Evaluation of Accredited Social Health Activist (ASHA) in

Andhra Pradesh

Commissionerate of Family Welfare GoAP, Hyderabad – 500 095

Indian Institute of Health and Family Welfare Vengalrao Nagar, Hyderabad – 500 038

February, 2009

ACKNOWLEDGEMENTS

The core strategy of the NRHM is to have a female Accredited Social Health Activist (ASHA) for every

village with a 1000 population to act as an interface between the community and the public health systems.

ASHA receives performance-based compensation for promoting a variety of primary health care services

for institutional deliveries, universal immunization, DOTS treatment for Tuberculosis etc.

The Government of Andhra Pradesh also incorporated the ASHA volunteer scheme in the Program

Implementation Plan (PIP) since 2005-06. The First Common Review Mission of NRHM (2007) adjudged

the quality of ASHA training and methodology as of very high standard. The Government of Andhra

Pradesh placed about 55,400 ASHA workers in the state as a first referral for any small ailments in the

villages. Andhra Pradesh was the first state which completed training of ASHA volunteers, and their

deployment in their respective villages. The present study is an attempt to review the training strategy,

evaluate the knowledge and practices of ASHAs, their work performance and to identify existing lacunae

and incorporate mid-term revision of the NRHM initiative.

We would like to thank Commissionerate of Family Welfare, Department of Medical, Health and Family

Welfare, Government of Andhra Pradesh for funding this study.

We sincerely acknowledge the studies of CORT (UNFPA) on ASHA and JSY in different states which

was a source of inspiration in the preparation of questionnaire and draft. Special thanks are due to Dr M.

Prakasamma, Director and Mr.G.S. Chowdhary, Training Coordinator, Academy of Nursing Studies,

Hyderabad, for their active interest in the project and for providing timely guidance as well as sharing their

views during preparation of questionnaire. We wish to express our thanks to Dr M. Srinivasa Rao,

Additional Director, Dr G. Srinivas Rao, Project Officer and Mr. B. Brahmanandam, Deputy Director

(Demography) of the Commissionerate of Family Welfare, Govt. A.P for offering useful comments to

finalize the survey instruments and their active participation in the dissemination workshop.

Special mention and thanks are due to Dr. N.V. Rajeswari, Dr. K. Anand Reddy and Mr. Ch.V.S.

Sitarama Rao, faculty IIHFW and Mrs. Prameela for sharing their views and enriching our knowledge on

the training and other aspects. We also extend our thanks to the investigators for completing field work in

record time.

We appreciate the immense help received from the computer staff (Mr. PSVN. Kumar, Mr. Mir Wajahat

Ali and Mr. K. Ravindra Babu, Mr. K. Santhosh and Mr. K. Vijay) in developing the software package

and carrying out data cleaning, data entry, data processing and preparation of tables. We thank our

respondents-officers at the district and PHC level, ANMs, community members, ASHAs and the JSY

beneficiaries for their cooperation.

AuthorsAuthorsAuthorsAuthors

CONTENTS

S.No. Topic Page

Chapter 1

1.1 Introduction 1

1.2 National Rural Health Mission 2

1.3 Need for the study 4

1.4 Objectives of the study 5

1.5 Presentation of the Report 5

Chapter 2 - Data and Study Design

2.1 Questionnaires

A. ASHA Questionnaire 6

B. Beneficiary questionnaire 7

2.2 Sample Design 8

2.3 Field work 9

2.4 Data Editing and Analysis 9

Chapter-3- Training Strategies of ASHA in Andhra Pradesh

3.1 Training Strategy 10

3.2 Training of ASHA Volunteer in Andhra Pradesh 11

3.3 Training Strategy 12

3.4 Training Process 12

3.5 Methods & Materials 13

3.6 Monitoring Systems 13

3.7 Training Programme Outcome 13

Chapter-4 - ASHA Intervention in Andhra Pradesh

4.1 ASHA intervention 17

4.2 Background Characteristics of ASHA 18

4.3 ASHA Selection and Motivation factors for joining

Working status before joining as ASHA 19

Training of ASHAs 19

Payments during training 20

Use of reading material / Drug kit 21

Knowledge of ASHA Volunteers 21

Knowledge about Newborn Care 22

Knowledge about role and responsibilities 23

Organization of work by ASHAs 24

Record updation 25

ASHAs clientele 25

Perceptions of ASHA 26

Cash remuneration received by ASHAs 27

Monitoring System 29

Cash incentives to ASHAs 29

Chapter-5 - Beneficiaries of ASHA for Delivery Care

5.1 Respondent profile 39

5.2 Awareness about JSY 39

5.3 Knowledge on JSY Aspects 40

5.4 Utilization of ANC Services by JSY Beneficiaries 41

5.5 Role of ASHA in Micro-Birth planning: 41

5.6 Intention and Actual Place of Delivery: 42

5.7 Process of Arranging Transport 42

5.8 Motivation for Institutional delivery. 43

5.9 Quality of services available at the place of delivery 43

5.10 Impact of JSY on institutional delivery 44

5.11 JSY beneficiaries – place & type of delivery 44

5.12 Role of ASHA in JSY 44

Chapter-6 – Summary and Recommendations Recommendations 50

Policy 50

Programme Management 50

Demand Generation 51

LIST OF TABLES

S. No. Topic Page No.

Table 4.1 Profile of ASHA functionaries 31

Table 4.2 Motivation for being an ASHA 31

Table 4.3 Topics Covered in the Training of ASHA 32

Table 4.4 Expected follow-up action on recognition of signs of complications in pregnant

women by ASHA 33

Table 4.5 ASHA’s Knowledge about Common Complications during delivery that could

Result in Maternal Mortality 33

Table 4.6 Knowledge about Likelihood of Neonatal mortality 33

Table 4.7 ASHA’s Awareness about their Responsibilities 34

Table 4.8 Networking of ASHA with other Stakeholders 34

Table 4.9 Working Situation of ASHA 35

Table 4.10 Suggestions for further strengthening the work of ASHAs 36

Table 4.11 Challenges faced by ASHAs 37

Table4.12 Reasons for Delay in Incentive Payments 37

Table 4.13 Expected Monthly salary by ASHA as Worker Remuneration 38

Table 4.14 Awareness of ASHA Day Attendance and TA and DA on ASHA Day 38

Table 4.15 Expected Incentives of ASHAs for other Activities 38

Table 5.1 Profile of Respondents (ASHA Beneficiaries) 45

Table 5.2 Place and Source of Information Regarding JSY 45

Table 5.3 Stage of Pregnancy and Place of Registration for ANC 46

Table 5.4 Micro-Birth Planning of JSY Beneficiaries 46

Table 5.5 Responses of JSY Beneficiaries about Intended and Actual Place of Delivery 46

Table 5.6 Motivational factors for JSY beneficiaries for opting institutional delivery 47

Table 5.7 Shift in the place of delivery before & after JSY 47

Table 5.8 Place of delivery of JSY beneficiaries 47

Table 5.9 Type of delivery of JSY beneficiaries 48

Appendix

S. No. Topic Page No.

Appendix 1 The list of villages Selected in the Survey 15

Appendix 2 Mandal-wise PHC and Sub centre in the selected Districts 54

EXECUTIVE SUMMARY

The ‘omnibus approach’ of NRHM is to provide accessible, accountable, affordable, effective

and reliable primary health care, especially to the poor and vulnerable sections in the community. The

NRHM has been envisaged as a focal point of all the earlier health interventions programs after wide

deliberations of various field experts, adaptations of the successful best practices and learning from

the failures in the past, all have made the NRHM a different program.

The NRHM aims to have a village-based female ASHA to act as the interface between the

community and the public health system and negotiate health care for poor women and children. The

Indian Institute of Health and Family Welfare (IIHFW), based at Hyderabad conducted this evaluation

of ASHA and beneficiary perceptions to understand the implementation of NRHM programme for

Commissionerate of Family Welfare, Government of Andhra Pradesh. This report is based on the

quantitative and qualitative assessment of ASHA intervention and beneficiaries covering the three

regions of the state.

Using the semi structured study tools, 941 ASHAs and 1121 JSY women beneficiaries were

interviewed by 30 well-trained investigators. Information also collected from key stakeholders at

district level, PHC level and village leaders.

The Government of Andhra Pradesh adopted an innovative training approach, and initiated 21

days in-house training in every district headquarters covering around 180-200 ASHAs every month. The

Academy of Nursing Studies (ANS), an NGO, was entrusted the responsibility of selection of trainers,

conducting of TOTs, deployment of trainers, facilitator’s guide and audio-visual support for conducting

training in a record period of 18 months time frame.

Training was designed to be participatory and adult learning oriented, with overall

personality development, empowerment, self confidence and orientation to health as the main

objectives. All trainees were reviewed daily in the morning (about previous day’s activity) and evening

review (to recapitulate the day’s activities) followed by weekly reviews and written examination and

role plays by involving all trainees.

The Andhra Pradesh training model (21 days residential) was successful in completing the

training of all ASHAs in the state within the stipulated time schedule laid down by the NRHM time-

frame. All the ASHAs working in the field were well acquainted with their job schedule.

The training strategies adopted in Andhra Pradesh taken as a role model and suitable

modifications/ actions can be initiated by other states in overcoming teething problems of selection,

quality training etc, Whatever the training methodology we had chosen, it is very important to deploy

the ASHA volunteers in all villages and really bring about the change that is expected by the NRHM

visionary.

Involvement of ASHA and JSY beneficiaries

About half of the ASHAs indicated that they were selected by ANM and about one-fifth (21

percent) were recommended by Sarpanch/Politician, followed by 10 percent who were

approved/selected by Gram panchayat. The Gram panchayat approved the selections of ASHAs and

nominated them for training at district headquarters.

Eighty-nine percent of ASHAs indicated they preferred to be ASHA in order to serve the

community, earning extra money for the family was indicated by 58 percent followed by 30 percent

stating the purpose to save the children and bring awareness on health issues.

More than a half (55 percent) of ASHAs are house wives / economically active women and less

than one third (31 percent) are agriculture laborers followed by less than 3 percent of ASHAs reporting

their association with ANM/AWW or participation in the health programs of Indira Kranthi Patham ( a

program to eradicate poverty, introduced in Andhra Pradesh).

Among the selected districts, 82-97 percent of ASHAs appreciated the training centre logistics

like seating arrangements and 82-95 percent appreciated size of the room as ‘big’ and ‘good’. More

than eighty percent (79-96 percent) of ASHAs appreciated food arrangements and accommodation

facilities.

Knowledge of ASHA on high risk of pregnant women was assessed by six components (Short

stature, Low age <18 years and above 34 years of age for delivery, first pregnancy, birth order four

and above, High BP/Diabetic symptoms and Anemia). ASHAs had good practical knowledge of

identifying high risk pregnancy and knew where to shift the pregnant women in case of emergencies.

The familiarity of tasks indicated by ASHAs were immunization services (98 percent) provision

of ANC care (97 percent), accompanying delivery cases (85percent), family planning operations

(71percent), working as DOT provider for TB cases (59percent).

Ninety-eight percent of ASHA volunteers organized their work regularly and coordinated with

the ANM and Anganwadi center activities in the village. The respondents unanimously indicated that

they used to meet ANM/AWW during the weekly immunization sessions and called all the pregnant

women for timely ANC check-up and helping in organizing of Village Nutrition Day at AW center.

Thirty-seven percent of ASHAs in the survey revealed that they maintained records regularly

(23-24 percent in Kurnool and Mahabubnagar districts and 63 percent in East Godavari district). The

weekly updating of records varied between 29-53 percent across districts. Thus the survey indicated

that 66-80 percent of ASHA volunteers update their records within seven days.

Ninety-eight percent of ASHAs handled a JSY case for delivery in hospital and the last JSY client

was accompanied 24 days prior to the date of interview. Seven out of ten (71 percent) of ASHAs stayed

for one day, 15 percent stayed for two days along with the JSY beneficiary for delivery services.

The common suggestions for improving the ASHA intervention were mainly related to

enhancing the cash assistance for making timely money payments, provision of complete information

and practical trainings. Propagation of the NRHM schemes by the lady medical officer, doctors and

nurses helping ASHA to propagate healthy practices easily in the community.

The ASHAs, on an average earned about Rs. 545/- (range of Rs. 200 – 1875; calculated on the

basis of cases motivated for RCH activities in the reference period of three / one month) prior to the

survey. ASHAs received higher incentives for accompanying institutional delivery (36 percent), post

natal care (19 percent), one ANC with MBBS doctor (13 percent), Measles and Vitamin-A ((11 percent)

respectively. Only one-fifth of ASHAs (19 percent) were satisfied with incentive they had received

(more than state average recorded in Karimnagar 32 percent) followed by Kurnool (28 percent). Sixty-

seven percent of ASHAs were not satisfied with the cash assistance commenting on ‘too much work

with too little payment’ followed by delays in receipt of payment.

Ninetynine percent of ASHAs were aware of monthly ASHA Day meetings and equal number

attending regularly, obtaining counseling from district program officers, PHC staff along with NGOs

(Table 4.14). Ninetyeight percent of ASHAs indicated the usefulness of the ASHA Day.

Beneficiaries of ASHA for Delivery Care

The mean age of the respondent was 22.8 years. Only 3 percent of respondents were aged

more than 30 years. Nine out of ten women respondents were in the age group of 20-29 years. In the

sample, less than 11 percent of respondents had passed intermediate and higher education level. Less

than sixty percent (58 percent) of JSY respondents belonged to BC community (with BPL white card)

and remaining 42 percent were from SC and ST community. The average household monthly income

was Rs.2034/- and varied between Rs.1840/- in Karimnagar and a high of Rs. 2271/- in Mahabubnagar

district respectively. About 65 percent of respondents (residing in the ASHA volunteers locality) were

providing the services in the SC/ST and BC colonies respectively.

Regarding the source from where they heard of JSY, about 82 percent mentioned ASHA

volunteer and 66 percent as ANM. Around 20 percent of beneficiaries indicated other sources of

information like T.V, Radio, Relatives and Gram panchayat (Table 5.2). The knowledge regarding JSY

scheme in the state was mainly disseminated through interpersonal communication rather than mass-

media channels.

Majority of beneficiaries had interactions with ASHA on the Micro-Birth planning issues.

Eighty-four percent (84 percent) of beneficiaries informed about the date of next check-up, sixty-eight

percent had received information on place of delivery, forty-six percent advised on expected date of

delivery (EDD) but lower than one-fifth of beneficiaries indicated that ASHA informed them about the

referral place to visit in case of any emergency. Birth planning is one of the key elements taken up

during the refresher training and ANMs and AW workers interaction sessions

Sixty-nine percent of beneficiaries reported safety to mother and child for choosing institution

delivery followed by 63 percent due to monetary benefits offered under JSY scheme. Twenty-eight

percent of beneficiaries were motivated ‘due to better access of service at medical institution in the

nearest locality’ and ‘support provided by ASHA’. Less than ten percent were motivated due to

compulsion like ‘the previous birth in hospital’ and ‘availability of transport’ for availing services from

medical institutions.

The JSY beneficiaries were asked about place of delivery of the last child born prior to the

index child of JSY beneficiaries interviewed. Out of 1145 total beneficiaries only 745 had history of

previous child birth. Data from these 745 beneficiaries was cross tabulated by place of delivery of

previous child with that of the index child. In other words, the analysis would indicate a shift in place

of delivery before and after introduction of JSY. It was observed that 610 JSY beneficiaries in the

preceding index child birth had an institutional delivery while the remaining 135 (18 percent) were

home deliveries. ). In case of index pregnancy, 730 (98 percent) births were institutional and only 15

(2 percent) births were home deliveries. It may however be mentioned here that this can not be

generalized as the sample had been confined to only those who had availed JSY. The results may be

considered as indicative of their change in behavior.

Andhra Pradesh: Shift in the Place of Delivery before and After JSY

Particulars For last but one child For last (JSY) child

Place of delivery

Institutional 82 (610) 98 (730)

Home 18 (135) 2 (15)

Number of beneficiaries with two or more children : 745

ASHAs briefed women about the JSY. ASHAs informed the JSY beneficiaries about early

registration in first trimester, hospital delivery and postnatal care. Higher percentage of JSY belonged

to SC/ST and BPL group availed the benefits and was satisfied about the role played by ASHA. This is

evident from the beneficiary assessment wherein it was found that they were supportive right from

pregnancy to child birth in three-fourth of deliveries. The ASHA role in motivating beneficiaries for

institutional delivery services and accompanying them to institutions has emerged significantly.

CHAPTER 1

1.1 Introduction

AIDS can kill by stigma even when lifesaving medical treatment is available. Until

recently, an HIV-infected woman in Sauri, Kenya, was discouraged by her husband, also

HIV-infected, from seeking medical care because of his fear of stigma. All too often, death

quickly ensues in such cases. But not in this one. Husband and wife were saved by Mary

Wasonga, a fellow villager recently trained to be a community health worker by the

Millennium Village Project, which is helping more than 400,000 people in dozens of

African communities fight extreme poverty, hunger and disease. Wasonga visited the

couple and encouraged them to get home-based HIV testing and counseling, and then

helped them enroll in a treatment program. Indeed, she and the 82 other community

health workers in Sauri have helped thousands of villagers do the same.

These workers also attend to women in labor who need urgent transport to a

delivery room, individuals too weakened by cholera to get to a clinic, children with

malaria and many others. They do this with one year of on-the-job training that builds on

at least some secondary education. That basic training is enough to save lives in vast

numbers”. Thorough training is sufficient to facilitate the multiple task-shifting and task-

sharing.

Jeffrey D. Sachs, TIME, 28th August, 2008

Across the globe, programs are under way that are reminiscent of China's successful

barefoot doctors initiated a few decades ago. The mother of all community health efforts is

India's National Rural Health Mission initiated by Prime Minister Manmohan Singh in 2005. In

just over three years, the mission has mobilized more than half a million new community

health workers, each known as an ASHA - short for "accredited social health activist," and the

Hindi word for hope”. The ‘omnibus approach’ of NRHM is to provide accessible,

accountable, affordable, effective and reliable primary health care, especially to the poor and

vulnerable sections in the community. The NRHM has been envisaged as a focal point of all

the earlier health interventions programs after wide deliberations of various field experts,

adaptations of the successful best practices and learning from the failures in the past, all

have made the NRHM a different program. Moreover, no government program was as

meticulously prepared or planned as NRHM since Independence (Lahariya, Khandekar and

Prasuna, 2007). In order to achieve the National Health Policy goals and health-related

Millennium Development Goals (MDGs), the mission adopted convergence among the sectors

of health, family welfare, AYUSH, nutrition and sanitation. The NRHM emphasized the result-

based management approach in order to attain different health goals: Millennium

Development Goal (MDG, 2000), National Health Policy (NHP, 2002) and Tenth Plan Goals

(last two years of plan period) and Eleventh Plan (2007-12) through provision of right number

of service providers with right skills at right place and at right time beginning from village to

state level (Satpathy and Venkatesh, 2006).

According to a study, the health facilities at PHC, CHC have fallen short of people’s

needs both in quantitative and qualitative terms. The NRHM is an architectural correction in

tackling available optimum fund utilization, higher accountability and better utilization of

resources. The availability of an appropriately trained residential health care provider in

every village reduces loss of human days due to absence of timely first contact care by the

village community. In view of the failure of official Community Health Worker (CHW) scheme

launched in 1978 identifying the flaws in that program, the NRHM reconceptualised the

ASHA program (Jan Swasthya Abhiyan, 2006).

In the health care system, sub-center is the most peripheral level of contact with the

community covering a 3000 population in rural areas, but effectively in Andhra Pradesh it is

serving 4424 population on an average. Out of the existing 12522 sub-centers in the state,

about 84 percent of sanctioned positions of MPHA (F) were filled (RHS, 2007), but slightly

less than half (48 percent) of sanctioned positions of MPHA (M) are vacant. It is one of the

crucial bottlenecks hindering the implementation of vertical National Health Programs and

outreach services in the rural areas. The Anganwadi centers in the villages, under the

Integrated Child Development Scheme (ICDS) are engaged in organizing supplementary

nutrition programmes and other supportive activities. The posting of additional MPHA

(F)/ANM at the sub-centers could not completely address problems in the provision of basic

health facilities at the village level. Thus a new brand of community health functionaries,

named as Accredited Social Health Activist (ASHA) was introduced in the existing rural health

care delivery system.

1.2 National Rural Health Mission

The thrust of the NRHM is to establish a fully functional, community-owned,

decentralized health delivery system with an emphasis on inter-sectoral convergence with

sanitation, water, education, nutrition, social and gender equality besides strengthening all

health facilities with Indian Public Health Standards (IPHS). Although NRHM covers all the

States of India, special focus was laid on 18 EAG states that have weak public health

indicators and/or weak health infrastructure facilities.

Technological companies and foundations extended support under Public private

partnership by providing Mobile phone for training, reporting of vital statistics and calling

ambulances. The Emergency Management Research Institute (EMRI, Hyderabad) under Public-

private partnership with the Andhra Pradesh State Government has been providing

emergency-response coverage for 84 million people for maternal and child care, accidents

and other related emergency services.

Andhra Pradesh is a non-focused and high performance state. The State has to

adhere to mutually agreed milestones of NRHM objectives by signing MOU with the GOI. The

Andhra Pradesh State NRHM Mission proposed a budget of Rs. 888.9 crores (about 15.3%

State Government share of NRHM allocation to A.P) for the year 2008-09. After two years of

NRHM, different interventions/ infrastructure developed including the following (PIP 2007-

08):

• About 70,700 ASHAs (Women Health Volunteers1) are trained and positioned in

their respective villages tribal areas for working towards the betterment of

women and children

• Implementation of Janani Suraksha Yojana (JSY) for encouraging the institutional

deliveries by SC/ST and BPL groups

• Strengthening of 151 CEMONC centers

• 800 round-the-clock MCH centers

• 299 urban health centers in municipalities of towns

• 160 Neonatal Intensive Care Units

• 92 Mobile units in remote rural and tribal areas

• 502 Rural Emergency Health Transport Services (108 of EMRI)

ASHA volunteers programme is the one of the core strategies from the first Andhra

Pradesh Programme Implementation Plan (2005-06). ASHA will be the first port of call for any

health related demands of deprived sections of the village community. In the state there are

about 51,200 ASHAs in rural villages (remaining in urban and tribal areas) at the rate of 1 for

1000 population. As an honorary volunteer, ASHA receives performance-based compensation

for promoting a variety of primary health care services in general and reproductive and child

health services in particular. Andhra Pradesh is the first state in the country that successfully

completed the selection, training and placement of ASHAs in all villages as per the NRHM

guidelines. The State government attempted to complete the training of ASHA within first

two years (as per the Guidelines of NRHM), so that they could have five more years to

perform; and in cases required, mid-course corrections have been undertaken for sustainable

implementation of the program. The Government of Andhra Pradesh implemented in

conjunction with the initiative of ASHA, the demand-driven, intertwined programme of Janani

Suraksha Yojana2 (JSY) from late 2005-06.

BOX-1 Roles and responsibilities of ASHA

• Create awareness and provide information to community on determinants of health

(nutrition, basic sanitation & hygienic practices, healthy living and inform on health

services and need for timely utilization of health and Family Welfare services.

• Counsel women on Antenatal care – birth preparedness, importance of safe delivery,

breastfeeding and complementary feeding, immunization, contraception and

prevention of common infections, RTI/STI and care of young children.

• Mobilize the community and facilitate in accessing health and health-related services

available at village/sub-centre/PHC such as immunization, ANC checkup, Post natal

checkup, ICDS and sanitation.

• Work with the Village Health and Sanitation Committee of the Gram Panchayat to

develop comprehensive Village Health Plan.

• Escort/accompany pregnant women & children requiring treatment/ admission to the

nearest pre-identified health facility in PHC/CHC/FRU.

• Provide primary medical care for minor ailments such as diarrhea, fever and first aid

minor injuries and reduce man hours lost in attending a PHC or a health facility. She is

also a provider of Directly Observed Treatment Short-course (DOTS) under RNTCP.

• A depot holder for ORS, IFA tablets, chloroquine, oral pills and condoms.

• Inform about births and deaths in her village and any unusual health problems/

disease outbreaks in the community to SC/PHC.

1.3 Need for the study

The cornerstone of the NRHM program is positioning a trained community link

worker (ASHA for every 1000 population) in all villages in the country. Most states have

demonstrated remarkable enthusiasm in scaling up ASHA activities of identification, selection,

training and placement in their respective villages. However, the impact of ASHA volunteer in

the community depends on proper selection, training (knowledge, inter-personal

communication skills), due recognition from health and other staff at local levels as well as

from the family members) and timely payment of incentives etc. The twenty-one days’

residential ASHA training in Andhra Pradesh was adjudged as the best strategy in the country

(NRHM First Common Review Mission, 2008). The present evaluation conducted after two

years of their placement in their respective villages to examine the knowledge levels and

views of ASHA volunteers about the scheme, problems faced in discharging responsibilities

towards health staff and community is necessary for sustainability of program. Further it is

worthwhile to know the extent of benefit community experienced, from the ASHA program at

local level. Andhra Pradesh being the first state with trained ASHAs working in the field, it is

also required to identify and note suggestions and common complaints in order to make any

mid course corrections.

1.4 Objectives of the study

The specific objectives of the study are to

a) Study the adherence with guidelines for ASHA selection in the villages

b) Review the training strategy including design, material development and

implementation, quality of training and post-training follow-up

c) Analyze work performance and support of health system to ASHA

d) Study the satisfaction of ASHAs with the delivery of scheme, suggestions and

comments including compensation / reimbursement

e) Map community perceptions of Janani Suraksha Yojana beneficiaries with whom

the ASHAs accompanied to institution for delivery

1.5 Presentation of the Report

The report has five chapters; the present one gives a brief introduction NRHM and

study objectives of the evaluation. Chapter 2 elucidates the study design and survey

instruments used and sample methodology. Chapter 3 discusses training strategy and

implementation of the ASHA programme in Andhra Pradesh. ASHA’s profile, selection

criteria, training, knowledge about different aspects of NRHM (RCH) and other related issues

are discussed in chapter 4. Chapter 5 covers the evaluation of JSY beneficiaries on the ASHA

work performance and their perceptions. The last chapter 5 is on programmatic

interventions for enhancing ASHA intervention and strengthening JSY scheme.

CHAPTER 2

DATA AND STUDY DESIGN

The data used for the study has been collected through a combination of quantitative

and qualitative evaluation techniques. Detailed structured questionnaires were developed in

collaboration with the CFW program officers, Academy of Nursing Studies (training agency)

and canvassed among the ASHA volunteers and beneficiaries in the five selected districts. The

questionnaires and study sample design are discussed in the following sections.

2.1 Questionnaires

Two types of questionnaires were developed for the present study: the ASHA

schedule and the Beneficiary schedule. The overall content and format of the questionnaires

were designed keeping in mind the objectives of the study. The preliminary draft

questionnaires prepared after three meetings between the training agency and IIHFW faculty

were field tested in Keesara PHC, Ranga Reddy district. After obtaining feedback, the

questionnaires were pre-tested in Shamirpet PHC, Ranga Reddy district. Following the

approval of the final questionnaires and methodology from the Commissionerate of Family

Welfare (funding agency) it was decided to select about 700 ASHA volunteers (slightly more

than 10%) and an equal number of beneficiaries for the selected districts.

A. ASHA Questionnaire

The ASHA questionnaire was designed to identify the topics covered in the training,

spontaneous responses on RCH aspects of compensation /incentives and suggestions for

program sustainability.

Section-1 Identification

Identification particulars such as name of the mandal, PHC, sub-center, name of the

ASHA volunteer, age, qualification, marital status, work experience before joining, area and

population covered by ASHA

Section-2 Training component

This part of the questionnaire covered information on logistic arrangements made in

the training centers in the districts and different topics covered in the 2-day in-house training

Section-3 Knowledge of ASHA about NRHM

This section deals with ASHA perceptions and spontaneous responses of knowledge

levels based on a) different components of Antenatal care, danger signs pregnancy,

symptoms of high risk pregnancies, factors causing maternal mortality and causes for infant

deaths etc.

Section-4 Functions of ASHA volunteers

The coordination of ASHA volunteer with health and other department personnel are

highlighted in this section. The section includes place and periodicity of the meeting with

ANM/AWW as well as information on the frequency of updating the records and periodicity

of births and deaths registration with village panchayat etc.

Section-5 Working aspects by ASHA

This section includes the general profile of the last client who availed the ASHA

services, mean days of last service provided to the client, type of service availed, escorting

the JSY beneficiary by ASHA for hospital delivery, mode of transport arranged to shift the

pregnant woman for delivery, mean days of ASHA’s stay at the hospital etc. Information was

also collected on the receipt of cash incentive, satisfaction about the incentive provided to

various activities and likely amount expected by ASHA as a monthly remuneration.

Section-6 Work and Remuneration

This section includes the supply and re-filling of ASHA drug kit and remuneration

received under different schemes by SC/ST and BPL groups besides the incentive for

promotion of family planning sterilization.

B. Beneficiary questionnaire

The draft Report of the NRHM Common Review Mission (2007-08) highlighted that

ASHA are actively involved in majority of the states and their main work was linked with their

accompanying the JSY beneficiary, immunization and promotion of sterilization acceptors

rather than attending eight tasks of ASHA as given in the NRHM Guidelines (First Common

Review Mission, 2008). In this section we enquire about the background information of

respondent beneficiary, delivery information of last child (in case of 1 or more children),

when they come to know about the scheme, details of ANC, counseling by ASHA/ANM, place

of delivery, receipt of timely incentive etc.

Section-1 Identification of beneficiary

This section includes identification particulars such as name of the beneficiary/

respondent, age, caste, number of children, white card status and monthly income etc.

Section-2 Knowledge of JSY

Information is included in this section regarding when the beneficiary heard about

the JSY scheme, source of information etc.

Section-3 Prenatal and Natal care of JSY beneficiary

Information sought includes time of ANC registration, place of JSY registration,

counseling about ANC etc.

Section-4 Satisfaction of JSY beneficiaries

Information is sought from the beneficiaries about mode of transport for shifting the

pregnant woman for delivery, arrangement of transport, satisfaction of the services obtained

at the health facility, opinion/value added due to the accompaniment of ASHA to the hospital

during delivery and post- natal care etc.

2.2 Sample Design

It was decided by the CFW to that the survey be conducted in five districts of Andhra

Pradesh. The selection of districts (high performance and low performance) was based on

District Human Development Index (CESS, 2007) as well as monthly program reports. It was

also decided to select one district from Rayalaseema region and two districts each from the

Coastal and Telangana regions of Andhra Pradesh.

The two selected districts were East Godavari and Srikakulam from Coastal Andhra

region, Karimnagar and Mahabubnagar form Telangana region and Kurnool district from

Rayalaseema region. The survey adopted a multi-stage-systematic sampling design. In each

district, the PHCs (mandals) were selected in the first stage using systematic random

sampling. In the second stage, all the villages in the PHC were ranked depending on the

number of ASHA workers (a proxy for population proportion to size) and six villages selected

by using Systematic random sampling procedure. In the final stage, all ASHA volunteers in

the selected village were interviewed. Information was also sought from local panchayat

sarpanch / panchayat member/ local committee members /ANM about their perceptions and

views about ASHA’s work and opinion and performance by beneficiaries (the pregnant (JSY)

women who were accompanied by ASHA to the institution for delivery).

The overall sample size was initially fixed at 700 (10% of the 70,700 ASHA volunteers

in the state). The study covered about 941 ASHA volunteers and 1100 ASHA beneficiaries

who availed the services from the ASHA volunteers (for accompanying delivery to a health

institution) during recent past. Thus in each district, from the 70-80 PHCs, about 15 PHCs

were selected randomly and then from each PHC area, six villages were selected. All the

ASHA workers and one or two beneficiaries who delivered under JSY scheme and who were

accompanied by ASHA were interviewed by using an in-depth questionnaire. The list of

villages selected in the survey is given in Appendix-1. The survey design is given below:

SURVEY DESIGN

Number of Mandals / PHCs selected 75 Number of Sub centers selected 387

Number of Villages selected 532 Number of ASHAs interviewed 941

Number of Beneficiaries interviewed 1121

2.3 Field work

About 36 interviewers with experience in Health/Demographic surveys were

recruited. They were provided intensive training both by coordinators and program officers

on various aspects of conducting quality field work and different NRHM interventions. The

training consisted of instructions in interviewing techniques and field procedures, a detailed

review of each item in the questionnaires, mock interviews among participants in the class

room situation and practice interviews conducted in the Keesara and Shamirpet PHC villages

of Ranga Reddy district. The field work of the study was carried out during November 2008

by four teams of 8 interviewers and 4 supervisors. All the completed questionnaires were

verified manually for internal consistency.

2.4 Data Editing and Analysis

The data were entered in EPI-INFO package developed by internal computer faculty

and SPSS 16.0 package utilized for cross-tabulation analysis.

Coastal

Andhra

Rayalaseema Telangana

Srikakulam East Godavari Kurnool Mahabubnagar Karimnagar

15 PHCs 15 PHCs

78 Sub

Centers

80 Sub

Centers

127 villages

102 villages

15 PHCs

74 Sub

Centers

93 villages

15 PHCs

79 Sub

Centers

97 villages

15 PHCs

76 Sub

Centers

113 villages

Andhra Pradesh

CHAPTER-3

TRAINING STRATEGIES OF ASHA IN ANDHRA PRADESH

The positioning of trained community link workers in all villages is one of the core

strategies of the mission and most states have demonstrated remarkable enthusiasm in

scaling up implementation activities. The present chapter covers broad areas of selection of

ASHA, training, logistics of training adopted, topics covered etc. The primary role of ASHA is

to create awareness on health and its social determinants and mobilize the community

towards local health planning and increase utilization and accountability of the existing

health services. The eight tasks of ASHA are Village planning, Linkages with health staff,

Village water and sanitation, IEC and counseling, Primary medical care, Timely referral, Depot

holding and Record keeping. Training is an important element of the ASHA programme since

it goes a long way in determining its effectiveness.

Box 3.1 Key Activities of NRHM

The Accredited Social Health Activist is called by the acronym ASHA. She must be a

primary resident of the village with formal education up to the eighth class, and

preferably in the age group of 25-45 years. She would be selected by the Gram Sabha

through an intense community mobilization process, and provided with training. She

would also be equipped with a drug kit. After selection, ASHA will be given induction

training for 23 days spread over a period of 12 months. Training manuals have been

prepared. ASHA will be given periodic training, re-training and on-the-job training. She

will act as a mobilizer, facilitator and a link between ANM at the sub-centre, Anganwadi

worker and the community, and play a major role in forging ownership of the

community for the health programme. ASHA will be first port of call for any health-

related demands of deprived sections of the population, especially women and

children, who find it difficult to access health services. She will ensure better access to

universal immunization, safe delivery, newborn care, and prevention of water-borne

and other communicable diseases, nutrition, and sanitation. She will be accountable to

the panchayat, and will be entitled to receive performance-based compensation for

providing health services.

3.1 Training Strategy

The Ministry proposed the training of ASHAs for 23 days’ duration spread over five

rings/exposures in one year period. The first round of induction training consists of seven

days to provide preliminary knowledge on eight tasks of ASHA. The responsibility of ASHA

training and monitoring was given to the State Institutes of Health and Family Welfare along

with a reputed NGO with working experience in health area. The trainings conducted in the

states of Uttar Pradesh, Rajasthan, Jharkhand, Bihar and Orissa showed discouraging

experience of identification, selection, induction training and subsequent rounds of ASHA

trainings (Garg and Nath, 2007).

The Government of Andhra Pradesh adopted an innovative approach, and initiated

21 days in-house training in every district headquarters covering around 180-200 ASHAs

every month. After prolonged deliberations concerning training experience and extensive

planning, the huge task of ASHA training in the State run (Department of Women and Child

Welfare, GoAP) training centers in each district was initiated. The Academy of Nursing

Studies (ANS) was entrusted the responsibility of selection of trainers, conducting of TOTs,

deployment of trainers, development of manual, facilitator’s guide and other audio-visual

support for conducting the 21 days training in a record period of 18 months from early 2006.

3.2 Trainings of ASHA Volunteer in Andhra Pradesh

In order to train massive number of ASHA volunteers, it was proposed to conduct

the training in all the 22 districts (except in Hyderabad urban district) covering around 3500-

4000 volunteers every month. This task was fulfilled successfully with the close co-ordination

and cooperation and monitoring among the three agencies. The process of selection and

approval and timely deputation of ASHA volunteers for the training was closely monitored by

the Commissionerate of Family Welfare. The Andhra Pradesh State Women Finance

Corporation (a wing of Department of Women and Child Welfare) provided accommodation,

food and other training arrangements in their ‘Mahila Pranganams’ (training center for

empowering women groups). The task of developing training manual, Facilitator’s training

manual, Demonstration material were under taken by the Academy of Nursing Studies (ANS),

Hyderabad, a reputed NGO in the state.

3.3 Training Strategy

The Academy of Nursing Studies developed the necessary manuals and audio-visual

aids in a record time. In response to a paper advertisement, the ANS selected more than 350

trainers (ANMs with additional educational qualifications) along with a commitment to work

for 12-15 months period. A fifteen days TOT was conducted for these selected trainers who

subsequently provided with quarterly refresher trainings. The Women Finance Corporation

(WFC) has spacious training centers (Mahila Pranganams) located in every district

Headquarters capable of accommodating about 200 female trainers. The lodging, boarding,

class room availability and other training requirements in each district were taken care of by

the District Manager (a female officer), WFC and supporting staff.

Research studies related to training of health personnel, showed that majority of the

National Health Program initiatives started with training and ended with training activities

without proper evaluation to assess the success of the initiated programme. It is necessary to

ensure that training of ASHA is completed within first two years of NRHM so that they have 5

years’ period to perform and, if required, mid-course correction can be undertaken in the

implementation. (Umesh Kapil, 2006).

3.4 Training Process

The NRHM Mission directorate, the WFC authorities and the ANS decided to train

180-200 volunteers per district in a month. Two batches were conducted simultaneously for

a duration of 21 days at the training centre and five days in the field and another 2 days at

their respective PHCs for providing feedback on the training in order to strengthen linkages

between them and the PHC staff.

3.5 Methods & Materials

Training was designed to be participatory and adult learning oriented, with overall

personality development, empowerment, self confidence and orientation to health as the

main objectives. The ANS training adopted discussions, practical experience, reviews, quiz

programmes, songs, video shows, yoga and folk arts during training period. All trainees were

reviewed daily in the morning (about previous day’s activity) and evening review (to

recapitulate the day’s activities) followed by weekly reviews and written examination and

role plays by involving all trainees.

3.6 Monitoring Systems

The key for the success of Andhra Pradesh model of ASHAs / WHVs training in a

record period (18 months) was attributed to the triangulation of coordination among the two

government departments and the NGO. The District training manger (a senior DPHNO)

monitored the nomination, field training, review and the distribution of kits and

remuneration aspects. The regional coordinators of ANS staff monitored the training

programme. The State level monitoring was conducted by DM & HO and other program

officer in-charge. The CFW in collaboration with ANS appointed a state level coordinator to

monitor timely nominations, conducting the training as per the norms indicated in the PIP

according to the ASHA guidelines.

3.7 Training Programme Outcome

The pre-test and post-test evaluations and other weekly evaluations and the

responses of the trainees indicated remarkable difference in their behavior (especially in

their dressing, inter-personal communication (talking, increased participation in discussions)

by the end of first week of training. It is interesting to observe that a small percentage

(below two percent) of ASHAs discontinued the 21 day residential training due to health

reasons and family problems indicating that well planned and designed training programs

will falsify common perceptions that women may not prefer long duration trainings. The

State Government ASHA training strategy, also successfully completed the refresher-training

course in all the districts successfully.

Bajpai et al (2008) reported that the crash course of ASHA trainings in Andhra

Pradesh was inadequate in terms of quality training and allocation of time for different

training aspects. The authors pointed to the need for an on-going short-duration training of

ASHA at regular intervals throughout the year and the need to share the rich experience of

ANMs in the training sessions as per the GOI guidelines. Bang (2007) advocated for extending

training days from 23 days per annum to 150-180 days over a period of 3-5 years. The Rural

Health Watch Survey conducted interviews with 250 ASHAs in around 80 districts and

reported that most of ASHAs had yet to initiate work (Rajyalakshmi, 2007). Sharma (2007)

observed in Rajasthan that the ASHA trainings were inadequate with reference to tasks

performed and that ASHA volunteers had poor knowledge about JSY related concepts,

components and provisions. Moreover, ASHAs in Rajasthan preferred longer initial training in

the first round from 7 days (Sharma, 2007).

It is interesting to observe that the Andhra Pradesh training model (21 days

residential) was successful in completing the training of all ASHAs in the state within the

stipulated time schedule laid down by the NRHM time-frame. All the ASHAs working in the

field were well acquainted with their job schedule. The refresher training course, Monthly

ASHA Day meetings helped ASHAs to strengthen the skills. This rich experience of Andhra

Pradesh may be extended to other NRHM states which are lagging in selection and

completion of five rounds of training and finding other teething problems.

The CARE agency under the Integrated Nutrition Health Project (INHP) developed a

training program of 6 days of three hours duration on the convergence ASHA Day with a

stipulated period of 6 months duration. The organization developed a module and started

the intervention through DPHNO /Nodal officers in the PHC area under the guidance of

Mission Director, Government of Andhra Pradesh since October 2008. Some of the

monitoring reports indicated the need a) to strengthen newborn care with IYCF knowledge

to the DPHNO/ Nodal officers, b) strengthening of monitoring ASHA Day by district / PHC

programme officers; and c) ASHAs in many PHCs expressed that inputs provided by CARE on

ASHA Day were useful and expressed qualitative improvement in outcome indicators.5

To sum up, the training strategies adopted in Andhra Pradesh serve as a role model

and suitable action should be initiated by other states in overcoming teething problems of

selection, quality training on different aspects.

Whatever the training methodology we had chosen, (5 rounds of 4-5 days duration in

a span of one year period or 21 days in-house training), to achieve the goals of NRHM

initiatives, it is very important to deploy the ASHA volunteers in all villages and really bring

about the change that is expected by the NRHM visionary.

Appendix- 1

Matrix indicating broad Training strategies adopted by GOI and AP Model

GOI norms of ASHA training Andhra Pradesh ASHA Training

Duration of training

Twenty-three days of training in five

rings/exposures spread in 12-18 months.

Seven days induction training.

Twenty-one days residential training and

seven days of practical field training in

respective PHC area.

Operational difficulties in conducting four

or five rounds training. Difficult to sustain

same motivation in all rounds and

operational difficulties.

Cost-effective in conducting twenty-one days

training at district headquarters under Govt.

training centre ‘Mahila Pranganam’ under

Dept. of Women and Child Welfare, Andhra

Pradesh.

Method of training

Interactive techniques including pictorial

materials, story telling, role plays, folk

media (Kalajathas) and local radio

programs.

Interactive techniques covering pictorial

materials, group discussion, melodious folk

songs composed with health messages, role

plays, skits and special health education

video shows.

Module

Reading material in the form of five books.

First book provides preliminary knowledge

on major ASHA themes. Aspects covered

step by step from module one to module

five. Flexibility to delete and add topics

according to local needs by States.

ASHA training module, Facilitators Guide and

Demonstration Aids prepared in the initial

year 2005-06 in local language. Reviewed

periodically and additional topics included

from time to time by the NGO on the request

of Health department.

Periodic training

After completion of seven days induction

training, periodic training for 2 days in

every alternate month at appropriate level.

After completing twenty-one days of

induction training, Refresher Training for 3

days twice in a year conducted for updating

skills and knowledge. On ASHA day of every

month CARE INDIA conduct convergence

meeting in pilot districts.

On-the-Job –Training

As ASHA needs On-the-Job support after

induction and other periodic trainings, it is

proposed to provide on-the-job training

during immunization days and out reach

service days by ANM and on monthly

nutrition day by AWW.

ANM and AWW provide on-the-job training

to ASHA during out reach service days.

Author’s field experience indicates that

ASHAs are in a position to question the non

availability (absenteeism) of ANM in the

village.

GOI norms of ASHA training Andhra Pradesh ASHA Training

Venue of Training

PHC or Panchayat Bhavan or other facility

closer to their habitation. Empirical

evidence indicates that trainings are not up

to the mark in terms of training quality and

quantitative rounds of training.

Government Women and Child Welfare

Department ‘Mahila Pranganams’ which

accommodate 180 participants at a time with

good quality boarding & lodging and training

center facilities. In 18 months time, all ASHA

trainings could be completed in the State.

Selection of ASHA

It is proposed that every State government

should ensure that at least 40% of the

induction training is completed in first year

and rest of ASHAs training may be

subsequently completed in second and

third year of NRHM (by 2008-09).

All ASHA workers trainings completed in

Andhra Pradesh by end of 2007 and Ninety

percent of ASHAs completed refresher

training

ASHA is the main stakeholder and higher

attrition rate of ASHA may take one year for

selecting and replacement in the village.

Five rounds of training of one year duration

may increase operational costs.

In case of attrition of ASHAs, new volunteers

may be selected and placed within a span of

3 months with cent per cent replacement.

Operational Problems

Timely communication to the volunteers

about the batches/rounds, availability of

time and their inability to get away from

work or sickness or domestic problems

may cause poor turnout for training

program.

Operational problems can be managed.

ANMs involved from recruitment of ASHA.

She personally brings the deputed volunteer

from the sub-center village to the training

center and introduces them to the trainers

on the first day of training.

Chance of dropout rate from induction to

5th round of training due to various

operational and personal reasons.

Dropout cases may be effectively tackled

with less operational cost.

The NRHM trainings of ASHA preferred in

five rounds due to shortage of initiation

and development of modules for the

training. The retaining capacity of the

trainees may cause a serious block in this

cascade approach.

Trainers are evaluated on a daily/weekly

basis by training coordinators /district

manager. The CARE agency trainings on

ASHA Day, refresher trainings enrich the

coordination of knowledge update.

Chapter-4

ASHA INTERVENTION IN ANDHRA PRADESH

4.1 ASHA intervention

The government of India formulated guidelines on roles and responsibilities of ASHA,

institutional mechanisms, selection and training of ASHAs, work arrangements and linkages

with ANMs and Anganwadi workers, incentives to ASHA on work performance etc. In the

previous chapter, we elaborately discussed issues related to the ASHA selection, training

procedures adopted in Andhra Pradesh. The District Medical & Health Officer (DM & HO) and

District Programme Management Unit (DMPU) of NRHM are implementing and reviewing the

district level monitoring of ASHA intervention programme .The PHC medical officers, ANMs

directly monitor the performance, on-the-job guidance, payment of incentives and

convergence with other departments. Strenuous efforts are made by Gram Panchayat,

Sarpanch, PHC / SC staff, ANM, Women Health Group members and AWWs for motivating the

village women with necessary criteria as ASHA workers. The PHC staff indicated that in

majority of the places women had not shown any interest due to lower educational

qualifications, lack of interest to work in SC /BC colonies by forward caste and vice versa and

low and uncertain incentives, unfavorable comments from the family members etc. In some

places the ANM and AW workers and Village Sarpanch had taken personal interest along with

the PHC Medical Officers for motivating the women.

The State of Andhra

Pradesh adopted national

guidelines of selecting ASHA

volunteers but provided

relaxation in education

qualification from 8th

standard to 7th standard

pass. The selection

procedure guidelines were

translated into Telugu

language and were

transmitted to the district

and PHC level officers for effective implementation. A series of workshops was organized by

the State Mission Directorate in all districts and for familiarizing objectives and mechanism

of selection of ASHA volunteers. The State level program officers in turn conducted and

monitored the block level and PHC level workshops. The DWCRA (Women Help Groups) in

every village acted as a catalyst and helped the village level selection of ASHA Volunteer. The

10035

41166

7816 8054

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

2005-06 2006-07 2007-08 2008

Trained ASHAs in Andhra Pradesh

Triangulation of efforts by the three agencies namely DM&HO representative (senior DPHNO)

and district manager of the Women Finance Corporation and ANS enabled massive training

of 70,700 ASHA volunteers in a record time of 18 months. As indicated in the methodology

section we selected five districts in Andhra Pradesh and about 75-80 PHCs and around 990

ASHA workers in the PHC villages. An equal number of beneficiaries who availed the services

of ASHA recently in the village were also selected.

In the following paragraphs we would discuss the Socio-demographic profile of

ASHAs, the motivating factors to take up ASHA volunteership, the selection process, training

and gauging of retention of training knowledge regarding antenatal and child care aspects.

Their roles and responsibilities, ways of motivate clients and service assurances were also

discussed. Information on ASHA’s last clientele (to understand the nature and type of

interactions), networking with key stakeholders, cash assistance received by ASHAs, their

suggestions and bottlenecks for the sustenance of the program is presented below.

4.2 Background Characteristics of ASHA

The survey covered a sample of 941 ASHAs (a maximum of 224 in East Godavari and a

minimum of 165 in Mahabubnagar district) from five districts of Andhra Pradesh. The ASHAs

interviewed were young with a mean age of 28 years (ranging between 19-50 years) and

about eighty-six percent of the ASHAs had above 7th standard of school education (Table 4.1).

Eight out of ten ASHAs interviewed were currently married women, 13 percent un-married

and remaining seven percent were divorced / widowed / separated. More than half (57

percent) of ASHAs belonged to scheduled caste/ scheduled tribe groups followed by 35

percent from backward castes and the remaining 7 percent were upper caste Hindus. One

percent of the ASHAs belonged to Christian / Muslim communities. All ASHAs were residing

in their respective villages. With regard to the experience, three-fourth (76 percent) ASHAs

had completed more than 18 months of work experience in the field and less than one-fifth

(18 percent) had completed below one year. All the ASHAs had completed 21 days of

residential training in their respective district head quarters. It was also observed that nine

out of ten (92 percent) had attended three days refresher training in the early months of

2008. The ASHA volunteers welcomed the refresher trainings, twice per annum along with

the on-the-job-training of monthly convergence meeting on ASHA Day (last Tuesday of every

month). Most (87 percent) of the ASHAs had children and the average number of living

children was 1.9. While answering the question of the age of last child of ASHA, 54 percent

of ASHAs had their last child born more than 60 months earlier and only 20 percent of ASHAs

have last child born within one year prior to the survey.

4.3 ASHA Selection and Motivation factors for joining

The Commissinerate of Family Welfare conducted dissemination workshops in all the

districts and sub-regions and at lower levels and communicated selection process and ASHA’s

role and responsibilities to the Village Gram panchayat. It is important for the village

community to understand the process and selection of appropriate person as ASHA within

the NRHM framework. More than half of the ASHAs came to know about ASHA selection from

ANMs and Anganwadi workers. About half of the ASHAs indicated that they were selected by

ANM and about one-fifth (21 percent) were recommended by Sarpanch/Politician, followed by

10 percent who were approved/selected by Gram panchayat. The Gram panchayat approved

the selections of ASHAs and nominated them for training at district headquarters. Eighty-nine

percent of ASHAs indicated they preferred to be ASHA in order to serve the community,

earning extra money for the family was indicated by 58 percent followed by 30 percent

stating the purpose to save the children and bring awareness on health issues (Table 4.2).

Working status before joining as ASHA

The Survey collected information from the ASHAs about the work they usually

attended to before becoming an ASHA. More than a half (55 percent) of ASHAs are house

wives / economically active women and less than one third (31 percent) are agriculture

laborers followed by less than 3 percent of ASHAs reporting their association with

ANM/AWW or participation in the health programs of Indira Kranthi Patham ( a program to

eradicate poverty, introduced in Andhra Pradesh).

Training of ASHAs

As per the norm, every ASHA was supposed to attend 21 days residential induction

training and 7 days of field based (at PHC/SC) training. All ASHAs interviewed had attended

the induction training program in their respective district headquarters. Contrary to the GOI

guidelines of ASHA followed in other states in a phased manner, all aspects were highlighted

in the ASHA training by way of group discussions, communication skills, story telling, songs

with health messages in local language, video shows, clearing of doubts in the morning

during assembly and evening between 4-6 pm during training programme.

ASHAs who had attended the residential training were questioned about the topics

covered. The spontaneous responses included maternal and child health, eight tasks of

ASHAs, nutrition and HIV/AIDS. Aspects related to community health and sanitation, curative

care was also included. A special emphasis was made to include aspects of interpersonal

communication (IPC), methods of organizing community meetings, skills to discuss with

higher authorities etc. which were taught and practically demonstrated in the training

program (Table 4.3). The training team used to invite some of the ASHAs of previous batches

and working in the field to the

training program in order to share

the experiences. The training

aspects covered in ASHAs training

was assisted by series of 13

questions. Each correct response

was given a score of one mark and

equal weightage was given. Later,

the scores were categorized into

Grade A- 9-13 correct responses,

Grade B- 6-8 correct responses and

Grade C- 1-5 correct responses.

Eleven percent of the ASHAs scored

Grade A, 50 percent of ASHAs

scored Grade B and 35 percent

scored Grade C. In other words, sixty eight percent of ASHAs had reasonably good

knowledge of training topics. This indicated the need to emphasize some of the aspects in

refresher training programme.

The ASHAs were further asked about the logistic arrangements during their training

period. Training of ASHAs was held in a training institute ambience ‘Mahila Pranganams’ at

the district head-quarters. ASHA trainings were conducted in other states mostly at PHC /

CHC and schools which have relatively poor ambience for training environment for village

women to learn about the health aspects (CORT, 2007). Among the selected districts, 82-97

percent of ASHAs appreciated seating arrangements and 82-95 percent appreciated size of

the room as ‘big’ and ‘good’. More than eighty percent (79-96 percent) of ASHAs appreciated

food arrangements and accommodation facilities. The IIHFW faculty observed during the

field work excellent facilities in majority of training centers though a few complained about

the need for more number and clean toilet and bathroom facilities. All the training centers

were constructed on the outskirts of district head-quarters; the health officials felt difficulty

to monitor daily proceedings of ASHA trainings (IIHFW, Annual Report, 2007-08).

Payments during training

The project officer (District training team, DTT) from the DM&HO office used to

disburse the payments at the end of the last day of training. Each ASHA used to get payments

as per the guidelines. Discussion with the trainers of NGO and the WFS personnel revealed

smooth flow of funds from the CFW to all district training centers in regular intervals.

Scoring Knowledge of Training

Grade B

50.3%

Grade C

38.7%

DK

0.3% Grade A

10.7%

DK Grade A Grade B Grade C

Use of reading material / Drug kit

ASHAs were given reading material ‘ASHA Margadarshini’ in local language on the first

week of training. All ASHA trainees received the manual and used to answer the questions,

exercises on filling the blanks provided at the end of each lesson. About eighty-one percent

of ASHAs indicated that they were provided with ASHA drug-kit during training.

Knowledge of ASHA Volunteers

a) Component of Antenatal services

Knowledge of ASHAs on

antenatal care services was assessed

through seven types of ANC checkups

(Measurement of weight and height, BP

checkups, Blood sample and Hb, Urine

sample examination, HIV Test, Medical

examination / Abdominal Checkup and

Blood grouping). Each correct response

was given a score of one mark,

otherwise zero. They were divided into

Group –A correct answers of 5-7 score;

Group-B correct answers of 3-4 and Group-C below 2 correct answers. Interestingly,

fiftyseven percent of ASHAs knew all aspects of Antenatal services and fortythree percent

reported 3-4 correct answers. The aspects of Antenatal Checkups are widely popular and the

field experience indicates that ASHA worker were requesting for additional incentive for

accompanying the pregnant women for HIV test. More than sixty percent of score was

recorded in East Godavari and Karimnagar districts.

b) Recognizing pregnancy complications

The major signs of complications included in the scoring pattern pertained to those

that required: i) immediate reference to the nearest FRU, ii) request the patient to consult

ANM/PHC, iii) refer to Govt. / Private accredited hospital and iv) call 108 Ambulance. About

sixtyfive percent of ASHAs reported that they advise to shift the patient to the nearest FRU.

Eightytwo percent of ASHAs indicated a call to 108 ambulances for immediate shifting of

patient / pregnant women (Table 4.4).

Score of ASHAs Knowledge on

Antenatal Care

Grade A

56.6%

Grade B

43.4%

Grade A Grade B

c) High risk of pregnant women

Knowledge of ASHA on high risk of pregnant women was assessed by six components

(Short stature, Low age <18 years and above 34 years of age for delivery, first pregnancy,

birth order four and above, High BP/Diabetic symptoms and Anemia). Each correct response

was given a score of one mark,

otherwise zero. We made three groups,

Grade- A correct answers of 4-6 score,

Grade-B correct answers of 1-3 score

and Grade-C zero score. Below one

percent of ASHAs scored Grade- C,

sixtyfour percent of ASHAs scored

Grade-B and thirtysix percent indicated

Grade-A. In other words, ASHAs had

good practical knowledge of identifying

high risk pregnancy and knew where to

shift the pregnant women in case of

emergencies.

d) Complications during delivery

Regarding the complications which can result in maternal mortality at the time of

delivery, ASHAs indicated excessive bleeding (86 percent), blood pressure problem (53

percent), convulsions / fits (53 percent), abnormal position of the foetus (47 percent), and

tetanus (44 percent) respectively. Less than 25 percent of ASHAs mentioned abdominal pain,

foetus died in mother womb and placenta problems (Table 4.5). There is a great need to

reinforce during refresher training and convergence meetings of CARE in the pilot districts

and by department in non-CARE focus districts the knowledge of ASHAs on the factors that

can cause maternal deaths.

Knowledge about Newborn Care

Less than forty percent (38 percent) of the ASHAs said that newborn are most likely

to die between 3-4 weeks of birth, followed by thirtyone percent of the ASHAs who reported

it could be soon after the birth/first day birth and about 23 percent mentioned a period

within one week of birth. Another 20 percent of ASHAs indicated ‘Don’t know’ (Table 4.6). A

lower percent of ASHAs with lack of knowledge about Neonatal death varied (4-5 percent) in

Mahabubnagar and Karimnagar districts of Telangana regions.

Score on High Risk Pregnancy

Grade B

63.8%

Grade A

35.6%

DK

0.6%

DK Grade A Grade B

Knowledge about role and responsibilities

The evaluation study explored ASHAs familiarity with their roles and

responsibilities (tasks). The aspects included: help in bringing children for immunization,

accompanying delivery cases to health facility, health awareness activities, providing ANC

counseling, working with

Anganwadi worker, registration of

births and deaths, motivating and

mobilizing community on health

and sanitation aspects, family

planning information, Village

health planning, counseling

villagers on health aspects,

promotion of good health

practices, treatment of minor

elements, timely referrals,

participation in National

programme and working for DOTS. Each of these fifteen tasks of ASHA volunteers was scored

as one mark for correct response and equal weightage was given for incorrect answer. Later

the scores were categorized into three Grades, Grade-A 12 -15 correct responses, Grade-B 8-

11 correct responses and Grade-C for 4-7 correct responses. About a half of the respondents

were in Grade B (8-11 correct responses) followed by 42 percent in Grade C (4-7 correct

responses).

A comparison of individual tasks of ASHA volunteers is presented in Figure-1. The

familiarity of tasks indicated by ASHAS were immunization services (98%) provision of ANC

care (97%), accompanying delivery cases (85%), family planning operations (71%), working as

DOT provider for TB cases (59%). A lower number of ASHAs indicated counseling (13%) and

work with AWW/Dai (17%) as their responsibilities in (Table 4.7). A few ASHA volunteers

stated that they promote good health facilities, counseling and timely referrals as their other

responsibilities. These are the core areas which need emphasis during refresher training,

CARE-INDIA convergence meetings on ASHA Day and the on-the-job trainings.

Score of ASHA responsibilities

Grade C

42.2%

Grade B

50.1%

Grade A

7.7%

Grade A Grade B Grade C

Figure 1 – ASHA’s awareness about their responsibilities

98.3

84.8

46.3

97.4

16.7

50.1

31.8

71.3

30.1

13.5

21.5

55.8

28.9

55

44.1

58.6

0 20 40 60 80 100 120

Help in immunization program

Accompanying delivery cases

Create awareness on health

Provide ANC Care

Work with Anganwadi Worker/Dai

Registration of birth and death

Motivating & mobilizing community

Family Planning

Village health planning

Counselling

Promote good health practices

Treatment of minor ailments

Make timely referrals

Increase in Institutional delivery

Participating in National Health Program

Working as DOT provider for TB cases

Organization of work by ASHAs

Ninety-eight percent of ASHA volunteers organized their work regularly and

coordinated with the ANM and Anganwadi center activities in the village. The respondents

unanimously indicated that they used to meet ANM/AWW during the weekly immunization

sessions and called all the pregnant women for timely ANC check-up and helping in

organizing of Village Nutrition Day at AW center. Field experience indicates that majority of

ASHA volunteers were highly dependent on ANM and AW workers. The roles and

responsibilities and the work organization of ASHA indicates that the ASHA was acting as

assistant to the ANM/AWW rather than a village health activist.

Research studies indicated that the work performance of ASHA is highly linked to JSY

beneficiaries accompanying to hospital for delivery, Family Planning operations and bringing

children for immunization rather than attending to other tasks. A potent program like ASHA

was being used for merely escorting women to the hospital and assisting the ANM and AWW.

This requires a re-look at the activities and ensures that ASHA gets sufficient role in the

NRHM as envisaged in the document.

Record updation

Thirtyseven percent of ASHAs in the survey revealed that they maintained records

regularly (23-24 percent in Kurnool and Mahabubnagar districts and 63 percent in East

Godavari district). The weekly updation of records varied between 29-53 percent across

districts. Thus the survey indicated that 66-80 percent of ASHA volunteers update their

records within seven days. It should be emphasized that cent percent of births and deaths

registration in the village be done immediately or within one week. A combined effort of all

ASHAs in every village may provide a timely and reliable estimate of infant deaths and

maternal deaths at district level (Table 4.8).

ASHAs clientele

ASHA volunteers indicated that they provided services to the client, on an average

six days prior to the survey date (the model / mode of average days reported was two days).

CORT research studies indicated that the provision of services by ASHAs to the clientele was

on an average 28 days in Orissa, 25 days in Bihar (CORT, 2007). It is also very heartening that

the services provided to the clients were accompanying for institutional deliveries of JSY (94

percent), Family planning operations (80 percent), Diarrhea/ARI cases (31 percent) and

Accident/Born cases (19 percent) respectively. It is also observed that a small percent of

ASHAs indicated that they are accompanying the client to PHC/CHC for other health related

purposes including ANC Check up, HIV test for pregnant women, distribution of DEC, eye

operations, and Thyroid care.

Less than half of

the clientele of ASHA

belonged to Scheduled

Caste and Tribe

communities followed

by forty-seven percent

of backward caste (BPL

group) remaining were

of general category

(10%). The grading of

the eleven types of

services provided by

ASHA to the clients is

presented in (Table 4.9). Each correct response was given a score of one mark and equal

weightage was given. Later, the scores were categorized into Grade- A 8-11 correct answers,

Grade-B 5-7 and Grade-C 5 or less correct answers. In all only 11% of the ASHAs scored Grade-

Scoring knowledge of services provided to clients

Grade C(<5)

46.8%

Grade B(5-7)

42.6%

Grade A(8-

11)

10.6%

Grade A(8-11) Grade B(5-7) Grade C(<5)

A, 43 % scored Grade-B, and 47% Grade-C. The purpose of clients who visited ASHA for the

purpose of collecting medicines, for fever, back pain and vomiting (82 percent), child

immunization (77per cent), antenatal care advice (64 percent), and registration of pregnant

women for ANC (59 percent).

Ninety-eight percent of ASHAs handled a JSY case for delivery in hospital and the last

JSY client was accompanied 24 days prior to the date of interview. Ninety-three percent of

ASHAs stayed with the client at the place of delivery and average number of days of stay was

1.87 (the number recorded 2.19 in East Godavari and 2.25 days in Mahabubnagar districts).

Seven out of ten (71 percent) of ASHAs stayed for one day, 15% stayed for two days along

with the JSY beneficiary for delivery services.

Perceptions of ASHA

The informal qualitative information from the selected village leaders, panchayat

members and elders and ANMs indicated that the ASHA programme intervention has value

added as observed by higher turnout of mothers for child immunization, ANC checkups and

preference of institutional delivery as compared to home deliveries. In Ahobilam PHC of

Kurnool district, the ASHA worker daily visited S.C colony for monitoring the consumption

tablets provided under DOTS programme. The important suggestions reported by ASHA were

timely (monthly) payment of incentives (91 percent), having a dress for ASHA for easy

identification (71 percent), timely supply of drug kits and drugs replacement (56 percent),

arrangement for transport / Bus pass for attending hospitals for delivery of JSY beneficiaries

(51 percent), increase in cash incentives / equal remuneration for all communities (43

percent), improvement of facilities at village or at hospital to ASHA (33 percent) are the

major suggestions (Table 4.10). A meager percentage of ASHAs reported higher interaction of

lady doctors/doctors/ Nurse with JSY beneficiaries, higher propagation in media regarding the

NRHM (ASHA and JSY), good behavior of hospital staff towards ASHA and no doctors/ANM

not demanding perks for timely payment of incentives.

The common suggestions for improving the ASHA intervention were mainly related

to enhancing the cash assistance for making timely money payments, provision of complete

information and practical trainings. Propagation of the NRHM schemes by the lady medical

officer, doctors and nurses helping ASHA to propagate healthy practices easily in the

community.

A half of the ASHAs mentioned the complaints of JSY beneficiaries about untimely

payments, staying long hours away from home, un-timely schedules, dislike of the

husband/family for her job (29 percent), reluctance among families and women to go for

institutional delivery (25 percent), reluctance of women to consume IFA tablets (16 percent)

which constituted major challenges faced by ASHA volunteers in delivering the services3

(Table 4.11).

Cash remuneration received by ASHAs

ASHAs were asked about

the delay in cash incentives received

by them. The JSY incentive received

by ASHA varied substantially from

one day (3 percent) to more than

one month (56 percent). The various

reasons for the delay are given in

Table 4.12. Thirty-eight percent of

ASHAs indicated delay in the

approval process of incentives, and

27 percent mentioned lack of

advance money at the medical

facility. Less than ten percent of

ASHAs indicated non-availability of

signing authority or delay in obtaining Sarpanch signature etc.

The ASHAs were asked about the case incentives received by them. Eighty percent of

ASHAs received remunerations for child immunization, 74-79 percent for escorting delivery

(of JSY beneficiary) followed by family planning cases and antenatal care. About 42 percent of

ASHAs had received remuneration for National Health Programs and 19 percent for DOT

services.

Regarding duration of work as ASHA it was found that 60 percent had worked for

more than two years and marginal variations were reported in the selected districts. More

than 64 percent had completed two years of work as ASHA in Srikakulam, East Godavari and

Karimnagar districts. On the other side, about 40 percent in Kurnool and 29 percent in

Mahabubnagar districts indicated below 18 months of work experience. Ninety-eight

percent of ASHA volunteers had received incentives during three months preceding the

reference period. The government of Andhra Pradesh developed a special work and

remuneration record sheet for ASHA workers. Based on the performance, the ASHA will enter

the details and that will be counter signed by ANM after verification and endorsement by the

sarpanch. The different items covered are a) Number of pregnant women registered in the

first trimester (SC family cases only); b) 3 ANC received from ANM / Other health staff (SC

family only); c) Pregnant women received at least one ANC from doctor (SC and BPL families);

d) institutional deliveries (SC and BPL families); e) Post natal care by home visit (SC and BPL

Score of Remuneration by ASHA

>3 Months

18.4%

After 1

Month

59.6%

Below 1

Month

19.0%

Same day

3.0%

Same day Below 1 Month

After 1 Month >3 Months

families); e) infants who received vaccinations (both SC and BPL families); f) children who

received Measles and Vitamin - A (both SC and BPL families); g) registration of birth with birth

weight below 2000 grams (both SC and BPL families); h) family planning methods (both SC

and BPL families and other than the general RCH activities) respectively.

Out of 919 ASHA volunteers who indicated the incentives, only 74 percent

mentioned information of items (a) to (h) and the remaining 242 respondents stated family

planning incentive and the total amount only. The ASHAs, on an average earned about Rs.

545/- (range of Rs. 200 – 1875; calculated on the basis of cases motivated for RCH activities in

the reference period of

three / one month) prior to

the survey. ASHAs received

higher incentives for

accompanying institutional

delivery (36 percent), post

natal care (19 percent), one

ANC with MBBS doctor (13

percent), Measles and

Vitamin-A ((11 percent)

respectively4. From the

responses, the average

figure recorded for RCH

activities was Rs. 467/- (a

range of Rs. 300 – 1100).

Only one-fifth of ASHAs (19 percent) were satisfied with incentive they had received

(more than state average recorded in Karimnagar 32 percent) followed by Kurnool (28

percent). Sixty-seven percent of ASHAs were not satisfied with the cash assistance

commenting on ‘too much work with too little payment’ followed by delays in receipt of

payment. ASHA is one of the main actors in the Mission, and the woman responsible for a

variety of tasks, but she does not have a fixed remuneration (Rajyalakshmi, 2008). The study

also enquired the respondents to mention the ‘willingness to receive’ or the expected salary

of remuneration. Thirty seven percent of ASHAs viewed the salary between Rs. 1500-2000

and slightly lower than 32 percent indicated Rs. 1000/- as a fixed remuneration (Table 4.13).

The mean salary expected was RS. 1600/- and the model salary (indicated by majority of

ASHAs) expected was Rs. 2000/ respectively.

INCENTIVES RECEIVED BY ASHA

Newborn <

2000 gms

0.7%

Measles &

Vit.A

11.5%

Immunization

7.4%

Postnatal Care

19.5%Institutional

Delivery

36.1%

One ANC by

Doctor

13.4%

3 ANC by ANM

7.1%

ANC in first

trimester

4.3%

ANC in f irs t t rimester 3 ANC by ANM

One ANC by Docto r Inst itut io nal D elivery

P ostnatal C are Immunizat ion

M easles & Vit .A Newbo rn < 2000 gms

Monitoring System

All ASHA volunteers reported proper maintenance of record book (including

information a) on pregnant woman particulars, b) information on child immunization

coverage, and c) record of health services provided and particulars on remuneration

received). Field experience indicates that ASHAs were updating information on regular basis

in all the districts. Ninetynine percent of ASHAs were aware of monthly ASHA Day meetings

and equal number attending regularly, obtaining counseling from district program officers,

PHC staff along with NGOs (Table 4.14). Ninetyeight percent of ASHAs indicated the

usefulness of the ASHA Day. However, when it came to payment of TA/DA of RS.40/- towards

attending ASHA Day, the matter required close monitoring by program officers. Srikakulam

district results indicate that 97 percent of payments of TA & DA followed by 73-80 percent in

East Godavari, Mahabubnagar, and Karimnagar districts. Sixty percent of volunteers reported

timely payment of TA&DA in Kurnool district which requires improvement in regular

monitoring.

Some of the ASHA’s stated that special incentives were required namely for

conducting survey work (72 percent), increase of PPI incentive (37 percent) followed by

assisting School Health Program (35 percent) (Table 4.15). The CARE organization

intervention through training ASHAs in IYCF aspects improved their knowledge levels on

newborn care in the eight districts.

Moreover the ‘Supplementary Nutrition Model’ initiated by Andhra Pradesh

government under NRHM was a role model for other states to emulate. Under the program

daily nutritious / iron-rich food supply starts from fourth month of pregnancy for all pregnant

women on a daily basis at village-level through self-help groups. A pilot project showed on a

sample of 2150 pregnant mothers, no single case of maternal mortality and the birth weight

of babies were above 2.75 kilograms (The Hindu, 15th December 2008).

Cash Incentives to ASHAs

Almost all ASHAs received cash incentive money for RCH services and FP services.

Majority of ASHAs received incentives for escorting JSY beneficiary for delivery to a hospital

(36 percent) followed by postnatal care (19 percent), at least one ANC by a MBBS doctor (13

percent) and Measles and Vitamin A to the children below one year (11 percent) respectively.

The mean monthly amount received by ASHA volunteer was Rs. 574/- (ranging between Rs.

493 in Karimnagar and Rs. 669 in Mahabubnagar districts). Seven out of ten ASHAs were

unsatisfied with cash incentives as it was ‘too much work with little incentive money’ or

‘because of delays in payments’ respectively.

To sum up, the training strategy of 21 days and 7 days of field training of ASHAS

rendered it possible to deploy them in their villages and we can assess the performance of

ASHAs, as well as suggestions and corrections to be taken up by the mission. ASHA’s

knowledge on various reproductive and child health aspects was good; however, there is a

need for strengthening their knowledge about registration of ANC in first trimester,

consumption of IFA tablets and nutritious food, counseling during ANC on best practices,

new born care etc. ASHAs are coordinating their work with ANM and AW centers and helping

them on immunization day and monthly nutrition days. ASHAs mentioned areas of

strengthening that could be incorporated in refresher training, monthly on-the-job trainings

in the convergence meetings by CARE and NGOs. Timely payment of incentives and dress

code to ASHA are welcomed. The incentives limited to SC and ST groups may be extended to

all pregnant women from other communities who are economically backward.

Table 4.1 – Andhra Pradesh: Profile of ASHA Functionaries

Profile SKLM EG KRL MHBN KRM All

Total number of ASHAs interviewed 176 224 179 165 197 941

Age of ASHA (in completed years)

Below 19 years 1.7 1.3 2.8 6.7 1.0 2.6

20 – 24 years 25.6 15.2 21.2 32.1 35.0 25.4

25 – 29 years 42.0 42.0 34.6 36.4 40.1 39.2

30 – 34 years 19.3 21.4 20.7 17.6 18.3 19.6

35 years & above 11.4 20.1 20.7 7.3 5.6 13.3

Mean (in years) 27.54 29.50 28.97 26.32 26.65 27.88

Year of schooling completed

No formal education 0.6 1.3 1.1 1.8 0.0 1.0

Studied up to 5th class 13.6 17.9 13.4 10.9 7.1 12.8

7th standard 20.5 16.1 17.9 15.8 23.9 18.8

Secondary ( 8 – 10 standard) 60.8 58.5 58.1 65.5 62.4 60.9

Inter and above 4.5 6.3 9.5 6.1 6.6 6.6

Mean (years of schooling) 3.55 3.50 3.61 3.63 3.69 3.59

Caste / Tribe of ASHA

Scheduled Caste & Tribe 48.3 74.1 50.8 40.0 64.0 56.7

Backward Caste 46.0 18.8 36.3 49.1 31.0 35.1

Other Community 5.7 6.7 9.5 9.1 4.1 6.9

Minority 0.0 .4 3.4 1.8 1.0 1.3

Table 4.2 – Andhra Pradesh: Motivation for being an ASHA

Profile SKLM EG KRL MHBN KRM All

Total number of ASHAs interviewed 176 224 179 165 197 941

Means of Selection

Selected/approved by Gram Panchayat 23.9 32.1 6.7 16.4 12.7 18.9

ANM got me selected 32.4 37.5 78.2 64.2 46.7 50.9

Was working as Anganwadi Worker 3.4 0.4 1.7 0.6 2.5 1.7

VHSC 0.6 1.3 0.0 0.0 0.5 0.5

Because of my good nature 0.0 0.0 0.6 1.8 0.0 0.4

Because of Politician / Sarpanch 39.8 26.3 6.7 10.9 17.3 20.5

Mahila Samithi / by PHC members 0.0 1.3 3.9 1.8 3.0 2.0

Others 0.0 0.9 2.2 4.2 17.3 5.0

Profile SKLM EG KRL MHBN KRM All

Reasons for wanting to be an ASHA*

Serving / helping the community 92.6 97.8 81.0 85.5 86.8 89.2

Earning money 78.4 60.3 43.6 47.3 59.9 58.1

To remove misconceptions 5.7 4.9 2.2 9.7 4.6 5.3

Bring awareness on health issues 23.3 38.4 27.4 33.3 23.4 29.4

Save children from dying / for benefit of

children 25.6 46.4 13.4 40.6 11.2 27.8

Others 0.0 0.9 6.1 2.4 1.5 2.1

* Multiple responses

Table 4.3 – Andhra Pradesh : Topics Covered in the Training of ASHA

Profile SKLM EG KRL MHBN KRM All

Total number of ASHAs interviewed 176 224 179 165 197 941

Topics covered during training program for

ASHA*

Women and Health (ANC, breast-

feeding) 100.0 98.7 100.0 95.8 96.4 98.2

Infant and Child Care (Immunization) 97.7 98.2 97.2 98.2 93.4 96.9

ASHA (my eight tasks) 21.0 9.8 18.4 21.2 8.6 15.3

Reproductive and Sexual Health

problems 18.2 17.9 11.7 13.9 16.8 15.8

Aspects on safe drinking water 23.9 33.5 50.8 31.5 31.5 34.2

Disposal of waste water / clean drainage 46.0 56.7 62.6 39.4 55.8 52.6

Nutrition 77.8 70.1 62.0 52.1 69.0 66.6

HIV and AIDS 73.9 81.7 59.2 66.7 82.2 73.4

Curative Care 27.8 62.5 30.2 27.9 42.6 39.6

Organizing a group meeting 6.3 12.5 2.8 14.5 6.1 8.5

Adolescent health education of girls 11.9 46.9 28.5 29.7 36.0 31.6

Management of Diarrhea and

Pneumonia 30.1 33.0 9.5 21.2 25.9 24.4

Family Planning methods 85.2 57.6 39.7 58.2 68.5 61.7

Percent mentioned logistics arrangements at

training were adequate / good

Sitting arrangements 96.6 87.5 82.7 81.8 86.3 87.0

Size of the room 94.9 82.1 86.0 89.1 85.3 87.1

Accommodation facilities 96.0 79.0 83.2 87.9 87.8 86.4

Arrangements for food 91.5 78.6 83.8 73.9 89.8 83.5

* Multiple responses

Table 4.4 – Andhra Pradesh: Actions Supposed to be Taken if ASHA

Recognize Signs of Complications in Pregnant Women*

Profile SKLM EG KRL MHBN KRM All

Immediately refer to the nearest FRU (CHC) 60.8 62.9 61.5 57.0 80.7 64.9

Ask her to consult the ANM the next day 52.8 50.9 31.3 38.2 20.8 39.0

Refer to Govt. accredited hospital 26.1 17.0 28.5 33.3 18.3 24.0

Refer to Private hospital 4.0 4.9 3.9 7.9 12.7 6.7

Call 108 91.5 84.4 72.1 81.2 81.7 82.3

* Multiple responses

Table 4.5 – Andhra Pradesh: ASHA’s Knowledge about Common

Complications during Delivery that could Result into Maternal Mortality

Profile SKLM EG KRL MHBN KRM All

Total number of ASHAs interviewed 176 224 179 165 197 941

Common complications during pregnancy /

delivery that can result into death of a woman*

Excessive bleeding 96.0 95.5 72.1 86.1 77.7 85.8

Tetanus 30.1 73.7 29.1 27.3 50.3 44.0

Blood pressure problem 40.3 52.2 64.8 60.0 46.2 52.5

Abdominal pain 34.1 22.3 8.4 33.3 23.9 24.1

Abnormal position of the foetus 19.9 67.0 34.6 41.2 62.9 46.7

Convulsions / fits 75.6 41.1 46.4 40.6 60.9 52.6

Foetus dies in mother’s womb 13.6 9.8 26.8 32.7 60.4 28.4

Fever 57.4 25.9 37.4 21.8 30.5 34.2

Placenta problems 7.4 6.3 14.5 13.3 11.2 10.3

* Multiple responses

Table 4.6 – Andhra Pradesh: Knowledge about Likelihood of

Neonates Dying after Birth

Profile SKLM EG KRL MHBN KRM All

Total number of ASHAs interviewed 176 224 179 165 197 941

Period (in life) when newborns are most likely

to die

Soon after birth / first day of birth 18.8 20.1 33.5 47.9 36.5 30.7

Within one week of birth 40.9 21.0 22.3 18.8 12.7 22.8

Between one to two weeks of birth 11.4 5.8 4.5 4.2 3.0 5.7

Between 3 – 4 weeks of birth 29.0 53.1 37.4 25.5 43.1 38.7

Others 0.0 0.0 2.2 1.8 3.6 1.5

Don’t Know 0.0 0.0 0.0 1.8 1.0 0.5

Table 4.7 – Andhra Pradesh: ASHA’s Awareness about their Responsibilities

Profile SKLM EG KRL MHBN KRM All

Help in immunization program 100.0 99.1 100.0 98.2 94.4 98.3

Accompanying delivery cases 88.1 90.6 91.1 70.9 81.2 84.8

Create awareness on health 30.7 51.8 49.2 42.4 54.8 46.3

Provide ANC Care 99.4 99.6 97.8 93.9 95.9 97.4

Work with Anganwadi Worker/Dai 27.8 8.5 14.5 24.2 11.7 16.7

Registration of birth and death 80.1 53.1 25.7 50.3 41.6 50.1

Motivating & mobilizing community 39.2 26.3 23.5 26.7 43.1 31.8

Family Planning 84.1 70.1 50.3 66.7 84.3 71.3

Village health planning 27.8 20.5 35.2 37.6 32.0 30.1

Counseling 5.7 23.2 14.0 13.3 9.1 13.5

Promote good health practices 9.7 28.1 27.9 24.2 16.2 21.5

Treatment of minor ailments 39.2 73.7 44.7 41.2 72.6 55.8

Make timely referrals 23.3 34.8 37.4 23.6 23.9 28.9

Increase in Institutional delivery 69.3 59.8 47.5 40.0 56.3 55.0

Participating in National Health Program 63.1 72.3 8.4 33.3 36.5 44.1

Working as DOT provider for TB cases 48.9 72.3 43.6 53.3 69.5 58.6

Table 4.8 – Andhra Pradesh: Networking of ASHA with other Stakeholders

Profile SKLM EG KRL MHBN KRM All

Meet ANM / AWW regularly 98.9 99.6 99.4 99.4 100.0 99.5

Frequency of meeting ANM/AWW in

Village immunization sessions 99.4 100.0 98.3 98.8 98.5 99.0

Help in conducting village surveys 81.8 96.9 89.4 87.9 98.0 91.3

Call ANM/AWW for Nutrition day /

camps 78.4 89.7 89.4 86.7 92.4 87.6

Call all pregnant women for timely ANC 96.0 98.7 96.6 94.5 86.8 94.6

Updating Records

Daily once 30.1 62.9 24.0 23.0 35.5 36.7

Weekly once 35.8 28.6 53.1 48.5 45.2 41.6

Fortnightly 15.3 3.1 5.0 6.1 2.0 6.1

Once in a month 15.3 2.7 14.0 17.6 16.2 12.6

Less frequently 2.3 1.8 0.0 4.2 0.0 1.6

Incomplete 1.1 0.9 3.9 0.6 1.0 1.5

Table 4.9 – Andhra Pradesh: Working Situation of ASHA

Profile SKLM EG KRL MHBN KRM All

Working days back the client availed ASHA services

Mean 4.78 5.73 8.42 8.15 3.50 6.02

Median 4.00 3.00 5.00 5.00 2.00 4.00

Mode 5 2 3 1 2 2

Caste of the client

SC 31.3 35.3 34.6 37.0 52.8 38.4

ST 12.5 12.9 5.0 11.5 1.5 8.7

BC 52.8 30.8 43.0 47.9 41.1 42.4

General 3.4 21.0 17.3 3.6 4.6 10.5

Reasons for interaction or ASHAs contact with them*

Collect medicines for fever, backpain,

vomiting 96.6 88.4 74.9 60.0 88.3 82.4

Pregnant woman for registration 65.9 46.4 71.5 36.4 76.1 59.3

Antenatal care / advise 72.7 67.4 69.3 43.6 64.5 64.0

IFA tablet distribution 55.1 33.0 55.3 37.6 58.9 47.6

Delivery / advice about place of delivery 61.9 48.7 39.1 24.8 27.9 40.8

Helping mother to get JSY for BPL 50.0 27.2 13.4 10.9 26.4 25.8

Postnatal care 52.8 38.8 30.2 20.6 36.0 36.0

Immunization 84.7 81.3 80.4 43.0 90.9 77.0

Information about FP methods 48.3 19.2 25.1 11.5 42.6 29.3

Procuring Mala D and condom 8.5 3.1 3.9 4.8 8.6 5.7

Treatment / advise for pain in lower

abdomen 5.1 4.5 7.8 9.7 4.1 6.1

No. of days since ASHA last accompanied a

woman for delivery 25.46 17.55 28.60 25.46 23.98 23.87

Number of ASHAs who had handled a JSY

case 98.9 99.1 99.4 97.6 95.9 98.2

Percent of ASHAs who stayed with JSY

beneficiary at the place of delivery 99.4 97.7 95.5 82.6 88.4 93.1

Average Days ASHA stayed with JSY beneficiary

at place of delivery 1.77 2.19 1.66 2.25 1.48 1.87

Table 4.10 – Andhra Pradesh: Suggestions ASHAs Work

Profile SKLM EG KRL MHBN KRM All

Suggestions made by ASHA for improving the scheme*

Should get monthly payment 98.9 95.1 70.4 92.7 94.9 90.6

Cash assistance should be more 47.2 50.0 23.5 44.2 49.7 43.4

Some officials / doctors / nurse should

come and talk about JSY 15.9 17.0 5.6 15.2 3.6 11.5

Should give complete information 17.0 25.4 18.4 18.8 36.0 23.6

Lady doctor should be there 7.4 4.0 2.2 10.9 24.9 9.9

Arrangement of transport / bus pass 65.3 55.4 28.5 49.7 57.4 51.5

ASHA should have a dress code 75.0 89.3 46.4 52.7 85.8 71.3

Should get good / practical training for

ASHA 38.6 37.9 26.8 29.7 20.3 30.8

Facilities should be improved 40.9 40.2 14.0 30.3 35.5 32.6

Should use posters, role play for training

ASHA 4.0 12.5 5.6 4.8 2.5 6.2

More incentive for sterilization 38.6 18.8 1.7 21.8 30.5 22.2

More propagation / advertise on TV / Paper 2.3 1.8 3.9 8.5 14.7 6.2

Good behaviour with woman at the place

of delivery 6.8 14.7 4.5 12.7 5.6 9.0

Should get drug or medicine kit 64.8 75.4 36.9 35.2 58.9 55.6

People should recognize me as ASHA 49.4 22.3 10.6 23.0 14.2 23.6

Health systems should deal with myths and

misconceptions 1.1 2.2 0.6 3.6 5.6 2.7

Cash assistance should be given timely,

doctors / ANM should not demand money 6.3 2.7 3.4 7.9 0.5 3.9

Others 6.8 29.0 36.3 9.7 19.8 20.9

* Multiple responses

Table 4.11 – Andhra Pradesh: Challenges faced by ASHAs

Profile SKLM EG KRL MHBN KRM All

Village people are not ready for

institutional delivery 34.7 21.9 15.1 32.1 25.4 25.5

I do not get money on time 45.5 57.6 35.2 52.1 52.8 49.1

Woman do not listen regarding

immunizing child 11.4 9.8 17.9 17.0 7.6 12.4

Opposition from community / illiterate

people 9.1 21.0 6.7 13.3 27.9 16.2

Women are not ready to take IFA tablets 14.2 12.9 5.6 24.2 21.3 15.5

Women do not listen regarding weighing

the baby 4.5 3.1 2.8 8.5 6.1 4.9

ANM does not allow to work 0.0 1.3 1.1 3.0 2.0 1.5

Sterilization cases motivated by us are

registered by ANM 5.7 3.6 2.2 7.3 4.6 4.6

My husband / family do not like my job 38.1 22.3 12.8 23.0 50.8 29.5

Others / doctors says if woman dies it will

be ASHA’s responsibility / other ASHAs take

away my cases

1.1 1.3 3.4 4.8 1.0 2.2

No distinction of incentives for ASHA

working in SC colony and other areas 6.3 9.8 0.6 6.1 14.2 7.7

Table 4.12 – Andhra Pradesh: Reasons for Delay in Incentive Payments

Profile SKLM EG KRL MHBN KRM All

Lack of advance money at the facility 38.6 25.0 11.7 19.4 38.1 26.8

Got money after 2 – 3 months 22.2 29.0 2.8 20.6 32.0 21.9

Delay in payment by ANM 7.4 4.9 1.1 1.8 1.5 3.4

Not getting amount as per entitlement 0.0 0.9 3.4 12.7 1.0 3.3

Delay in approval process 18.2 39.3 73.7 39.4 22.3 38.4

Signing authority not available 0.0 0.0 0.6 2.4 1.5 0.9

Sarpanch not signing 0.6 0.4 1.1 1.2 0.0 0.6

Table 4.13 – Andhra Pradesh: Salary Expected per Month by

ASHA Volunteer as Remuneration

Salary Amount (Rest) SKLM EG KRL MHBN KRM All

<1000 18.8 28.6 56.4 30.3 26.4 31.9

1001-1500 33.0 22.8 17.9 21.2 25.4 24.0

1501-2000 40.9 39.7 19.6 36.4 45.7 36.8

>2001 7.4 8.9 6.1 12.1 2.5 7.3

Total 100.0 100.0 100.0 100.0 100.0 100.0

Mean salary expected is 1600/-

Median salary expected is 1500/-

Mode salary expected is 2000/-

Table 4.14 – Andhra Pradesh: Awareness of ASHA Day Attendance and TA and DA

Awareness SKLM EG KRL MHBN KRM All

Awareness of ASHA day 99.4 100.0 97.2 98.8 100.0 99.1

Attending regularly ASHA day 99.4 100.0 98.9 99.4 99.0 99.4

Usefulness of ASHA day 99.4 100.0 98.9 93.3 98.5 98.2

Receipt of TA/DA for attending ASHA day 97.7 76.3 59.8 80.6 73.1 77.3

Table 4.15 – Andhra Pradesh: ASHAs Expect Incentive for the Activities*

Profile SKLM EG KRL MHBN KRM All

Doing survey work 86.4 84.4 52.5 70.3 62.4 71.6

Assisting school Health prog. 61.9 41.1 20.7 37.6 14.7 35.0

Conducting health Camps 47.2 31.7 14.0 27.3 12.7 26.5

Covering >1000 Population 22.7 10.7 3.9 12.7 16.2 13.2

Increase PPI incentive 42.6 29.9 7.3 28.5 73.6 36.9

Processing to get JSY benefits 26.1 14.3 11.2 13.9 3.6 13.6

Others 3.4 12.9 16.2 9.1 4.1 9.2

*-Multiple responses

CHAPTER-5

BENEFICIARIES OF ASHA FOR DELIVERY CARE

The selection, training, work performance, cash incentives, and suggestions for

improvements were discussed at length in the previous chapter. We have highlighted that

more than eighty percent of clients/ beneficiaries availed ASHA services for escorting delivery

in the medical institution.

The second important intervention after ASHA under NRHM is the Janani Suraksha

Yojana (JSY) all over the country to promote safe delivery practices. Cash assistance is

integrated with antenatal care during the pregnancy period, institutional care during delivery

and immediate post partum period in health continue by establishing a system of

coordinated care by field level health worker.

In the beneficiary survey we interviewed about 1440 JSY beneficiaries in all the

villages who had availed the services of ASHA in the recent past prior to the survey.

Awareness of the programme, complete information, understanding of program, eligibility

criteria of beneficiaries, cash assistance etc play a crucial role in the success of the

intervention.

5.1 Respondent profile

The respondent profile of JSY beneficiaries is presented in Table 5.1. The mean age

of the woman respondent was 22.8 years. Only 3 percent of respondents were aged more

than 30 years. Nine out of ten women respondents were in the age group of 20-29 years.

Forty percent of respondents had no formal education and the figure varied across districts

of Mahabubnagar (64 percent) and Kurnool (51 percent) respectively.

In the sample, less than 11 percent of respondents had passed intermediate and

higher education level. Less than sixty percent (58 percent) of JSY respondents belonged to

BC community (with BPL white card) and remaining 42 percent were from SC and ST

community. The average household monthly income was Rs.2034/- and varied between

Rs.1840/- in Karimnagar and a high of Rs. 2271/- in Mahabubnagar district respectively. About

65 percent of respondents (residing in the ASHA volunteers locality) were providing the

services in the SC/ST and BC colonies respectively.

5.2 Awareness about JSY

The JSY beneficiaries were enquired about how and when they had heard about the

scheme. More than a half (55 percent) of respondents knew about JSY scheme during the

pregnancy and slightly more than

one third (36 percent) of

respondents had heard of it before

being pregnant / before ANC

registration. Regarding the source

from where they heard of JSY, about

82 percent mentioned ASHA

volunteer and 66 percent as ANM.

Around 20 percent of beneficiaries

indicated other sources of

information like T.V, Radio,

Relatives and Gram panchayat

(Table 5.2). The knowledge

regarding JSY scheme in the state

was mainly disseminated through interpersonal communication rather than mass-media

channels.

5.3 Knowledge on JSY Aspects

The JSY beneficiaries were enquired about the details regarding JSY scheme which

they were told. More than sixty percent (66 percent) of the beneficiaries understood that

they would get some money for availing JSY services and thirty six percent (36 percent) heard

JSY as a scheme for promotion of institutional delivery (Table 5.2). About Thirty percent (30

per cent) mentioned the free institutional delivery for poor pregnant women and twentysix

percent (26 per cent) stated that the scheme was intended to improve the intake of

nutritional food for the benefit of

pregnant women. A few

respondents viewed that JSY is for

population control and did not

know about the scheme. Wide inter-

district variations were recorded

regarding the purpose of JSY. It is

essential that correct message is

communicated before ANC

registration. Better BCC is required

to focus correct and consistent

message is disseminated about the

scheme.

Time when Beneficiary heard about JSY

After

Delivery

9.4%

During

pregnancy

54.7%

Before

being

pregnant

35.9%

Before being pregnant During pregnancyAfter Delivery

Score of Beneficiaries heard about JSY

Grade O

10.3%

Grade A

71.6%

Grade B

18.1%

Grade O Grade A Grade B

An attempt was made to score the knowledge levels of JSY beneficiaries. The five

items regarding JSY included were: a) provision of cash incentive for hospital delivery b)

promoting institutional delivery c) family planning d) free institutional delivery for poor

women and e) nutritional benefit and transportation. Each correct response was given one

mark. Responses were categorized into three Grades. Grade O-Don’t Know, Grade A- 1-2

correct responses and Grade B 3- 5 correct responses. Seventytwo percent (72 percent) of

beneficiaries indicated 1-2 correct responses and Eighteen percent (18 per cent) indicated 3-

5 correct responses.

5.4 Utilization of ANC Services by JSY Beneficiaries

The beneficiaries were asked about the month and place of registration for ANC.

Sixty percent of beneficiaries registered for ANC during first trimester. Wide variation was

reported across districts. More than three fourth (79-88 percent) of beneficiaries in East

Godavari and Karimnagar registered for ANC in their first trimester of pregnancy. Less than

half of respondents (46-48 percent) registered in first trimester in Srikakulam and

Mahabubnagar districts followed by 39 percent in Kurnool districts. Three percent of

beneficiaries indicated ‘Don’t Know’ / ‘No contact’. In order to reduce the pregnancy

complications, ASHA volunteers must ensure cent per cent of ANC coverage in first trimester

(Table 5.3). The respondents availed ANC services for the index child from PHC/ Sub centre

(49 percent), private accredited hospitals (32 percent) and Sub-district/CHC (16 percent)

respectively. On an average, four ANC checkups (ranging 1 - 9) were reported during their

pregnancy period by JSY beneficiaries in the selected districts.

5.5 Role of ASHA in Micro-Birth planning

The Micro-Birth planning

includes counseling and informing

the date and place of next check-up,

place of delivery, expected date of

delivery and place of referral in case

of any complications (CORT, 2007).

Majority of beneficiaries had

interactions with ASHA on the

Micro-Birth planning issues.

Eightyfour percent (84 percent) of

beneficiaries informed about the

date of next check-up, sixtyeight

percent had received information

Score of Mocro-Birth Planning

Grade C

26.4% Grade A

12.1%

Grade O

6.1%

Grade B

55.4%

Grade O Grade A Grade B Grade C

on place of delivery, fortysix percent advised on expected date of delivery (EDD) but lower

than one-fifth of beneficiaries indicated that ASHA informed them about the referral place to

visit in case of any emergency. Birth planning is one of the key elements taken up during the

refresher training and ANMs and AW workers interaction sessions (Table 5.4). The responses

of beneficiaries on the aspects of micro-birth planning were scored and data presented. Each

correct response was given one mark for all questions. Responses were categorized into four

Grades. The categorization was Grade O- Don’t Know, Grade A- All correct aspects, Grade B-

2-3 correct aspects and Grade C- only one aspect. It was surprising to find that only twelve

percent of beneficiaries stated all the four aspects, fifty five percent of beneficiaries knew 2-3

aspects and six percent don’t know any of the above. This could be an area that needs

strengthening and can be linked as part of Micro-Birth planning along with other aspects.

5.6 Intention and Actual Place of Delivery

The respondents were asked to state about the place where they intended to deliver

and the place where they actually delivered. Information was cross tabulated and analyzed in

Table 5.5. Eightyeight percentage of beneficiaries interviewed were intending to deliver in an

institution (56 percent in public and 30 percent in private) and remaining, at home. Out of 13

percent of beneficiaries who had intended to deliver at home changed their opinion and

preferred medical institution (11 percent). Among institutional deliveries, majority of

beneficiaries delivered at the private medical institutions as compared to public institutions.

The motivating factors for institutional deliveries are given in Table 5.6. Sixtynine

percent of beneficiaries reported safety to mother and child for choosing institution delivery

followed by 63 percent due to monetary benefits offered under JSY scheme. Twentyeight

percent of beneficiaries were motivated ‘due to better access of service at medical institution

in the nearest locality’ and ‘support provided by ASHA’. Less than ten percent were motivated

due to compulsion like ‘the previous birth in hospital’ and ‘availability of transport’ for

availing services from medical institutions.

5.7 Process of Arranging Transport

Some of the major delays in accessing health services during delivery were time

taken in recognizing the problem, arranging the transport, travelling time and delay in

getting services after reaching the place of delivery. The Andhra Pradesh Government as part

of the NRHM intervention introduced 108 emergency rural medical health ambulances

throughout the state and the field experiences indicate that people were very quite familiar

with the scheme and availing the services.

In the case of ninetytwo percent of JSY beneficiaries, transport facility for shifting

from home to medical institution was arranged by family members. The ASHA volunteer

arranged transport for 16 percent of beneficiaries while ANM, AWW/SHG and relatives also

played a role (10 percent) in arranging transport. Regarding time of reaching the place of

delivery, it can be observed that 64 percent beneficiaries reached the facility during the day

(between 6 am and 6 pm) followed by 24 percent during late evening (between 6 pm to 12

am) and the remaining 12 percent, at early hours.

Concerning accompanying of beneficiaries to health facility, it was reported that

mother of the beneficiary, husband and other family members were commonly cited. Seven

out of ten were accompanied by mother, followed by husband 56 percent and mother–in-law

32 percent. In the selected districts, about 49 percent in Kurnool and a maximum of 66

percent in East Godavari districts, ASHA volunteers accompanied the JSY beneficiary for

delivery. The field observations indicated that presence of ASHA in the hospital provided a

physical assurance to the family members and the beneficiaries also indicated that they

received timely services due to the presence of ASHA at the time of delivery.

5.8 Motivation for Institutional Delivery

The monetary benefits offered under JSY (63 percent) and for safety of mother and

child (69 percent). Twentyeight percent of beneficiaries (Table 5.6) of JSY were motivated

because ASHA support in natal and at delivery time. One interesting observation of the study

is that ASHA volunteers were also playing crucial role in decision making for institutional

delivery on par with the mother-in-law and husband and other family members. The role of

ASHAs was very significant in decision making regarding institutional delivery and

discouragement of home deliveries.

5.9 Quality of Services Available at the Place of Delivery

The study attempted to ascertain the quality of services at the place of delivery like

promptness in attending on the delivery case, waiting time, persons attending on the

delivery etc. On an average, the study found that it took 12 minutes to complete the

administrative process at the hospital. About 94 percent of JSY beneficiaries were admitted

in the health facility between 10- 30 minutes of duration by the hospital staff. The time taken

to attend on the delivery was below 10 minutes as indicated by 48 percent of beneficiaries

and 30 minutes as indicated by 11 percent after reaching the hospital respectively. About 70

percent of deliveries were normal, 2 percent were assisted and 29 percent were caesarean

deliveries.

5.10 Impact of JSY on Institutional Delivery

The JSY beneficiaries were asked about place of delivery of the last child born prior

to the index child of JSY beneficiaries interviewed. Out of 1145 total beneficiaries only 745

had history of previous child birth. Data from these 745 beneficiaries was cross tabulated by

place of delivery of previous child with that of the index child. In other words, the analysis

would indicate a shift in place of delivery before and after introduction of JSY. It was

observed that 610 JSY beneficiaries in the preceding index child birth had an institutional

delivery while the remaining 135 (18 percent) were home deliveries (Table 5.7). In case of

index pregnancy, 730 (98 percent) births were institutional and only 15 (2 percent) births

were home deliveries. It may however be mentioned here that this can not be generalized as

the sample had been confined to only those who had availed JSY. The results may be

considered as indicative of their change in behavior.

5.11 JSY beneficiaries- Place and type of delivery

The study tried to ascertain the place of delivery and type of delivery in the selected

districts. Almost 98 percent of beneficiaries delivered at medical institutions in all the five

selected districts. Fiftyone percent of deliveries were conducted in public institutions and 47

percent in private nursing homes and private hospitals (Table 5.8). A comparison of inter-

district variations of JSY beneficiary deliveries indicated that 32-49 percent of deliveries were

conducted in private hospitals (except 82 percent in Karimnagar district). The JSY beneficiary

deliveries indicating that 66 percent were normal and 32 percent caesarian sections followed

by assisted deliveries (2 percent). The caesarian sections varied from 22-26 percent in

selected four districts and recorded more than fifty percent in Karimnagar district (Table 5.9).

5.12 Role of ASHA in JSY

ASHAs briefed women about the JSY. ASHAs informed the JSY beneficiaries about

early registration in first trimester, hospital delivery and postnatal care. Higher percentage

of JSY belonged to SC/ST and BPL group, availed the benefits and was satisfied about the role

played by ASHA. This is evident from the beneficiary assessment wherein it was found that

they were supportive right from pregnancy to child birth in three-fourth of deliveries. The

ASHA role in motivating beneficiaries for institutional delivery services and accompanying

them to institutions has emerged significantly. The deliveries conducted in both public and

private institutions were almost equal in all districts except in the case of Karimnagar district.

Why the beneficiaries in Karimnagar district were more inclined towards private institutions

for ANC, delivery care require further probing.

Table 5.1 – Andhra Pradesh: Respondents’ Profile of ASHA Beneficiaries

Profile SKLM EG KRL MHBN KRM All

Age(Completed years)

Below 19 4.0 7.0 8.7 7.2 4.9 6.4

20-24 69.0 72.9 72.6 64.6 57.0 67.9

25-29 25.2 18.6 15.2 23.6 34.8 22.9

30 years or more 1.8 1.5 3.5 4.6 3.3 2.8

Education

No formal education 37.4 19.5 50.6 63.7 32.8 39.7

Up to 5th 20.2 27.7 19.7 10.5 22.5 20.6

Passed 7th 9.2 12.8 8.7 4.6 12.7 9.8

Studied 8 to 10th 26.1 28.7 17.1 12.7 25.8 22.8

Passed Intermediate & above 7.1 11.3 3.9 8.4 6.1 7.4

Religion

SC\ST 39.0 58.8 33.5 45.31 32.0 42.1

Others 61.0 41.2 66.5 54.9 68.0 57.9

Table 5.2 – Andhra Pradesh: Place and Source of Information Received about JSY

Profile SKLM EG KRL MHBN KRM All

Source of JSY information

ASHA 98.5 83.2 72.6 77.2 73.0 81.7

AWW/center 35.0 4.6 5.2 19.8 18.9 16.5

MPHA(F) 92.0 50.0 70.0 55.3 56.1 65.7

Television 17.8 10.1 3.2 2.1 1.6 7.6

Doctor 25.2 11.0 20.3 17.7 3.7 16.1

Relative 15.0 6.1 5.2 6.3 2.5 7.3

Other JSY Beneficiary 44.8 10.4 28.7 19.4 7.4 23.0

Radio 3.7 0.9 0.6 1.3 - 1.4

Gram Panchayat 1.5 6.4 1.9 3.4 - 2.8

Information heard about JSY

Get cash incentive for Hospital deliveries 93.9 59.5 60.6 73.4 39.3 66.4

Promotion of Institutional Deliveries 43.9 50.3 31.0 34.6 17.2 36.5

Family Planning 40.5 19.2 11.9 14.3 9.8 20.1

Free intuitional delivery services for poor

women

28.8 37.5 35.5 26.2 18.0 30.0

For intake of nutrition food 8.0 39.3 19.4 14.8 54.1 26.4

For rich & influential families 1.8 6.1 0.6 1.7 0.8 2.4

Population control/take care of Newborn

care

1.2 3.7 0.6 1.7 2.5 1.9

Do not know/can’t say 0.3 1.5 3.5 4.6 6.1 3.0

Table 5.3 – Andhra Pradesh: Stage of Pregnancy and Place of Registration for ANC

Stage of Pregnancy of Woman for

Registration SKLM EG KRL MHBN KRM All

First Trimester 48.8 88.4 39.0 45.6 78.7 60.2

Second Trimester 46.9 7.6 49.7 45.1 14.3 32.8

Third Trimester 3.7 2.7 9.7 6.3 1.2 4.8

After delivery 0.3 - - - - 0.1

Do not know 0.3 1.2 1.6 3.0 5.7 2.1

ANC services for index child

PHC/Sub Centre 66.3 59.8 40.3 50.6 21.3 49.1

Dist Hosp/CHC 22.0 11.3 21.9 15.6 5.3 15.8

Private accredited Hospital 11.7 25.9 35.8 28.4 65.6 31.8

AW Centre - 0.3 1.0 3.8 - 0.9

Other - 2.7 1.0 1.6 7.8 2.4

Total 100 100 100 100 100 100

Table 5.4 – Andhra Pradesh: Micro-Birth Planning of JSY Beneficiaries

Information on ANC SKLM EG KRL MHBN KRM All

Date of next check up 98.5 77.4 82.3 82.3 79.9 84.4

Date of expected delivery 57.5 40.9 42.6 50.2 38.1 46.1

Place of delivery 88.3 59.1 77.7 61.2 44.7 67.6

Place of referral in case of complications 16.3 7.6 21.3 17.7 18.4 16.0

Table 5.5 – A.P: Responses of JSY Beneficiaries about

Intended and Actual Place of Delivery

District

Home Delivery Govt. Hospital Private Hospital Percentage change between

intended & actual

Intended Delivery

took place Intended

Delivery

took place Intended

Delivery

took place Home

Govern-

ment

Hospital

Private

Hospital

Srikakulam 15.6 0.6 69.4 66.4 14.7 33.0 -96.1 -4.3 124.9

East Godavari 5.2 0.9 57.6 49.8 37.2 49.2 -83.1 -13.5 32.3

Kurnool 16.8 1.9 59.7 58.8 23.5 39.3 -89.0 -1.5 67.2

Mahabubnagar 17.7 6.5 63.3 56.7 19.0 36.8 -63.0 -10.4 93.7

Karimnagar 11.5 2.2 26.2 17.5 62.3 80.3 -80.9 -33.2 28.9

ALL 13.1 2.2 56.4 51.4 30.4 46.4 -83.2 -8.9 52.6

Table 5.6 – Andhra Pradesh: Factors Motivated

JSY Beneficiary for Opting Institutional Delivery

Factors SKLM EG KRL MHBN KRM All

Money available under JSY 71.7 64.6 43.9 67.9 39.8 62.6

Better access to Institutional delivery

services

30.1 26.6 37.1 29.5 16.0 28.4

For safety of child /mother 68.4 57.0 79.0 65.0 78.7 69.3

Support provided by health personnel 14.1 15.5 14.8 11.8 19.7 15.2

Had health problems 21.8 17.4 17.4 13.1 29.5 19.7

Support provided by ASHA 15.0 19.2 14.5 25.3 10.2 28.0

Previous child born in hospital 12.8 5.5 5.8 7.6 19.7 10.0

Availability of transport assistance 17.2 4.9 2.3 8.0 21.7 10.4

Previous caesarean, miscarriage 0.9 18.0 3.2 3.4 3.7 6.2

Table 5.7 – Andhra Pradesh: Shift in the Place of Delivery Before and After JSY

Particulars For last but one child For last (JSY) child

Place of delivery

Institutional 82 (610) 98 (730)

Home 18 (135) 2 (15)

Number of beneficiaries with two or more children : 745

Table 5.8 – Andhra Pradesh: Place of Delivery of JSY Beneficiaries

Place of delivery

District Home Public Private All

Srikakulam 0.9 66.7 32.4 100.0

East Godavari 1.8 48.9 49.2 100.0

Kurnool 1.0 58.4 40.6 100.0

Mahabubnagar 5.6 54.5 39.8 100.0

Karimnagar 0.9 17.5 81.7 100.0

All 1.9 50.9 47.2 100.0

Table 5.9 – Andhra Pradesh: Type of delivery of JSY Beneficiaries

Type of Delivery

District Normal Assisted Caesarian All

Srikakulam 76.9 0.9 22.2 100.0

East Godavari 73.2 2.5 24.3 100.0

Kurnool 75.3 1.3 23.4 100.0

Mahabubnagar 72.7 0.9 26.4 100.0

Karimnagar 42.3 5.7 52.0 100.0

All 65.9 2.1 32.0 100.0

CHAPTER 6

SUMMARY AND RECOMMENDATIONS

In this evaluation study an attempt has been made to understand the process

adopted for operationalization of ASHA intervention in the state of Andhra Pradesh. ASHA

volunteers were interviewed to assess their awareness of topics in the training, work

performance, suggestions and cash incentives. Besides, the study also interviewed ASHA

beneficiaries (who were JSY beneficiaries and availed institutional delivery) from the same

villages where the ASHAs were working. The study as a whole yielded better understanding

of the implementation of ASHA and the ways to improve the programme.

The Government of Andhra Pradesh adopted an innovative approach, and initiated 21

days in-house training in every district headquarters covering 180 – 200 ASHAs every month

differing from the GOI - proposed training of 23 days duration spread over five exposures in

a year period. The key for the success of Andhra Pradesh model of ASHAs training in a

record period of 18 months was attributed to the triangulation of coordination among the

two government departments and the NGO (Academy of Nursing Studies). A negligible

percentage (below two percent) of ASHAs discontinued the residential training due to health

reasons and family problems indicating that well planned and designed training programs

will discount the common perceptions that women may not prefer long duration training.

The revised training strategy in the State enabled to train all the ASHA Volunteers (one per

1000 population) who could be deployed in their respective villages within two years of

introducing NRHM.

In general the ASHAs were selected as per norms in terms of age, education

qualification, residence in village etc. ASHAs were questioned about the topics covered in the

training. The spontaneous responses for the aspects of women health, infant and child care,

eight tasks of ASHA, nutrition and HIV/AIDS were satisfactory. As majority of ASHAs had 18 –

24 months of service, there is a need to strengthen knowledge on the above aspects in the

refresher training, CARE ASHA Day convergence meetings and on-the-job trainings.

In executing their role as ASHAs, they were networking with various stakeholders

other than Anganwadi Workers and ANMs and the community started recognizing the work

of ASHA. Performance-based cash incentives to ASHAs were untimely and there were delays

in payment. Majority of ASHAs were dissatisfied with the incentives and felt receiving ‘less

money’ for ‘higher work load’.

About JSY, inter-personnel communication played a vital role in disseminating

information regarding JSY. Around 48 percent of the beneficiaries belonged to SC/ST and 52

percent had BPL card. Most of the beneficiaries (55 percent) heard about JSY during

pregnancy through ASHA and ANMs, but their knowledge about different aspects of the

scheme was inadequate. Aspects pertaining to micro-birth planning by ASHAs to the

beneficiaries require improvement in order to help reduce MMR and IMR. The JSY along

with ASHA schemes have brought awareness among poor and socially disadvantaged

population. The preliminary observations of place of delivery of the last child prior to the

index child of JSY beneficiaries interviewed showed a shift from home to institutional

deliveries.

As for the private sector in JSY, almost 40 – 50 percent deliveries were conducted in

private nursing homes / hospitals. In Karimnagar district more than three-fourth of JSY

beneficiaries availed ANC, delivery from the private sector institutions. However the rate of

Caesarian sections (more than 50 percent) in the district is alarming and require further

probe.

Recommendations

Important recommendations stem from an analysis of the findings and discussions

with stakeholders. These findings are organized in three groups namely policy, programme

related and demand-side issues.

Policy

The Commissionerate of Family Welfare and the Academy of Nursing Studies have

mainly shouldered the implementation of ASHA intervention. At the field level, monitoring,

supervising and providing support of ASHA is the need of the hour.

1. The Senior DPHNOs who are actively involved during training should be made

in-charge at district level to monitor and supervise ASHA. The ASHA Day and

convergence meeting must be monitored by senior DPHNO by provision of

vehicle for 8 – 10 days a month.

2. The PHC DPHNOs / Nodel Officers knowledge on IYCF required updation in order

to train the ASHA on these aspects during ASHA Day.

Programme Management

1. ASHA Resource Centre / State Health Resource Centre should pay more attention

to monitoring, supervising, re-training and improving knowledge of ASHAs in the

different PHCs in the State.

2. Continuing education is an important component and has to be supplemented in

all districts of IYCF aspects by CARE and NGOs.

3. Timely release of incentives for all sections of population.

4. Provision of the Iron and nutrition supplements implemented in the pilot

districts has been a success and needs to be extended to all districts in order to

achieve NRHM goals.

Demand Generation

There is a need to develop programme-related communication at different levels.

Communication interventions were limited to disseminating guidelines in the form of

circulars and media activities like radio / TV programmes, posters etc. The recent attempts

namely :

a) Scrolling on TV channels made an impact on Family Planning and this must be

extended to propagate good healthy practices messages.

b) State should conduct re-orientation programmes for medical and health

department for effective dissemination of ASHA and JSY.

Notes:

1. According to the State PIP (2005-06), under the Maternal Health Interventions at

village level the Mission Director, RCH-II (later named as NRHM) initiated the

village level Women Health Volunteers Programme. The purpose is to identify,

train and position Women Health Volunteers (WHV) in the Gram Panchayats in

the state to act as health resource persons-of- first-resort in all Panchayats on all

maternal and child health matters in the villages, and to act as link-persons

between the community and the service providers in these villages. The WHVs

will be identified and selected by the village community through interactive

process in which all the members of village Mahila Swastha Sangh, Micro-credit

group leaders, women ward members of Gram Panchayat etc.

2. The NRHM launched Safe Motherhood interventions in the form of Janani

Suraksha Yojana (JSY) for reducing maternal and neo-natal mortality. In availing

institutional delivery services, the client needs escort and transport to reach the

institution and in case of complications, referral services are required. The

scheme considered all these elements and made provision for transport including

referral and escort and at the same time invested in improving public health

institutions and services through the Reproductive and Child Health (RCH)

Programme interventions. This scheme was started during the year 2005-06 with

an objective to encourage pregnant women for institutional delivery in

Government / Private Institutions in A.P. Under this scheme Rs.1000/- (Rs.700/-

under JSY (GOI) + Rs.300/- under Sukhibhava (State) scheme) is being paid to

rural BPL woman who undergoes an institutional delivery. From 1st April 2006,

JSY has been extended to BPL urban families also. 3.06 lakh beneficiaries have

been covered under JSY scheme during financial year 2007-08 (up to Dec-2007).

3. Field experience in certain tribal PHCs indicated that the tribal women/ families

are not interested to choose institutional delivery even after persistent

counseling by ASHA. They respect the customs rather than preferring

institutional deliveries.

4. The average incentive of Rs. 462 includes only for RCH services and did not

include incentive of RS. 150/- provided for accompanying family planning

operation cases.

5. CARE agency in Andhra Pradesh spread their activities in eight districts

(Srikakulam, Vizianagaram, Visakhapatnam, Khammam, Warangal, Karimnagar,

Nizamabad and Medak) and started the three hour convention session on ASHA

Day (last Tuesday of the month) and helping the ASHAs improve their knowledge,

skills and capacity building activities. ASHAs are supposed to visit newborn

houses and advise on infant feeding and other aspects using the home visit

planner developed by the agency.

References

Accredited Social Health Activist (ASHA) - Guidelines (2005), Ministry of Health & Family

Welfare, Government of India.

Ashtekar S (2008),’ The National Rural health Mission: A Stocktaking’, Economic and Political

Weekly, September 13, 2008, pp. 23-26.

Bajpai N, R.H.Dholakia and J D Sachs (2008), ‘Scaling up Primary Health Services in Rural

India: Public Intervention Requirements and Health Sector Refors: Case Studies of Andhra

Pradesh and Karnataka’, CGSD Working Paper No.33, The Earth Institute at Columbia

University, www.earth.columbia.edu

CORT (2007), ‘Assessment of ASHA and Janani Suraksha Yojana in Orissa’, Centre for

Operations Research& Training, Wadodara.

Indian Institute of Health and Family Welfare (2008 Annual Report 2007-08. IIHFW,

Hyderabad

National Rural health Mission (2005), Meeting people’s health needs in rural areas,

Framework for Implementation 2005-2012. Ministry of Health and Family Welfare,

Government of India.

Premchand Babu and K. Anand Reddy (2006),’ Training of Women Health Volunteers, A.P

experience’, Health Action, 23-25, Health Action, June 2006.

Rajyalakshmi, TK (2008),’Health Care –Gaps in a Mission, downloaded from Website

Satpathy, S.K and S. Venkatesh (2006), ‘Human Resources for Health in India’s National Rural

Health Mission: Dimensions and Challenges’, Regional health Forum, Vol. 10, No.1, 2006

Sharma, R (2007),’ Janani Suraksha Yojana: A Study of the Implementation Status in Selected

Districts of Rajasthan, Population Research Centre, Mohanlal Sukhadia University, Udaipur

Srinivasa Rao, M.S (2007), ‘Training of Women ‘NRHM Newsletter, Vol.2, No.3, March, 2007

Suneela Garg and Anita Nath (2007), ‘Current Status of National Rural health Mission’, Indian

Journal of Community Medicine, Vol. 32, No.3, July 2007

The Hindu ’Emulate Andhra Pradesh Model’, National Rural Health Mission lauds

supplementary nutrition for pregnant women. (15th December 2008)

Umesh Kapil (2006), ‘NRHM: Training of Health Functionaries’, (letter to the Editor), Indian

Journal of Pediatrics, Vol.73, March 2006.

Satpathy, S K and S. Venkatesh (2006),’ Human Resources for Health in India’s National Rural

Health Mission: Dimensions and Challenges’, Regional Health Forum, Vol. 10, No.1, 2006.

APPENDIX-2

SRIKAKULAM DISTRICT

Code Mandal PHC Code Sub centre Name of the village

1 Ranasthalam Ptharlapally 1 1.Kothapalem 1.Kothapalem 2. Jeerupalem

2 S.R.puram 3. S.R.Puram 4. Garikapalem

3 Pydi Bhimavaram 5. Pydi Bhimavaram

4 Kammesigadam 6. Velupurai 7. Arjunuvasala

5 Thippavalasa 8. Thippavalasa

2 Amadalavalasa Thogaram 6 Korlakota 9. Korlakota

7 Thogaram 10.Muddadpet

8 Buddadpet 11. PS Pet

9 Vedullavalasa 12. Vedullavalasa

13. Thurakapeta

10 Edurulavalasa 14. Bobbilipeta

11 Akkulapeta 15. Mondigam 16. SRC peta

12 Chittivalasa 17. Ponnana Peta

18. Gajulakullivalsa

3 Veeragattam Bittiwada 13 Hussanpuram 19. Konchali 20. Hussanpuram

14 Vandava 21. Adaru 22.Vanduva 23. Judi

15 Bittivada 24. Palametta 25. Bittivada

16 Neelanagaram 26. Neelanagaram

4 Seethampet Seethampet 17 Sanegendi 27. Sanegendi

18 Goidi 28. Goidi 29. Pattikagude

19 Devanapuram 30. Devanepuram

31. Sankkilligude 32. Pedaram

20 Seethampeta 33. Seethampeta 34.Vaiageoda

35. Kariguda

5 Rajam Pogiri 21 Polapeta 36. Rucchimpeta

22 Rajam 2 37.Mallikarjuna Colony

38. GayatriColony

23 Guravam 39. V.R. Agraharam 40. Guravam

24 Pogiri 41. Pogiri

6 Laxminarayapeta Laxminarayapeta 25 Ravichandra

42. Danukuvada

43. Ravichandra

26 Siddantham 44. Siddantham

45. Samanthapuram

27 Chorling 46. Pusam

28 Dabbapadu 47. Dabbapadu

29 Lommuvalasa 48. Moduguvalasa

49. Kommuvalasa

30 Laxminarayanapet 50. Laxminarayanapet

Code Mandal PHC Code Sub centre Name of the village

7 Sarubujjali Sarubujjali 31 Purushothapuram

51. Peddapalem/Chinnapalem

52. Purushothapuram

32 Galantri 53. Galantri

33 Sarubujjali 54. Marripadu 55. Vennilavalasa

34 Kothakota 56. Kothakota

35 Yaragam 57. LPM Agraharam

58. Pathapadu

36 Rottavalasa 59. Rottavalasa

37 Peddalavelapuram 60. Buridilavala nagar colony

8 Srikakulam Singupuram 38 Mavarambad 61. Mavarambad

39 Karimillapeta 62. Karimillapeta

40 S S valasa 63. Byrivanipeta

41 Eappli 64. Balivada

42 Peddapadu 65. Peddapadu

43 Singupuram 66. Singupuram

9 Echerla Echerla 44 S N puram 67. Lingalpeta

45 Kusalpuram 68. Kusalpuram

46 Allinagaram 69. Chilakalapalem

47 Pudivalasa

70. Venkatapuram

71. Sanapanvanipet

72. Pudivalasa

48 Jarjam 73. Jarjam

10 Hiramandalam Hiramandalam 49 Thulagam 74. Thulagam

50 Kittlapadu 75. Kittlapadu 76. Rillivalasa

51 Patha

Hiramandalam

77. Chinnakollivalasa

78. Patha Hiramandalam

52 Pedasakili 79. Subalari Colony- 2

53 Hiramandalam 80. Hiramandalam

54 Solipi 81. Padali

11 Saravakota Saravakota 55 Navathala 82. Savarabonthu 83. Patouru

56 Saravakota 84. Vaddinevalasa 85. Garibanda

86. Pedda Ratyba 87. Saravakota

57 Chinnagujjuwada 88.Saravabejji

89. Chinnagujjuwada

58 K S palli 90. Marripadu 91. K S palli

59 C N K paidu 92. Ryaveda 93, Burijavada

12 Kanchili Kanchili 60 P Shesanam 94. P Shesanam 95. J Shesanam

61 N S colony 97. S Baramali

98. Manikyapuram 99. Bugabelli

62 Kattivaram 100. Kattivaram 101. Peddatula

63 Kanchili 102.Purshothamapuram

103.Kanchili 104.Golla Kanchili

Code Mandal PHC Code Sub centre Name of the village

13 Palasa Rentikota 64 Chinnabandam

105. Garuda Khandi

106. Guralapuram

65 B Tharala 107. B Tharala

66 Rangoli 108. Rangoli 109.Manedimatu

67 Savagangaripuram 110. Sanagangaripuram

68 Kasibugga 111. Kasibugga

14 Tekkali Konasalakothur 69 Nawpada 112. Nawpada

70 Nawathala 113. Nawathala 114. Jandapeta

71 Ranivalasa 115. Jolusurepally

116. Bagovanpura

72 Pedasane 117. Polavaram

73 Jaganathapuram 118. Narasingapally

74 Tekkali 119. Tekkali

15 Nandigama Nandigama 75 Nandigama

120. Kottavalasa 121. Swamypeta

122. Pallavalasa

76 Raipuram 123. Raipuram 124. Belchi kolla

77 K Thambur 125. Devapuram

126. K. Thumbur

78 Haridasupuram 127. Haridasupuram

EAST GODAVARI DISTRICT

Code Mandal PHC Code Sub centre Name of the village

1 Rajanagaram Rajanagaram 1 Kalaracherla 1.Kalaracherla

2 Thokada 2. Thokada

3 Srirampuram 3. Srirampuram

4 Konda Guntur 4. Konda Guntur

5 Punya Shatram 5. Bhupalapatnam

6 Chekradwarabandham 6. Chekradwarabandham

2 Gandepalli Gandepalli 7 Gandepalli

7. NT Rajapuram

8. Singarampalem

8 8. Neeladrirao pet 9. Neeladriraopet

9 Yellamilli 10. Borrampalem

10 Surampalem 11. Surampalem

11 Mallepalli 12. Mallepalli

3 Razole Tatipaka 12 Kadali 13. Kadali

13 B Savaram 14. Palagummi 15. B. Savaram

14 Konavaram 16. Mulikipalli

15 Katrenipadu 17. Katrenipadu

16 Vegivaripalem 18. Vegivaripalem

Code Mandal PHC Code Sub centre Name of the village

4 Mamidikuduru Nagaram 17 Appanapalli 19. Appanapalli

18 Magatapalli 20. Magatapalli

19 Pasarlapudi lanka 21. Pasarlapudi Lanka

20 Mamidikuduru 22. Mamidikuduru

21 Magallakuduru 23. Geddada

22 Edarada 24. Makanapalem

5 P Gannavaram Gannavaram 23 Modupu lanka 25. L Gannavaram

24 P Gannavaram 26. Y S Palem

25 Narendrapuram 27. Narendrapuram

26 K Manjavaram 28. K Manjavaram

27 Vadrevupalli 29. Vadrevupalli

28 Udimudi 30. Udimudi

6 Ambajipet Ambajipet 29 Pulletukuru 31. K V Lanka

30 Moosampally 32. Irusumanda

31 G Agraharam 33. G. Agraharam

32 Nandapudi 34. Nandhapudi

33 K Pedapudi 35. K Pedapudi

34 Mukkamala 36. Mukamala

7 Amalapuram Bandarulanka 35 Batnavilli 37. Reddipally

36 Sakurru 38. Sakurru

37 Rollapalem 39. Rollapalem

38 Janipalli 40. Janipalli

39 Samanasa 41. Samanasa

40 Eedharapalli 42. Eedharapalli

8 Mummidivaram KothaLanka 41 Kotha Lanka 43. Karrivani revu

42 Thane lanka 44. Pallavari palem

43 Annampalli 45. Annampalli

44 Mummidivaram 46. Mummidivaram

45 Rajupalem 47. Rajupalem

46 Ananthavaram 48. Ananthavaram

9 Seethanagaram Seethanagaram 47 Chinakondupudi

49. Chinakondupudi

50. Cheepurupalli

48 Vangalapudi 51. Singavaram

49 Mulaka Lanka 52. MulakaLanka

50 Lankuru 53. Lankuru

51 Munikudali 54. Katavaram

10 Rampachodavaram Pedageddada 52 Pedageddada

55. Chinageddada

56. Sokulagudem

53 Lankapakalu 57. Peerukonda 58.Thiragathi

Rollu 59.Yarlamamidi

Code Mandal PHC Code Sub centre Name of the village

54 Kakawada

60. Annampalli

61. Chelakaveedhi

62. Suvarlawada

55 Musurumilli 63. Bornagudem 64.

ChinaBarangi 65. PedaBarangi

11 Y. Ramavaram Chavitidibbalu 56 P V padu 66. Tunikalapadu 67. Dalipadu

57 Bandigadda 68. Rachapalem

58 Yarlagadda 69. Vankabusi 70. Vattigadda

71. P Yerragonda

59 Chaviti Dibbalu 72. Thotakurapalem

73. Devaramadugu

60 Panasalapalem 74. Kokita Gondhi

75. Varnamamidi Gondhi

61 Y Ramavaram 76. Chinta Karrapalem

77. Chamagadda

12 Korukonda Kotikesavaram 62 Butchampet

78.Butchampet

79. Gummaluru

63 Bolladdupalem 80. Bolleddupalem

81. Raghavapuram

64 Kotikesavaram 82. Koti

65 S R Patnam 83.Sri Rangpatnam

13 Kirlampudi Kirlampudi 66 Rajupalem 84. Mukkollu 85. R.K puram

67 Srungarayunipalem 86. SrungaRayunipalem

68 Chillangi 87. Chillangi

69 Tamarada 88. Ramachandrapuram

70 Somavaram 89. Krishnavaram

14 Anaparthi Ramavaram 71 Ramavaram 90. Ramavaram

72 Polumuru 91. Polumuru

73 Anaparthi 3 92. Anaparthi savaram

74 Anaparthi 4 93. A. Kothuru

75 PRC puram 94. Peera Ramachandrapuram

95. Dumpalapudi

15 Rayavaram Machavaram 76 Chelluru 2

96. Buttayapet

97. Battulavari savaram

77 Venturu 98. Naralapet 99. Challangipet

78 Machavaram 100. Machavaram

79 Pasalapudi 1 101. Naralapalem

80 Chelluru 1 102. Chelluru

KURNOOL DISTRICT

Code Mandal PHC Code Sub centre Name of the village

1 Owk Owk 1 Singampalli 1. Singampalli

2 Uppalapadu 2. Uppalapadu, 3. Kanukunta

3 Peddakottalu 4. G. Singaram,

5. Peddakottalu

4 Cherlopalli 6. Sangapatnam

2 Atmakur Bairutla 5 Nallakaluva 7. Rudrakodurugudem

6 Byrutla 8. Siddapuram

7 Siddapalli 9. Musrapalli

8 Karivena 10. Charaka colony

9 Venkatapuram 11. Krishnapuram.

12 Venkatapuram

10 Atmakur 6 13. Atmakur 6

3 Nandyla Chapirevula 11 Chapirevula

14. Chapirevula,

15. Bapujinagar

12 Poluru 16. Venkateswapuram

13 Pusuluru 17.Pusuluru

14 Kanala 18. Kanala

15 Peddakottla 19. Peddakottla

4 Gonegandla Gonegandla 16 Gonegandla 20. Gonegandla

17 Gonegandla 2 21. Bc colony

18 Korur 22. Bodepadu

19 Alwada 23. Alwada,

24. Peddamarrireddy

20 Ontedidinne 25. Yernabadu

5 Adhoni Peddathumbalam 21 Narayanapuram 26. Chagi, 27. Dhanapuram

22 Arekallu 28. Arekallu

23 Kadhithota 29. Kadhitota

24 Peddathumbalam 1 30. Peddathumbalam 1

25 Virupapuram 31. Rajivnagar

6 Bandiatmakur Bandiatmakur 26 G.Lingapuram 32. G.Lingapuram,

27 G.C. Palem 33. G.C. Palem,

34. Navallakunta

28 Singavaram 35. Singavaram

29 Narayanapuram 36. Narayanapuram,

37. Chinnadevurapuram

7 Banaganipalli Pulukur 30 Palukuru 1 38. Devanagar

31 Palukuru 2 39. Palukuru 2

32 Nandivargam

40. Nandivargam,

41. Thimmapuram

42. Padlapuram

33 Berval 43. Berval

Code Mandal PHC Code Sub centre Name of the village

8 Aspara Aspara 34 Yettakal 44. Yteekal

35 Thagaradhone 45. Thagaradhone

36 Aspari 1 46. Aspari 1

37 Bingari 47. Bingari

38 Billakal 48. Putakalamarri

39 Aspari 2 49. Chirumanidoddi

9 Allagadda Ahobilam 40 Bachipalli 50. Kodampalli

41 Allagadda 2 51. Allagadda 5 Ward

42 Nallagatta 52. Nallagatla

43 Chinnakandukur 53. Chinnakandukuru

44 Allagadda 4 54. Gubagudem, 55. Ward- 4

10 Kalluru Ulindakonda 45 Kongapadu

56. Kollampalli thanda

57. Kongampadu

46 Chinnatekuru 58. Chinnatekuru,

59. Thadamkampalli

47 Bastipadu 60. Basthipadu, 61. Bollaram

48 Ulindakonda 62. Ulindakonda

11 Sirivella Sirivella 49 Sirivella 4 63. Sirivella 4

50 Sirivella 3 64. Sirivella 3

51 Gangavaram 65. Chennooru

52 Gamparamamididdne 66. Jennepalli

53 Kotapadu 67. Kamirinenipalli

54 Maharadevarapuram 68. Boilakunta

12 Done Kothaburuju 55 Udumulapadu

69. Jagadarthi,

70. Udumulapadu

56 Devarabanda 71. Rekulakunta

57 Dharapalli 72. Dharapalli

58 Done 1 73. Done1

59 Done 4 74. Done 4

13 Koilakunta Revanuru 60 Revanuru

75. Revanuru, 76. Muppaluru,

77. Yallampadu

78. Lingala

61 Peddakopparla 79. Kalagatta,

80. Peddakopparla

14 Bethamcherla Bethamcherla 62 Emboy 81. Seetharampuram

63 Buggaripalli 82. Buggaripalli

64 Gorlagutta 83. Hanumannagar

65 Bethamcherla 1 84. Bethamcherla 1

66 Bethamcherla 2 85. Bethamcherla 2

67 Bethamcherla 3 86. Bethamcherla 3

68 Bethamcherla 4 87. Bethamcherla 4

Code Mandal PHC Code Sub centre Name of the village

15 Chagalamarri Chagalamarri 69 Chagalamarri 2 88. Chagalamarri 2

70 Chagalamarri 3 89. Chagalamarri 3

71 Madduru 90. Madduru

72 Muthyalapadu 91. Muthyalapadu

73 Mallavemula 92. Mllavemula

74 Chagalamarri 1 93. Chagalamarri 1

MAHABUB NAGAR DISTRICT

Code Mandal PHC Code Sub centre Name of the village

1 Farooq Nagar Burgula 1 Kammadanam 1. Solpur

2 Burgula 2. Kasireddiguda

3 Dosakal 3. Dosakal

4 Veldnada 4. Buchiguda

5 Annaram 6. Peddchilakamarri

6 Madurapur 7. Devunibanda thanda

2 Kondadurg Kondadurg 7 Srirampur 8. Srirampur 9. Pullapraguda

8 Choudariguda 10. Choudariguda

11. Indiranagar

9 Peddayelikacherla 12. Peddayelikacherla

13. Veerannapeta

10 Pedmaram 14. Chegireddi Ghanpur

11 Venkirala 15. Old Agirala

3 Velidanda Velidanda 12 Cherukur 16. Cherukur

13 Peddapur 17. Peddapur

14 Kotra 18. Kotra

15 Ballampalli 19. Ballampalli

16 Jupalli 20. Jupalli

17 Tandra 21. Tandra

4 Tadoor Tadoor 18 Gunthakurudu

22. Yadireddipalli

23. Guntakuduru

19 Ithale 24. Ithole 25. Sivatharada

20 Kummera 26. Thummalasagar

27. Kummera

5 Bijinepally Palem 21 Allipur

28. Allipur 29. Salkarpeta

30. Khanapur

22 Palem 31. Palem

23 Kundlalavara 32. Kundlanlavara

24 Vasanthapur 33. Vasanthapur

6 Amrabad Mannanur 25 Macharam

34. Macharam

35. Mukamamidi

26 Venkateshwarabai 36. Venkateshwarabai

Code Mandal PHC Code Sub centre Name of the village

27 Amarabad 37. Telugubili

38. Jangamreddipalli

28 Mannanur 39. Mannanur

40. Prashanth Nagar

7 Balamur Balamur 29 Barala 41. Ramujupalli

30 Anthavaram 42. Narasaipalli thanda

31 Kondalagula 43. Thodalagadda

32 Jinkuntla 44. Kodepalli

33 Polisethipalli 45. Polisethipalli

34 Godal 46. Godal

8 Uppunuthala Uppunuthala 35 Kasanpalli 47. Thirumalapur

36 Penumella 48. Guvvalolipalli

37 Uppunuthala 49. Jayaram thanda

38 Ventoor 50. Ventoor

39 Kortikal 51. Kortikal

40 Upparpalli 52. Upparpalli

9 Panagal Panagal 41 Kethapalli 53. Kethapalli

42 Panagal 54. Pangal

43 Mandapur 55. Kothapeta

44 Annaram 56. Devajpalli

45 Telarallapalli 57. Telarallapalli

58. Tellarallapalli thanda

46 Gajapur 59. Madavaraopalli

10 Gopalpet Gopalpet 47 Gopalpet 60. Gopalpet

48 Palakapadu 61. Palakapadu

49 Edutla 62. Edutla

50 Tadipatri 63. Tadipatri

51 Kesampeta 64. Chakalapalli

52 Buddaram 65. Buddaram

11 Koilkonda Manikonda 53 Malkapur 66. Rampur

54 Garlapahad 67. Garlapahad

55 Parepalli 68. Parepalli

56 Burugupalli 69. Kagipur

57 Manikonda 70. Manikonda

58 Kesavapur 71. Perikivadu thanda

12 Damaragidda Damaragidda 59 Sajanapur 72. Maddalaveedu

60 Kanukurthi 73. Gadimunkampalli

61 Lokurthi 74. Hasanpalli

62 Itlapur 75. Ulligudem

63 Mogullamadaka 76. Annasagaram

64 Damaragidda 77. Damaragidda

Code Mandal PHC Code Sub centre Name of the village

13 Nawabpet Nawabpet 65 Nawabpet 78. Gurukunta

66 Yanamangandla 79. Yanamangandla

80. Chennreddipalli

67 Eppatur 81. Eppature 82. Karoor

68 Karukonda 83. Thigalapalli

69 Rudraram 84.Kakarlapadu 85. Rudraram

14 Amangal Amangal 70 Mysigandi 86. Mysigandi

71 Chennapalli 87. Chennapalli

72 Vittaipalli 88. Vittaipalli

73 Mangalpalli 89. Meddigadda thanda

74 Kadathal 90.Kadathal

91. Puligundathanda

15 Devarakadra Devarakadra 75 Devarakadra 92. Gokulapur

76 Devarakadra (B) 93. Gurukonda

77 Basavapalli 94. Basavapalli 95. Hagalapur

78 Nagaram 96. Pedda Rajamoor

79 Venkataipalli 97. Gaddaguduru.

KARIMNAGAR DISTRICT

Code Mandal PHC Code Sub centre Name of the village

1 Jullapalli Jullapalli 1 Vadkapur 1. Vadkapur 2. Kummarikunta

2 Narsapur 3. Narsapur 4. Raikaldevpally

3 Venkatroopalli 5. Venkarroopalli 6. Kachapur

4 Dulikatte 7. Muppidipally

5 Jullapalli 8. Jullapalli

6 Sulthanpur 9. Sulthanpur

2 Manakondur Veldi 7 Ootur 10. Ootur

8 Pachunoor 11. Pachnoor

9 Vefurupally 12. Vegurupally

10 Laxmapur 13. Laxmapur

11 Devampally 14. Pochampally 15. Kellada

16. Lalithapur 17. Devanpally

12 Lingapur 18. Jaggaiah pally 19.Lingapur

3 Kamalapur Kamalapur 13 Vangapalley 20. Vangapally

14 Ambala 21. Srirampally 22. Ambala

23. Sriram

15 Kanparthy 24. Shambunipally 25. Deshrajpally

16 Marripallygudem 26. Marripallygudem

4 Bejjanki Thotapalli 17 GannewVarma 27. Gannawvarma

18 G. Kondapur 28 Gundlapally

Code Mandal PHC Code Sub centre Name of the village

19 Thotapalli 29. Thotapally 30. Veerapur

20 Jangapally 31. Jangapally 32. Hannajpally

33. Gotlamitla

21 Khasimpet 34. Paruvella

5 Koheda Koheda 22 Samudrala 35. Samudrala

23 Basvapur 36. Posiddipally 37.Basvapur

24 Koheda 38. Koheda

25 Vinjampally 39. Vinjampally 40. Gotlamitla

26 Shanigaram 41. Shanigaram

6 Sulthanabad Garepalli 27 Gattepally 42. Gattepally 43. Neerukulla

28 R M Kunta 44. R M Kunta

29 Garepally 45. Garrepally 46. Bupathipur

30 Kodurupally 47. Kodurupak 48. Devunipally

31 Togarrai 49. Kadampur

7 Karimnagar Kothapally 31 Magnoor 50. Magnoor 51. Takerpet

32 Asifnagar 52. Asifnagar

33 Elagundla 53. Elagundla

34 Chanapally 54. Chamanpally

35 Kamanpur 55. Baddipally

8 Ibrahimpatnam Ibrahimpatnam 36 Ibrahimpatnam 56. Thimmapur

37 Thimmapur 57. Thimmapur

38 Dabba 58. Dabba

39 Varshakonda 59. Varshakonda

40 Godhur 60. Godhur

41 Vemulakurthy 61. Mularampur

42 Medipally 62. Rajeshwaraopet

9 Gambhirraopeta Gambhirraopet 43 Gambhirraopet 63. Ghambhirraopet

44 Gambhirraopet 2 64. Gambhirraopet 2

45 Gajasingaram 65. Gajasingaram

46 Dammanapet 66. Nagampeta 67. Dammanapet

47 Mallareddypeta 68. Mallareddypeta

10 Mallala Mallala 48 Mallala 69. Mallala 70. Gudipeta

49 Thatipally 71. Sarvapur 72. Kothapally

73. Balvanthapur 74. Thatipally

50 Takkalapally 75. Lambadipally

11 Vemulavada Vemulavada 51 Subhashnagar 76. Vemulavada

52 Nukalamarry 77. Nandigundlapally

78. Nukalammay

53 Vemulavada 79. Vemulavada

54 Mallaram 80. Mallaram

55 Marripallem 81. Pochatipalli

Code Mandal PHC Code Sub centre Name of the village

12 Medipally Medipally 56 Mannegudem 82. Dammanapeta

57 Kondapur 83. Kondapur

58 Venkatraopet 84, Oddada 85. Rajojipeta

86. Venkartropet

59 Porumalla 87. Porumalla

60 Kalvakota 88. Kalvakota

13 Metpally Jaggasagar 61 Jaggasagar

89. Ramchalpet 90. Kondrikarla

91. Jaggasagar

62 Metpally Urban 92. Metpally Urban

63 Metpally

Indranagar 93. Metpally Urban

64 Ambedkar Nagar 94. Metpally

65 Vellula 95. Vellula

66 Gajullapalley 96. Metpally Urban

67 Kalanagar 97. Metpally Urban

68 Mushimpura 98.Metpally

14 Boinpally Boinpally 69 Karem

99. Karem 100. Dandrapalli

101. Ananthapalli 102. Stambanpally

70 Boinpally 103. Boinpally 104. Ramamapet

105. Burgupally

71 Takakonda 106. Tadakonda 107. Malkapur

15 Sarangapur Sarangapur 72 Nagnur 108. Nagnur

73 Pembatla 109. Pembetla

74 Laxmidevipally 110. Laxmidevipally

75 Sarangapur 111. Potharam 112. Sarangapur

76 Beerpoor 113. Narsimhulupally 114. Beerpoor.

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