsidized cost of delivery. On the success side, the process of programme implementation such as selection and training of ASHAs has progressed and should be completed as per plan, with involvement of other parallel departments - PRI and ICDS. The state needs to nurture and further intensify this network. In Bihar, ASHAs are enthusiastic and motivated to serve the community, save children and earn some money. They learnt new things, moved out of the village and met many people. ASHAs were able to generate demand and mobilize clients for availing antenatal services to some extent. The process has just started and need to be further strengthened. Interviewing 241 JBSY beneficiaries v

Centre for Operations Research and Training, Vadodara showed that ASHAs informed them about JBSY (85 percent), contacted them first (73 percent), registered for JBSY (61 percent), motivated them to go for antenatal checkup (77 percent), advised during pregnancy, explained benefits of institutional deliveries. Thirty-nine percent of all interviewed beneficiaries said that it was actually the ASHA who decided to go for institutional delivery on behalf of the JBSY beneficiary, while 49 percent of ASHAs arranged for transport and 34 percent accompanied women to the health institution. It can be said that JBSY has shown impact in Bihar and ASHAs have started functioning enthusiastically. However, the readiness of the facilities and quality of care offered particularly at PHC and sub-centres needs to be improved to provide services for normal deliveries. The state needs to ensure that cash assistance due to the poor women is paid on time and the process of payment need to be simple. vi

CHAPTER 1 INTRODUCTION Background The Government of India launched the National Rural Health Mission (NRHM), in 2005. 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 were 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 were 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 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, 2005. The scheme aims to promote institutional deliveries among pregnant women living 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 would need to be escorted to an institution, would need transport to reach the institution and in case of complications, referral services are required. The scheme has considered all these elements and has made provision for transport including

Centre for Operations Research and Training, Vadodara 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 publicprivate 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 low institutional delivery rates (<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 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 Bihar and Uttar Pradesh, MOHFW sought the assistance of UNICEF. UNICEF, India commissioned the study to a professional research agency Centre for Operations Research and Training (CORT) based in Vadodara, Gujarat. This report is based on the fieldwork in Bihar, where JSY is popularly known as Janani avam Bal Suraksha Yojana (JBSY). Objectives of the Study The common objectives for ASHA and JBSY 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

Introduction For JBSY, specific objectives were as under: 1. Assess adequacy and simplicity of the processes set out by the state for claiming benefits under JBSY. 2. Examine the utilization of JBSY and analyze factors influencing/impeding utilization. 3. Review engagement of private sector including accreditation and compensation. 4. Analyzed decision making processes to identify key factors in choosing home delivery over institutional delivery as a JBSY beneficiary. 5. Analyze nature and scope of IEC interventions for raising awareness of JBSY. Study Design The assessment of ASHA and JBSY was based on a combination of quantitative and qualitative techniques. The study covered three districts of Bihar selected on the basis of performance of the district based on the number of JBSY beneficiaries and the number of ASHAs trained and in action. It represented good, average and poor performing districts. The Mission Director, NRHM from the Department of Health and Family Welfare in Bihar provided data regarding the number of JBSY beneficiaries in each district. The selection of the district was discussed and finalized with the State officials. Likewise, procedure of district-level consultation and secondary data review was undertaken by CORT in each of the district to select the two blocks. Thus, in all six blocks from three districts were covered in Bihar. Study Area This report is based on the assessment study conducted in Gopalgunj, Jamui, and Samastipur districts. The Sample The sample covered in the state included beneficiaries of JBSY. Several people associated with the scheme such as state and district programme managers, blocklevel providers, 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

Centre for Operations Research and Training, Vadodara Interviews of ASHAs: From each of the six study blocks, 30 ASHAs fulfilling the selection criteria were interviewed. To cover 30 ASHAs, 30 villages were visited, which included one CHC village, 2 PHC villages; nine sub-centre villages (3 SCs within each selected PHC/CHC), and 18 remote villages (2 remote villages from each of the selected sub centre). In all, 183 ASHAs who had undergone first round of training and had been active in the six months prior to the survey were interviewed in the state. Interviews of beneficiaries of JBSY: Altogether, 241 JBSY 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 JBSY beneficiaries were interviewed. List of JBSY beneficiaries was obtained from PHC and SC to select the beneficiary. ANMs and Anganwadi workers at times helped in locating the respondent, as the women were residing in inaccessible parts and were difficult to locate. Other stakeholders: In addition to quantitative survey of JBSY beneficiaries, officials including NRHM Mission Director, State Nodal Officers (JBSY and ASHA), state and district programme managers, block-level providers, State and District Accounts Manager, ANMs, PRIs, CBOs, AWWs and community members were also interviewed. In Bihar, Mission Director, NRHM, and State nodal officer were interviewed Table 1.1: Sample covered for qualitative and quantitative components in Bihar Type of stakeholders Number of stakeholders interviewed Qualitative study State Officials 3 District level officers 5 Block level provider 17 Trainers of ASHA 12 PRI/NGO/SHGs/AWW 16 ANMs 30 Community members 24 Quantitative survey ASHA functionaries 181 JBSY Beneficiaries 240 and were asked specific questions related to the implementation of the scheme, involvement of key people, processes involved and challenges faced. 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. Besides, five district officials and seventeen block development officers were interviewed about the utilization of the scheme, and steps required for future improvement of the scheme. Again, at block level, Block Medical Officer of Health, Block Accounts Manager, members of panchayati raj institutions, NGOs, self-help groups, CBOs, ANMs and AWWs were interviewed to assess their role in promoting JBSY. Community members: Awareness and understanding of the scheme at the community level is important to enhance utilization of the scheme. Community members informants, both male and female, in each district were asked about their awareness of JBSY, 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. 4

Introduction Study Tool The study tools were used by CORT in earlier assessments done in six states for UNFPA and GTZ. These were developed by CORT in collaboration with the professionals from UNFPA, Ministry of Health and Family Welfare, and GTZ. 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 JBSY. Field Operations Experienced Field Manager and Field Coordinators from social sciences coordinated the entire fieldwork in Bihar. Fourteen field investigators, males and females, were trained at Patna in Bihar for 4 days to conduct the fieldwork. At the grassroots level, female field investigators interviewed JBSY beneficiaries. Supervisors checked the selection of the eligible sample and ensured that the questionnaires were filled accurately and completely. UNICEF 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 Bihar was carried out during May 28 th 2007 to June 22 nd 2007. Ethical Considerations MOHFW and UNICEF had informed the authorities of the selected states, districts and blocks about the study and the need to share the information about ASHAs and JBSY 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. 5

Centre for Operations Research and Training, Vadodara Presentation of the Report The report has five chapters; the present one gives a brief introduction and the study design for assessment. Chapter 2 elucidates programme inputs and processes adopted in implementation of the scheme in the state of Bihar. ASHA s profile, selection, training, knowledge about different aspects of reproductive and child health and other related issues are discussed in Chapter 3. Utilization of JBSY by the beneficiaries, their views about the scheme and suggestions, which are the critical inputs for the programme are discussed in Chapter 4. The last Chapter 5 is on programmatic interventions for enhancing ASHA intervention and JBSY. 6

CHAPTER 2 OPERATIONALIZATION OF ASHA INTERVENTION AND JBSY IN BIHAR The Ministry of Health and Family Welfare has prepared a guideline to implement the ASHA intervention. The national ASHA guideline covers various elements and includes institutional mechanisms, selection and training of ASHAs, roles and responsibilities of ASHA, work arrangements and linkages with Anganwadi workers and ANMs, compensation to ASHA, fund-flow mechanism and monitoring and evaluation. The following paragraphs briefly discuss each of these components. Moreover, implementation of the Janani avam Bal Suraksha Yojana (JBSY) in Bihar is also presented. Project Implementation The State Health Society, Bihar (SHS, B) is implementing the NRHM in the state of Bihar and District Health Societies (DHS) are being set up at district level to implement the programme at district level. The State Health Society provides technical support to the DoHFW in monitoring the implementation of ASHA intervention. The district nodal officer provides monitoring and supervisory support to the District Health Officer (DHO). The DHSs through the block medical officers and other supervisory staff provide support and report on routine basis to the SHS, Bihar. Besides, the state envisaged to make contractual engagement of skilled professionals including private doctors, Chartered Accountants, MBA & MIS Specialist at State and District levels for enhancing capabilities of Programme Management and technical support to the NRHM well before the start of the Programme implementation. It is envisaged that at the block level, the Block Medical Officer will be the overall incharge of ASHA related activities. The Block Officer would be assisted by Block Facilitators (one for every 10 ASHAs). The Block Facilitators would provide feedback on the functioning of ASHAs to the BMO & Block level organizers and shall visit the villages regularly. As per a state official, block facilitators were not yet involved in the programme or in the selection of ASHAs. Thereby, at the time of the survey there were no ASHA facilitators in the state. Selection and Recruitment of ASHAs One of the key components of the National Rural Health Mission is to provide every village in the country with a trained female Accredited Social Health Activist (ASHA). They have been selected from the village itself and are accountable to the village head. ASHA must primarily be a woman resident of the village married/widowed/ divorced, preferably in the age group of 25 to 45 years and literate woman with formal education up to class eight. According to the State Nodal Officer, the state strategically decided to give preference to widows and trained dai as ASHAs. CMOs, and PHC Medical Officers also mentioned about giving preference to widows

Centre for Operations Research and Training, Vadodara The state adapted the national ASHA guidelines and adhered to it. It was estimated that around 74,313 ASHAs were to be selected as per the national norms of covering 1,000 population per ASHA to cover the entire state of Bihar. The state has decided not to implement the ASHA intervention phase-wise, but aimed to select around 65,000 (88 percent) ASHAs and give them induction training of module 1 by March 2008. Thereby, all the districts have been covered until now and out of the required 74,313 ASHAs, 61,309 have been selected and 44,513 ASHAs have been trained so far. A state officer said, We have not done any phasing but we have taken it as a goal to select and train about 90 percent of the required number of ASHAs by March 2008. Training modules are ready, and we have to complete this process of training by this date. Around 44,000 ASHAs have undergone the orientation training and all 38 districts have been covered. Another state official said, GOI proposed for phasing of the activities, bu t we felt it difficult to do so in Biha r, as there will be political pressure from local leaders to have ASHAs selection and training done in their districts first. So we thought that we will go for the entire state, and complete the coverage in two years 40 percent ASHAs in first year and 60 percent in second year. Further, the Civil Surgeons briefed the Medical Officers In-charge in a meeting about ASHA, the concept and the way she should be selected. Accordingly, MOIC visited the villages along with ANMs and LHVs, discussed with the villagers and village leader (Mukhiya) about the role of ASHAs. They also discussed that ASHAs should be a person with social services inclination and not only a job-oriented person. Mukhiyas, in consultation with ASHA and Gram Sabha, proposed and selected ASHAs for their respective village. Forty percent of the ASHAs were expected to be in position in the first year of project implementation. Therefore, selection process was initiated without any delay for these placements. Accordingly, in first year, the state selected around 32,000 ASHAs against the target of around 30,000 ASHAs to be selected. However, later, due to Panchayat elections and pulse polio drive, the state is lagging behind in the selection of ASHAs as per the state plan. A nodal officer said, We still have time to catch-up, so we will be able to fulfill our targe t by the end of this financial year. To expedite the process of selection of ASHAs, the state advertised in the newspapers asking the Mukhiyas to initiate the selection process. The state received ASHA guidelines and circulated it to the District Magistrates, Civil Surgeons and secretary of District Health Society. They were to reprint and circulate it to further to all the Mukhiyas in their respective district, and Civil surgeons shared it at the PHC and CHC level. The ASHA guidelines specified the role of DHS, a Nodal Officer, block officials, ICDS officials, gram sabha, village panchayat, trainers in the selection of ASHAs. In 8

Operationalization of ASHA Intervention and JBSY in Bihar Bihar, ICDS officials, Panchayati Raj Institution, gram sabha, and voluntary organizations were involved in the selection of ASHAs. ASHAs were chosen through a rigorous process of selection involving ANMs, community groups, self-help groups, Anganwadi workers, the Block officer, District Nodal officer, and the Gram Sabha. As per a nodal officer, all the stakeholders gave their advice for seconding name of ASHA. Explaining the selection process, he said, ANMs, LHV s, panchayat members, mukhiya and NGO staff members looked into the names of potential candidate s for ASHA work. They suggested the name to the Gram Sabhas that selected and approved it in consultation wit h the MOIC at the PHC. Training of ASHAs The state officials were oriented about the ASHA component of NRHM during the training of trainers that was organized at Patna for all the state trainers and officials of State Health Society, Bihar. The state trainers were from ICDS institution, Senior Medical Officers, and NGO representatives who were trained at the National Institute of Health and Family Welfare (NIHFW) for one day in November 2006. The district trainers including personnel from Red Cross, CDPOs from ICDS, Public Relations Officer at district level, and doctors were trained at the state level in five days training. Currently, district training teams comprising of 163 district level trainers are in position in all the 38 districts of Bihar. Besides, 1,810 Block Level Trainers have been trained and are involved in training ASHAs. A nodal officer said, We faced problems in constituting the team of trainers from various departments education, ICDS, and other department. Ultimately it is the health department to conduct training and carry out all the other related activities. The convergence that we have been talking about is not that easy. There were some problems in motivating people from other departments to attend training that is for the health department. People from other departments reluctantly attended the training. Several of them, being overloaded with work from their own department, initially gave training to ASHAs, but did not continue thereafter. It took some time to print the modules. Initially, there was no time lag between the selection of ASHAs and their training. But, because of Panchayat elections and pulse polio drive, only 44,513 ASHAs could be trained instead of 65,000 ASHAs and the state is lagging behind in training around 20,000 ASHAs. ASHAs were trained in a batch of 30s mainly at PHC. As the first training was for orientation, more focus was to make ASHAs understand their roles and make them aware about the health and hygiene issues. The reading materials for ASHAs have been widely circulated to each of the 38 districts in Bihar. A state official suggested that there need to be more field orientations and imparting in-depth knowledge about the subject in subsequent rounds of training. The state training coordinator agreed that the quality of training and logistic arrangements could be further improved. ASHAs underwent training to work as an interface between the community and the public health system. They 9

Centre for Operations Research and Training, Vadodara would further undergo a series of trainings to attain the necessary knowledge, skills and confidence for performing the roles envisaged from them. Name of the selected district Number of ASHAs to be selected Table 2.1: Status of ASHA training as on June, 07 Number of District Level Trainers trained Number of Block Level Trainers trained Numbers of ASHAs selected till now Number of ASHAs trained Percent target achieved Samastipur 3,271 5 92 2,945 2,945 9 Gopalgunj 2,022 4 33 1,796 1,739 86.0 Jamui 1,296 5 53 1,050 518 4 Total 74,313 163 1810 61,309 44513 59.9 In the study districts of Samastipur, Gopalgunj and Jamui, selection of ASHAs as per requirement is not complete (see table 2.1). In Samastipur and Gopalgunj, 86-90 percent ASHAs were trained as against the target. Due to Panchayat elections, the districts could not complete training for all the selected ASHAs. In Jamui, approximately 1,050 ASHAs were selected out of 1,296 as per the requirement and only 40 percent of them were trained. According to the district official though there are no reported drop-out cases among ASHAs, there could be 5-10 percent drop-outs among ASHAs, as they expected to get good remuneration and a job. Functioning of ASHAs The main role of ASHA remains to be link between the health facilities and villagers and ASHAs are responsible to look after the health and hygiene of the entire village or the population covered by her. According to a state official, she has to be a confident woman of that village who is able to cater to the needs of women and children. She should have a drug kit and will act as a depot holder for essential provisions such as Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet (IFA), Chloroquine, Disposable Delivery Kits (DDK), Oral Pills & Condoms, etc. ASHAs should liaison with ANMs, Anganwadi workers, and PHC doctors, create awareness on health, and mobilize the community for increased utilization of the existing health services. ASHAs should promote good health, timely referrals, and provide information to the community on antenatal and natal care, micro-birth planning, and importance of safe delivery, breast-feeding, immunization, contraception, nutrition, basic sanitation & hygienic practices. Her main role would be to motivate and escort women to the institution for delivery. In many villages in Bihar, the ASHAs are working well with the ICDS. Sahayikas and Sevikas coordinate with ASHAs as well. A state official said, So far there was no person working for 1,000 population to provide services, but now at least we have the ASHAs available at the village level. The health facilities and village panchayats are propagating and disseminating the programme at the grass roots level. The cooperation and coordination depends on individual basis and their inter-personal skills. 10