A Rapid Assessment of

Factors Affecting ASHA Roles and Incentives in ‘kbk’ region of Orissa

Commissioned by

The Technical Management and Support Team (TMST)

On behalf of The Health & Family Welfare Department (H&FW), Government of Orissa

D‐COR Consulting 131 (P), Punjabi Chhak, Satya Nagar, Bhubaneswar, Orissa, India, Pin: 751 007, Phone: +91 – 94376 98965 E-mail: [email protected], [email protected]

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

ACKNOWLEDGEMENT

It is a pleasure to acknowledge and extend our appreciation to all those people who were associated in the study. Page | 2

In the first place, I on behalf of D‐COR Consulting would like to record my sincere gratitude to Mr. G. Mathivathanan, IAS, Mission Director, NRHM, Government of Orissa (GoO) for extending all valuable support in carrying out the study. I am also much indebted to Mr. Sushant Kr. Nayak, State Facilitator, Community Participation, NRHM, GoO for his time to time technical inputs for undertaking the study.

The study respondents viz. ASHAs, AWWs, ANMs, other Block and district level service providers; and more importantly, the people in the sample villages require special mention for sparing their valuable time and patiently answering each and every questions asked by the interviewers.

Foremost, we are thankful to the Technical Management and Support Team (TMST) for reposing confidence on us to undertake this study. Many thanks go in particular to Ms. Alison Dembo Rath, Team Leader and Ms. Biraj Laxmi Sarangi, Social Development Specialist, TMST for their unflinching technical support and guidance throughout the study. Their methodical and scientific intuitions have enriched the output of this study. We are grateful to both of them and hope to keep our collaboration in future.

Collective and individual acknowledgements are also owed to my colleagues at D‐COR for the diligent effort put in by them in completing the study. My sincere appreciation goes in particular to Mr. Gopal Krushna Bhoi for his assistance in drafting the report; Mr. Upendra Panda, Sarat Ch Parida, Subhanarayan Samantray and others for collection and validation of primary data; and Mr. Sibabrata Behera for data analysis and tabulations. I owe my gratitude to each of them for their support and cooperation. Above all, it was a great experience and learning for each of us in undertaking this study.

Satyanarayan Mohanty D‐COR Consulting

D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

CONTENTS

EXECUTIVE SUMMARY...... 7 Chapter – I ...... 11 1. STUDY OVERVIEW & METHODOLOGY ...... 11 1.1 Health Scenario of Orissa ...... 11 Page | 3 1.2 An overview on health needs in KBK Region of Orissa ...... 11 1.3 Address of health needs through NRHM ...... 13 1.4 Positioning of ASHA: A Key Component of NRHM ...... 13 1.4.1 Conception and Need of ASHA intervention ...... 13 1.4.2 ASHA Intervention in Orissa ...... 14 1.5 Need and Relevance of the Study ...... 17 1.6 Study Objectives ...... 17 1.7 Scope of Work ...... 17 1.8 Methodology ...... 18 1.8.1 Study Design ...... 18 1.8.2 Secondary Data ...... 18 1.8.3 Primary Data ...... 18 1.8.3.1 Sampling ...... 18 1.8.3.2 Tools & Techniques of Data Collection ...... 20 1.8.4 IT Enabling of Data and Reporting ...... 20 Chapter – II ...... 21 2. INCENTIVE PROVISION FOR ASHA ...... 21 2.1 Payment Provision and System in Orissa ...... 21 2.2 Comparative Picture of Incentives Provision in Orissa and Other States ...... 22 Chapter – III ...... 23 3. STUDY FINDINGS ON FACTORS AFFECTING ASHA ROLES AND INCENTIVES ...... 23 3.1 Background Information about Study Respondents ...... 23 3.1.1 ASHA ...... 23 3.1.2 ANM and AWW ...... 24 3.2 Physical and Demographic Setting of the Operational Area of ASHA ...... 24 3.3 Roles and Responsibilities Undertaken by ASHA ...... 27 3.3.1 Knowledge about her own Roles and Responsibilities ...... 27 3.3.2 Activities Undertaken and Time Spent by ASHA in KBK region ...... 27

D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

3.3.3 Convergence of ASHA Role with ANM and AWW in KBK region ...... 29 3.3.4 Factors Adversely Affecting ASHA Roles and Responsibilities in KBK region ...... 32 3.4 Incentives Earned by ASHA ...... 36 3.4.1 Knowledge of ASHA about the Incentive Provisions ...... 36 3.5 Expected Annual Earning by an ASHA in Orissa ...... 37 Page | 4 3.5.1 Variance in Incentives Earned by ASHA ...... 38 3.5.1.1 Monthly Incentive Earned by ASHA ...... 38 3.5.1.2 Scheme wise variance in Income of ASHA ...... 39 3.5.1.3 Spatial Variance ...... 41 3.5.1.4 Average Income Expected vs. Income Earned by ASHA in KBK ...... 42 3.5.1.5 Perception of ASHA on Payment System and Procedures ...... 43 3.5.1.6 Backlogs (during May to September 2009) ...... 44 3.5.2 Factors Affecting ASHA Incentives ...... 45 3.5.3 Factors Feasible to Address ...... 46 Chapter – IV ...... 48 4. SCOPE OF EXPANSION OF ASHA ROLES AND POSSIBLE CHANGES IN ASHA PACKAGE ...... 48 4.1 Community health needs addressed by ASHA ...... 48 4.2 Willingness of ASHA to take up Additional Responsibilities ...... 49 4.3 Expansion of ASHA Role and Responsibilities ...... 49 4.4 Suggested Changes in ASHA Incentive Package for Discussion ...... 50 Chapter – V ...... 54 5. SUMMARY AND CONCLUSION ...... 54

TABLES Table 1 Socio‐economic snapshot of KBK region in Orissa ...... 12 Table 2 Job Responsibilities entrusted on ASHA ...... 16 Table 3 Outcome and Impact expected from ASHA intervention ...... 16 Table 4 Sample Coverage ...... 19 Table 5 Tools & Techniques of Data Collection ...... 20 Table 6 Incentive Provision for ASHA in Orissa ...... 21 Table 7 Comparison of Incentive Provision for ASHA in Orissa and other EAG States ...... 22 Table 8 Background Information about ASHAs ...... 23 Table 9 Background Information about ANMs and AWWs ...... 24 Table 10 Average households covered by an ASHA ...... 25 D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

Table 11 Average population covered by an ASHA ...... 25 Table 12 Health facilities visited by ASHA during Sep and Oct 2009 ...... 25 Table 13 Knowledge of ASHA about her own roles and responsibilities ...... 27 Table 14 Average time spent by ASHA in KBK districts (including time spent on mobility) ...... 28 Table 15 Activities undertaken by ASHA in convergence with ANM and AWW in KBK districts ...... 29 Page | 5 Table 16 Support expected by ASHAs from ANM and AWW in KBK districts ...... 30 Table 17 Support expected by ANM and AWW from ASHA in KBK districts ...... 30 Table 18 Knowledge of ASHAs about the incentive provisions ...... 36 Table 19 Expected Annual Earning by an ASHA in Orissa ...... 37 Table 20 Monthly income earned by ASHA from May to September 2009 ...... 38 Table 21 Scheme wise monthly income earned by ASHA ...... 39 Table 22 District and Block wise monthly income earned by ASHAs ...... 41 Table 23 Prospects of E‐payment ...... 43 Table 24 Backlog payments to be made to ASHA during May to September 2009 ...... 44 Table 25 District and Block wise backlog payments to be made to ASHA during May to Sep 2009 ...... 44 Table 26 Scheme wise backlog payments to be made to ASHA during May to September 2009 ...... 45 Table 27 Factors adversely affecting ASHA incentives in KBK region ...... 45 Table 28 Contribution of ASHA in addressing community health needs ...... 48 Table 29 Changes suggested in current ASHA package ...... 51 Table 30 Additional Package for ASHA ...... 52

D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

ABBREVIATIONS ADMO Assistant District Medical Officer IFA Iron Folic Acid ANC Ante Natal Care IMR Infant Mortality Rate ANM Auxiliary Nurse Midwife IUD Intra Uterine Device APL Above Poverty Line JSY Janani Surakhsya Yozana ASHA Accredited Social Health Activist KBK Koraput‐Bolangir‐Kalahandi Page | 6 AWC Anganwadi Centre LHV Lady Health Visitor AWW Anganwadi Worker MMR Maternal Mortality Rate BCC Behavior Change Communication MO Medical Officer BPL Below Poverty Line MoHFW Ministry of Health and Family Welfare BPMU Block Project Management Unit NFHS National Family Health Survey CBO Community Based Organization NGO Non Government Organization CDMO Chief District Medical Officer NIP National Immunization Program CHC Community Health Centre NRHM National Rural Health Mission DDK Disposable Delivery Kit NRHM National Rural Health Mission DHH District Headquarter Hospital OBC Other Backward Caste DLHS District Level Health Survey PHC Primary Health Centre DPM District Program Manager PNC Post Natal Care EAG Empowered Action Group RCH Reproductive and Child Health FGD Focused Group Discussion RTI Right To Information FY Financial Year SC Schedule Caste GDP Gross Domestic Product SHG Self Help Group GKS Gaon Kalyan Samiti SPSS Statistical Package for Social Science GOI Government of India ST Schedule Tribe HDI Human Development Index STI Sexually Transmitted Infection HH Household TBA Traditional Birth Attendant HMIS Health Management Information System THR Take Home Ration ICDS Integrated Child Development Service VHND Village Health and Nutrition Day IEC Information Education Communication

D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

EXECUTIVE SUMMARY three fourth of ASHAs (76.7%) in Non‐KBK belong to families having BPL card. Study Overview and Objectives The Accredited Social Health Activist (ASHA), a key When majority i.e. 75% of ASHAs in KBK cited social component under NRHM, is envisaged as a trained service, 80% in Non‐KBK attributed their family female community health volunteer who would act as interest as key motivating factor behind joining ASHA. an intermediary between people in the community 100% of ANMs and AWWs interviewed in Non‐KBKPage | 7 and health service outlets. Since she is not paid a fixed have education of 10th standard or above, whereas, salary, the performance based incentive package 90% of ANMs and 60% of AWWs in KBK have similar introduced for ASHA becomes crucial to retain her qualifications. When 45% of ANMs and 50% of AWWs motivation. in KBK belong to ST & SC, 100% in Non‐KBK represent The present study titled as “Factors affecting ASHA from OBC & General Caste communities. roles and incentives in the KBK region of Orissa” is the Physiographic and demographic setting of culmination of the need and importance of operational area of ASHA strengthening ASHAs positioned in the region. The The maximum number of hamlets covered by an ASHA study aimed to know various factors that affect her in KBK is 6 as against 4 covered in Non‐KBK. Maximum roles and incentives; assess incentives earned by ASHA distance that an ASHA has to cover is 8km in KBK as and reasons of variance; assess efficiency of payment against 3km in Non‐KBK for visiting a hamlet, that system for ASHA; and to know the contribution of indicating about dispersed human settlements in KBK. ASHA, time spent, her role and convergence with Also, the maximum distances that an ASHA have to other providers. cover to visit health facilities (Subcentre:15km,

Methodology PHC:55km & CHC:60km) in KBK is higher than those in The study was undertaken in four sample districts of Non‐KBK (Subcentre:7km, PHC:16km & CHC:15km).

KBK region (two in southern part of KBK viz. Rayagada On an average, an ASHA in KBK has to cover lesser & Nabarangpur; and rest two in western part viz. number of households and population (201HHs & 970 Bolangir & Kalahandi); and one district in coastal people) than Non‐KBK (275HHs & 1296 people). The region (i.e. Balasore) to have comparison with KBK. lowest number of households and population covered Further, in each district the study covered one nearest by an ASHA in KBK is only 50 and 191 respectively. and one distant Block from the district head quarter. Information in the study were collected from both In brief, ASHAs in KBK deal with lesser population primary and secondary sources through specially and households but have to cover higher distances to designed study tools or instruments. visit hamlets and health facilities than Non‐KBK.

Background characteristics of study respondents Knowledge of ASHAs about her roles and incentives In KBK, 43.3% of ASHAs are below 8th standard Except creation of awareness on RTI/STI, more than whereas in Non‐KBK (Balasore) 100% are 8th standard 70% of ASHAs in KBK know rest of their job or above. 83.3% of ASHAs in KBK meet the prescribed responsibilities. But, responsibilities like creating age criteria of 25 to 45yrs than 96.7% in Non‐KBK. The awareness on health & hygiene, RTI/STI, counseling on rest were below 25yrs of age. contraception and promote construction of toilet are known to only less than 50% of ASHAs in Non‐KBK. So, 70.8% of ASHAs in KBK belong to ST & SC, whereas, ASHAs in KBK have better knowledge about their 90% of ASHAs in Non‐KBK represents OBC & General own roles and responsibilities than those in Non‐KBK. Caste communities. In KBK, 20% of ASHAs are engaged in other income generating activities whereas only Regarding knowledge on incentives, more than 70% of 6.7% in Non‐KBK have to do so for earning their ASHAs in KBK know their incentive provisions for livelihood. Almost half of ASHAs (53.3%) in KBK and DOTS, Immunization, VHND, GKS, Sector Meeting, etc.

D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa whereas 58.3% and 43.8% were not aware of the KBK and 20% in Non‐KBK could earn more than Rs. provisions for male sterilization and blood sample 1,501/‐ pm, which was possible because of managing collection respectively. Even, more surprisingly, 90% much higher population and institutional deliveries (as of ASHAs in Non‐KBK were also not aware of the same. highest incentive of Rs. 600/‐ is attached to the same) than whose income was below Rs. 1,500/‐ pm. Activities undertaken and time spent by ASHA in KBK During two months prior survey, more than 80% of Thus, it can be construed here that coverage of more Page | 8 ASHAs were involved in activities like health planning; population and institutional deliveries give relatively awareness generation; mobilizing beneficiary and better income to ASHA irrespective of regions. attending health events like immunization day and Except Kalahandi, there is no significant difference VHND; and distribution of medicines. Only 3.3% found between the income of ASHAs operating in mobilized patients for leprosy treatment; 23.3% for nearest and distant Blocks of KBK districts. That means DOTS; and 35% escorted needy patients and 53.3% the distant and nearest blocks do not have much accompanied delivery cases to health facilities. impact on the amount of incentives earned by an Among various activities undertaken, the average time ASHA in KBK districts. spent by ASHA for accompanying pregnant women is However in Non‐KBK district, ASHAs operating in highest (44hrs) followed by awareness & counseling nearest Block (Rs. 1411/‐) earned significantly higher (21hrs); and participation in health events (18hrs) income of Rs. 579/‐ than those in distant Block (Rs. consumed next highest times of ASHA. The least time 832/‐). More importantly, it indicates that the income was spent on distribution of medicines (3hrs) which of ASHAs operating in distant Blocks of Non‐KBK was she does along with her domestic chores. On an found to be more or less same with KBK districts. That average, an ASHA spent 3hrs per day in undertaking means the ASHAs operating in remotest Blocks of various activities. Non‐KBK were not able to earn better income either. Convergence of ASHA with ANM and AWW Income expected vs. Income earned by ASHA The activities that were mostly undertaken by ASHA Based on the current trend, it can be projected that an with ANM are immunization (85.8%), VHND (56.7%), average expected income of ASHA can be home visit (44.2%) and ANC (32.5%). Similarly, the approximately Rs. 22,000/‐ pa or Rs. 1800/‐ pm. But, activities like growth monitoring (53.3%), VHND the actual income earned by an ASHA in KBK districts (51.7%), THR (44.2%), immunization (43.3%), etc. were (i.e. 954/‐) is almost two times lesser than the normally undertaken by ASHAs in convergence with expected income. Also in Non‐KBK, the actual income AWW. earned by ASHAs is also Rs. 500/‐ to 600/‐ lesser than Maximum of ASHAs expected the ANM (i.e. 64.8%) the expected income. and AWW (72.7%) to take joint home visit with them Payment mode and procedures in the village (out of 37.5% and 29.2% of ASHAs Maximum of ASHAs were made payment during requiring support from ANM and AWW respectively). August to September 2009 (notice was served by The other convergence issues that came out during government for clearing the backlogs). discussion with ASHA, AWW and ANM are on fixation All three modes of payment viz. Cash, Cheque and E‐ of immunization points, conflict of interest on Payment were evident in KBK. incentives, non‐functioning of GKS, etc. Increase in E‐Payment transactions was reported Incentive Earned by ASHA from May to October 2009. In KBK districts, the monthly average earning of an On the spot cash payments were made for GKS, ASHA was Rs.954/‐ in comparison to Rs.1,273/‐ pm in Sterilization and Training in all districts of KBK. Non‐KBK. 90% of ASHAs in KBK and 80% in Non‐KBK Except Bolangir, the payment for sector meeting earned below Rs. 1,500/‐ pm. Only the rest 10% in was made in cash in rest of the 3 KBK districts.

D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

In Non‐KBK, incentives to ASHA were paid through on local private practioner for delivery than visiting E‐Payment for all schemes except sterilization. the health facility. On the other side, Dhai / private practioner also motivate people for home delivery in Payment of Backlogs lesser cost. Apart from these, unwillingness of Irrespective of E‐Payment and backlog clearance pregnant women to conduct delivery by male doctor during May to September 2009, the average backlog in the health facility creates lot of difficulty for ASHA. works out to be Rs. 1,171/‐ in KBK and Rs. 789/‐ in Page | 9 Non‐KBK district. The highest amount of backlog was The other problems faced by ASHA include in Bhawanipatna Block (Rs. 3,245/‐) of Kalahandi discontinue or non‐receiving of services by TB patients district and lowest (Rs. 203/‐) in Gunupur Block of (due to inhibitions) and pregnant women (due to Rayagada district. Scheme wise highest i.e. 119 out of moving to maternal home); lack of trust on ASHA for 120 ASHAs interviewed in KBK had backlogs to be paid Blood slide collection; misconception of people on for immunization followed by 80 ASHAs for VHND, 35 sterilization (e.g. back pain, weakness, etc.); for JSY and 27 for GKS. dependence on quacks; migration; lack of timely information by people to ASHA, etc. which affect her Problems encountered for payment roles as well as earning of incentives. Delay in paying incentive to ASHA for immunization in Bolangir and Kalahandi districts (delay in fund Geographic and Communication Factors allocation to BADA). Major parts of KBK are covered with hilly terrains, Except Rayagada, ASHAs in Nabarangpur, Bolangir dense forests, river, etc. which restrict the movement and Kalahandi districts were not paid incentives for of ASHA as well as beneficiaries. Long distance of VHND during the reporting period. hamlets is the other important factor which limits More time consumed due to multiple Bank accounts interaction of ASHA with people and vice versa. maintained by BADA/BPMU. More importantly lack of roads, infrequent Long distance to withdraw money as accounts are transportation and high transportation costs create lot opened in Block headquarter of difficulties for both people and ASHA to visit the Maintain minimum savings balance of Rs.500/‐ in health facilities. Even, there are villages to which the bank account vehicle cannot come, which affects ASHA to Informal payment made by some ASHAs. accompany pregnant woman to health facility. These Factors Adversely Affecting ASHA Roles and communication problems also pose difficulties for Incentives in KBK ANM to visit the villages. Also, lack of telephone Personal Factors communication in some areas affects ASHA to contact Majority of ASHAs due to their low education and lack other providers and vice versa. The situation becomes of exposure face difficulty in motivating and mobilizing worse especially during emergencies. people in the community. Other personal factors such as pregnancy and small children of ASHA; engagement Work Facilities and Environment in economic and domestic activities; etc. also affect in Besides various geographic and demand side factors, delivering her roles & responsibilities. there are also constraints relating to delivery of health services or systems which de‐motivate people for Community / Demand Side Factors accessing the same viz. lack of doctors, beds, referral Apart from the above, various community factors e.g. of patients (due to lack of manpower & blind believes & superstitions; ignorance; and infrastructures), delay in submission of pathological inappropriate health practices pose major problem for test report, absence of staff on duty, informal ASHA to create demand for health services. payment, etc.

As evident, the home delivery by Dhai is still preferred Other factors which affect her work and incentives by people in the villages. In some areas, people trust include: the diversion of transportation payment of

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A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

ASHA to Janani Express; deduction of a part of JSY l) Organizing sterilization camps in the PHC / Block incentive due to still birth and not giving BCG; less headquarter number of immunization points/booths (sharing of m) Avoiding duplication of roles & responsibilities of incentive among ASHAs); lack of coordination ASHA with other providers (e.g. ANM and AWW between ASHA and AWW for GKS; incentive provision apart from ASHA are also engaged for providing to other providers for similar work; etc. DOTS, motivating people for sterilization, etc.) n) Joint home visit by ANM and ASHA for establishingPage | 10 Community health needs which remain unaddressed good rapport with villagers. (in KBK) Medicines for minor ailments like scabies, other skin o) Convergence between AWW and ASHA diseases, indigestion, body ache, etc. p) Opening up of zero balance savings bank account Dressing of wounds, cuts, burns, etc. of ASHA

Diagnosis & care of major ailments like Jaundice, Expansion of ASHA roles and responsibilities Typhoid, Gastroenteritis, Fids, Cataract, Leprosy, Before expanding the roles and responsibilities of STI/RTI, Chicken Pox, Measles, Bone fractures, ASHA, it is important for the State to address various Dental Problems, Mouth Ulcers, Appendicitis, factors that adversely affecting the delivery of her Stomach pain, Snake bite, etc. current responsibilities. Also, at the same time it is Post sterilization complications important to look into the various community health Provision of cash in hand for accompanying needs which remain unaddressed. So, a careful emergency cases to hospital examination of all these insinuates following three

Factors feasible to address options which the state may consider for An attempt has been made here to identify factors strengthening and improving the ASHA intervention in which are under the control of health system and can KBK region of the State: be addressed effectively. a) Retaining same role of ASHA with constraints a) Training and exposure to ASHA for improving their addressed and increased package; and/or

communication and mobilization skills b) Adding more individual services e.g. first aid, b) Provision of By‐cycles to ASHA for movement medicines for minor illness, etc.; and/or within the villages and visiting the sub‐centre c) Adding more group services e.g. school health c) Fixation of immunization point in each AWC program, more involvement in GKS, work with d) Medicines for other common minor ailments like skin diseases, body ache, indigestion, etc. Timely women’s groups / SHGs. replenishment of medicines to ASHA. *** e) Providing medicine storage facility to ASHA. f) Focused IEC & BCC interventions to dispel myths, misconceptions, blind beliefs, etc. of people. g) Provision of cash in hand with ASHA for dealing emergency delivery cases and patients h) Orientation of doctors and staff nurse for proper interaction with ASHA and beneficiaries i) Timely allocation of funds to BPMU and release of incentives to ASHA account j) Adequate manpower and infrastructure facility in PHCs and New PHCs k) Submission of pathological reports by PHC in time

D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

Chapter – I

1. STUDY OVERVIEW & METHODOLOGY

1.1 Health Scenario of Orissa Page | 11

Orissa is acclaimed for its natural resource base and is considered as one of the resource rich states of India. The State is gifted with vast mineral, forest and water resources. Because of its sizeable mineral reserve, Orissa is growing fast in the industrial sector.

The State would like to make similar progress in health sector as well. Orissa has made gradual progress in the health sector over last few decades but many of the health indicators of the State require a great deal of improvement as compared to other States of India. High morbidity and mortality rate are grave concerns for the State, which adversely affecting the chances of people living healthy and longer in Orissa. In comparison to Kerala, the male (60.05 years) and female (59.71 years) population of Orissa live at least 11.62 and 15.29 years lesser respectively1. The average life expectancy of people in the country is also higher (3.82 years more in case of males and 7.2 years more in case of females) to that of Orissa2. The State also remains far behind to Kerala State if the IMR status of both the States is compared (71 infant deaths in Orissa as against 13 deaths in Kerala per 1000 live births)3. The MMR of Orissa is also not different (303 deaths in Orissa as compared to 254 deaths in India per 1,00,000 live births)4. Every year, a significant percentage of people in the State also die because of malaria and tuberculosis. In fact, Orissa contributes 23% of malaria cases, 40% of PF cases and 50% of malaria deaths of the country5; and the State exhibits prevalence of Tuberculosis at a rate of 418 deaths per 1lakh population6. In brief, the health of people which is one of the key indicators of progress of contemporary societies certainly requires greater attention in Orissa.

1.2 An overview on health needs in KBK Region of Orissa

While the health status of people in Orissa differs from district to district, the Koraput‐Bolangir‐ Kalahandi (KBK) region of the State, in particular, requires more attention. The KBK region is greatly marred by its geo‐physical, social and economic constraints. Comprising of eight underprivileged districts (viz. Koraput, Rayagada, Nabarangpur, Malkangiri, Kalahandi, Bolangir, Sonepur and Nuapara), the KBK region largely contributes to poor health indicators of the State. The region accounts for around 31% of the total area of the State, but only 20% of the total population indicating the low density of population in the region. The region has large concentration of Scheduled Tribe and Scheduled Caste inhabitants; and in general, the people in the region have low economic and educational status. Mostly

1 MoHFW, GOI, 2001‐06 2 MoHFW, GOI, 2001‐06 3 SRS, 2008 4 SRS, 2006 5 ICMR Bulletin, October 2003 6 NFHS ‐ III, 2006 D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa covered with dense forests; hilly tracts and long terrains; and cut‐off or inaccessible areas, the demand for health care in the KBK region is palpable.

Malkangiri, Rayagada and Bolangir districts in KBK have exceedingly high level of mortality rates (IMR above 100 and MMR above 400) which brings down the life expectancy at birth to only below 56 years in the said districts 7 . The Page | 12 issues, more specifically, relating to inequity not only weigh heavily against people to access the health services but also pose enormous challenges for the health system of the State to create a dent in the region. Nonetheless, focused initiatives have been undertaken by different players including the State Government for the development of the region in health and other sectors. A socio‐economic snapshot including the health status of districts in the KBK region is presented hereunder:

Table 1 Socio‐economic snapshot of KBK region in Orissa

Development Districts in KBK Region KBK Orissa Source Rayagada Koraput Nabarangpur Malkangiri Bolangir Sonepur Kalahandi Nuapada

Indicators Average

Total Population (in 831,1 1,180 1,025 504,1 1,337 541,8 1,335 530,6 7,286, 36,804 Census of India thousands) 09 ,637 ,766 98 ,194 35 ,494 90 923 ,660 2001 Proportion of ST 62.8 56.5 57.8 60.6 22.6 10.2 30.4 36.3 42.2 24.6 Proportion of SC 13.9 12.9 13.6 20.9 17.2 23.6 17.7 13.3 16.6 17.2 Proportion of ST + SC 76.7 69.4 71.4 81.5 39.8 33.8 48.1 49.6 58.8 41.8 Population Density 118 134 194 87 203 232 169 138 153 236 Rural Literacy Rate 29.9 27.3 31.3 27.9 52.7 61.7 43.5 40.3 39.3 59.8 Female Literacy Rate 24.56 24.26 20.67 20.91 39.51 46.17 29.28 25.79 29.0 32.7 Villages Connected with 61.2 22.2 45.1 21.2 40.6 36.3 41.5 33.5 37.7 50.0 Paved Roads (%) Urbanization 13.9 16.8 5.8 6.9 11.5 7.4 7.5 5.7 9.4 15.0 Poverty Status (BPL 72.03 83.81 73.66 81.88 61.06 73.02 62.71 78.31 73.30 47.158 1997 census of Families) BPL families IMR 102 72 63 117 103 62 76 72 83.4 719 SRS‐08, Life Expectancy at Birth 56 62 62 53 55 63 61 63 59.4 6110 IIPS Estm. ‐01

7 IIPS Estimate, 2001‐02 8 SRS, 2008 9 MHFW, 2001‐06 D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

1.3 Address of health needs through NRHM

The National Rural Health Mission (NRHM) was launched in the year 2005 with an aim to improve the availability and access to quality health care by the rural people in general and the poor, women and children in particular. NRHM is considered as the biggest ever health initiatives in the country. The Mission is an articulation of the commitment of the Government of India to enhance the public spending on health from 0.9% of GDP to 2‐3% of GDP11. It aims to undertake architectural correction of the health Page | 13 system to enable it to effectively handle increased allocations and promote policies that strengthen public health management and service delivery in the country. The NRHM covers all the villages with special focus on 18 states (including Orissa) which have weak public health indicators and weak health infrastructures. The programs that come under NRHM are viz. the ongoing Reproductive and Child Health Phase II (RCH‐II) Program; National Immunization Program (NIP); National Disease Control Program and Inter‐Sectoral Convergence Efforts; and the NRHM New Initiatives. One of the key components under NRHM initiatives is:

Accredited Social Health Activists (ASHA);

It is satisfying to note here that after introduction of NRHM in 2005, a low performing state like Orissa has started showing signs of improvements in various health indicators e.g. Institutional Delivery (increased from 35.6%12 in 2006 to 75%13 in 2009‐10); Immunization (increased from 52% in 2005‐06 to 85% in 2009‐10‐progressive14); ‘+ve’ Malaria cases (reduced to 359619 cases in 2008 from 396573 cases in 200515); Malaria deaths (reduced to 226 in 2008 from 255 in 200516); Leprosy prevalence (reduced from 2.05 in 2005 to 0.87 in 200817); etc. Innovative and strategic initiatives like ASHA; JSY, etc. taken up under NRHM are reckoned as key factors for making progress in the health indicators. More importantly, NRHM has created state and country wide belief that progress in health indicators is possible.

1.4 Positioning of ASHA: A Key Component of NRHM

Named as ‘Accredited Social Health Activist (ASHA)’, she is primarily a trained female community health volunteer engaged in every village with a population of one thousand to act as a link between community and public health system.

1.4.1 Conception and Need of ASHA intervention

The need of positioning ASHA was felt when it was experienced that the ANM is overworked for catering health services to five thousand people in a health Sub‐centre. Similarly, it was also realized that the AWW, who was the only worker engaged at the community level cannot be expected to act as a change agent on health because of very nature of jobs undertaken by her like e.g. supplementary feeding, pre‐

10 Planning Commission, 1999‐2000 11 ASHA Training Manual, GOI 12 NFHS III (2006) 13 HMIS Report, NRHM, Orissa, 2009‐10 (progressive) 14 HMIS Report, NRHM, Orissa, 2009‐10 (progressive) 15 HMIS Report, NRHM, Orissa , 2008‐09 & 2005‐06 16 HMIS Report, NRHM, Orissa, 2008‐09 & 2005‐06 17 HMIS Report, NRHM, Orissa, 2008‐09 & 2005‐06 D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa schooling, etc. under ICDS scheme. Thus, to fill‐up the void between community and health service providers like ANM, AWW, etc. the ASHA intervention under NRHM has been designed and is being executed by the State Governments18.

But positioning community health volunteer or activists for achieving development results is not a new concept. It is practiced by various national and international agencies more specifically by NGOs since long. The best practice like ‘Change Agent’ experimented by various agencies in the health sector is one Page | 14 such example. The purpose behind engaging female Change Agents was to act as a bridge between the community and the health providers. The ASHA intervention under NRHM has been conceptualized and designed in similar lines. But keeping sustainability factor into account, ASHAs receive performance based incentives which was not the case with Change Agents. The past experience with Change Agents brought to light that volunteerism without cash incentives would not be a sustainable option19. In absence of any incentive mechanism, there was difficulty in sustaining the interest and motivational level of Change Agents. So based on past learning, performance based incentive is paid to ASHA for undertaking various activities.

To roll out ASHA intervention in the country, the GOI has articulated and issued detailed guidelines about the roles, responsibilities, profile, selection procedure, training modality and compensation package for ASHA; and it has given flexibility to the States for making necessary changes to adapt the ASHA guideline according to the local situation.

1.4.2 ASHA Intervention in Orissa

The ASHA intervention in Orissa is being executed as per the guidelines issued by the GOI. Wherever necessary, the State has made contextual modifications in the guidelines to fit in with the local situation. Compensation package for ASHAs has been also fixed keeping the local requirement into account.

Selection of ASHAs The State, as of November 2009, has positioned 38,083 ASHAs across 30 districts of the State and expected to reach 41102 soon. District wise segregated picture of ASHAs selected with regional (KBK and Non‐KBK) break‐up is presented in the figure 1.

18 Operational Manual on ASHA Program, Mission Directorate, NRHM, GoO 19 Engaging Communities to Improve Health and Nutrition Outcomes: Approaches, Processes and Lessons; CARE India D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

The selection of ASHAs in the State was undertaken in three phases. The first two phases of selection was done in FY 2005‐06 and 2006‐07 during which the State followed the norm of placing one ASHA per each AWC existing in the State. However, due to increase in the number of AWCs and in view of some ASHAs (selected in the first two phases) covering more than 1000 population, the State has now undertaken a third phase of selecting ASHAs. The ASHAs are selected through a village meeting facilitated by a trained person that involves ward member, ANM, AWW, CBO, SHG leaders, members of Page | 15 other committees / groups, etc. of the concerned village.

The criteria followed for selection of ASHA are as follows: i) ASHA must be primarily a woman resident of the village (married / widow / divorced). ii) She should be preferably in the age group of 25 to 45 years. iii) She should be literate woman with formal education up to Class – VIII. If suitable candidate with this qualification is not available in a particular age, then this may be relaxed up to Class‐V or ability to read and write. iv) She should have effective communication skills and leadership qualities.

Induction Training of ASHAs (Module I ‐ 5 days) Followed to their selection, series of trainings have Thematic been provided to equip ASHAs with required job (Module II to IV‐ knowledge and skills. As presented in figure 2, ASHA 16 days) Training majority of ASHAs in the State have been imparted Packagee induction (89.7%) and thematic training (84%). After Module V (4 days) completion of the said trainings, ASHAs have been

First‐AID also provided training on Module ‐ V and First‐aid, (2 days) which are all expected to be over by end of FY 09‐ 10.

Thematic Figure 2 Training Status of ASHAs in KBK Districts (in %) Induction 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

Bolangir 94.5 93.7 80.8 Sonepur 80.8 87.8 Kalahandi 87.8 89.8 Nuapada 89.8 Koraput 83.2 Districts

81.7 90.5 KBK Malkanagiri 88.1 72.8 Nawarangpur 72.8 Rayagada 90.8 90.8

l 85.9 KBK Tota 85.4

l 90.7

KBK 83.7 Non Tota ‐

l 89.7 sa 84.0 Oris Tota

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A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

The roles and responsibilities entrusted on ASHA are as follows:

Table 2 Job Responsibilities entrusted on ASHA20 A. Key roles & responsibilities Create Awareness: On Health, Nutrition, sanitation, health & family welfare services, etc. Counseling: Birth preparedness, safe & institutional delivery, breast‐feeding, immunization, contraception, prevention of RTI/STI, etc. Page | 16 Mobilization: Facilitate access of health services in sub center, PHC, CHC and DHH; and Village Health Plan Escort/Accompany: Escort needy patients and the woman in labor to the health institution Primary medical health care for fever, first‐aid for minor injuries, diarrhea, etc. Promote community level action to address health issues.

B. Specific role envisaged under JSY Identify pregnant woman, facilitate registration for ANC, assist her in necessary certifications Help the women in ANC, TT & IFA Identify a Government or Private health centre and counsel for institutional delivery Escort the beneficiary to health centre and stay with her till the woman is discharged Arrange to immunize the newborn till the age of 14 weeks and inform about birth or death of child Post natal visit within 7 days Counsel for initiation of breastfeeding within 1hr and continuance till 3‐6 months, and Promote family planning Assist in public health programs like DOTS, Malaria, Sterilization, etc.

Table 3 Outcome and Impact expected from ASHA intervention21 Outcome Indicators: Impact indicators : a) % of newborn who were weighed and families a) IMR counseled b) Child malnutrition rates b) % of children with diarrhoea who received ORS c) Number of cases of TB/leprosy cases c) % of deliveries with skilled assistance detected as compared to previous year d) % of institutional deliveries e) % of JSY claims made to ASHA f) % completely immunized in 12‐23 months age group g) % of unmet need for spacing contraception among BPL h) % of fever cases who received chloroquine within first week in a malaria endemic area

Apart from 27 days of training package, ASHAs in the State have been provided with various support facilities like drug kit, uniforms, ASHA Gruha at the hospitals, ASHA award and other logistic supports to deliver tasks entrusted on them.

The incentives paid to ASHA vary from activity to activity and range from Rs. 10/‐ to Rs. 600/‐ for undertaking activities like malaria slide collection, institutional delivery under JSY, TB treatment,

20 Operational Manual on ASHA Program, Mission Directorate, NRHM, GoO 21 Operational Manual on ASHA Program, Mission Directorate, NRHM, GoO D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa sterilization, attending training, meetings, health events, etc. (details about the incentive package of ASHA in Orissa is presented in Chapter II).

1.5 Need and Relevance of the Study

ASHA is attributed as a potential vehicle to generate adequate demand for health services among the Page | 17 people through mobilization, motivation and awareness generations on one side; and to ensure health care services reaching to people on other side. She is the focal point for various health interventions in the community; and the whole community health strategies and actions under NRHM revolve around her. Especially given the geo‐physical and socio‐economic context of KBK region in Orissa, her role carries profound significance to improve the health status in the region. Therefore, the incentive based service delivery strategy that has been adopted for ASHA becomes crucial for maximizing her performance in the region.

But it is observed that some ASHAs are able to manage more incentives as compared to others. There is variance in the income earned by ASHAs from the performance based incentive system introduced by the State. Thus, the State required understanding on why do some ASHAs earn better as compared to the others? Broadly, it could be due to factors relating to systems, service delivery and socio‐cultural and geographic environments which lead to variance in the income of ASHAs. Therefore, an understanding on the same would not only help to maximise the benefits gained by ASHAs but also to ensure certain health care services are delivered effectively in the process. This rapid assessment carried out in the KBK region was an attempt to know the factors affecting ASHA roles and incentives which would help the state for improving ASHA intervention in the region.

1.6 Study Objectives

i) To assess ASHA incentive in the state and identify reasons for variance (e.g. personal factors and motivation; work facilities and environment; community factors; geographic and communication factors) ii) To assess the efficiency of the payment system for ASHA iii) To assess the contribution of ASHA in facilitating delivery of health services, time she spends for the same and the fit of ASHA with other providers’ roles on different population norms. iv) Based on the findings, indicate possible changes to the ASHA package (for all or limited) and scope for expansion of ASHA role keeping the sustainability issues in mind.

1.7 Scope of Work

i) Review of current ASHA package / incentives for different schemes and find out the average income of an ASHA in a month. (review of payments during April to October 2009) ii) Review various assessment reports from Orissa of ASHA and schemes where she plays a role and assess the level of motivation, bottlenecks and sustainability of performance based incentive.

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iii) Review of ASHA package in other states and in differential population keeping in view of equalizing ASHA/AWC in the state. iv) Identify other factors (non‐financial) that motivate ASHA apart from the financial incentives. v) Assess the required time & incentive (based on the population covered by her and the various roles & responsibilities entrusted to her) vis‐à‐vis actual time & incentive received by ASHA for delivering services. Page | 18 vi) Assess the scope of expansion of ASHA roles and responsibilities and suggest possible changes in the same. vii) Assess the level of interdependence among ASHA, ANM and AWW. Assess whether there is any role duplication. viii) Analyze the progress in health indicators (e.g. JSY, Immunization, etc.) after the introduction of ASHA. ix) Assess the feasibility and sustainability of recently introduced e‐payment system to ASHAs

1.8 Methodology

1.8.1 Study Design

Keeping the above objectives and the scope of work into account, the study adopted an exploratory study design and collected data from both primary and secondary sources.

1.8.2 Secondary Data

The data that were collected from secondary sources are as follows:

Current ASHA Package / Incentive in Orissa as well as other States of India District wise no. of ASHA Comparison with other states Review of reports, documents on ASHA Population per ASHA, AWW and ANM

1.8.3 Primary Data

The study adopted sampling procedure and developed various structured and semi‐structured tools for collection of primary data. The details are as follows.

1.8.3.1 Sampling

Selection of districts: Four districts in KBK region and one district from the coastal region were selected and covered in the study. As the health status in the coastal region is relatively better to that of other regions in the State, the study purposefully covered one coastal district along with the KBK districts for making a comparative assessment of districts between two different regional set‐ups.

The four districts covered in KBK region include Rayagada and Nabarangpur in the southern; and Bolangir & Kalahandi in the western part of the region. Both southern and western parts of KBK region

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A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa comprise of four districts each, out of which the above two districts were selected (one district with highest and the other with lowest HDI value) in each part of the region. Malkangiri and Bolangir were identified as districts having lowest HDI value; and Rayagada and Kalahandi were identified as districts having highest HDI value. But, due to Naxal insurgence the study could not cover Malkangiri district, in place of which the district Nabarangpur was taken in the study. Apart from these four KBK districts, Balasore was covered as the coastal district. Page | 19

Selection of Blocks: In each selected district, two blocks (one each having highest and lowest distance from the district head quarter) were selected for the study with a total of 10 Blocks covered in five sample districts.

Selection of ASHA: The spread/dispersion of location of households in the operational area of ASHA was taken as the criteria for selecting ASHAs. In the selected Blocks, the ASHAs were first categorised into three types of operational area viz. i) ‘One compact Village/AWC having no hamlet’, ii) ‘Village/AWC with one hamlet’ and iii) Village/AWC with two or more hamlets’. Then five ASHAs were randomly interviewed from each of the three types of operational area. The idea behind this was to make a comparative analysis among ASHAs operating in different operational set‐ups. In total, 15 ASHAs were interviewed from each Block and 30 from each district. The total number of ASHAs covered in five sample districts comes to 150.

ANM and AWW: Apart from ASHAs, the study also interviewed five ANMs and AWWs each in the selected districts. In total 25 ANMs and AWWs each were covered in the study districts.

District ASHA Coordinator: The ASHA Coordinator of each of study districts was interviewed.

FGD with villagers: Apart from covering various health service providers, the study conducted focussed group discussion with villagers in the study districts to primarily understand the health needs of people vis‐a‐vis the contribution made by ASHA in securing health services for them. A total of 6 FGDs in each district (3 in each Block) were carried out.

Details about the sample coverage of the study are presented in Table 4:

Table 4 Sample Coverage Region Districts Blocks No. of No. of No. of ASHA No. of Distant Block Nearest Block ASHAs ANMs AWWs Coordinator FGD with from DH from DH villagers KBK Rayagada Gunupur Rayagada 30 5 5 1 6 (Sadar) Nabarangpur Umerkote Nabarangpur 30 5 5 1 6 (Sadar) Bolangir Tureikela Deogaon 30 5 5 1 6 Kalahandi Thuamul Kalahandi 30 5 5 1 6 Rampur (Sadar) Non‐KBK Balasore Bhograi Remuna 30 5 5 1 6 (Coastal) Total 5 Districts 5 Distant 5 Nearest 150 25 25 5 30 Blocks Blocks

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1.8.3.2 Toools & Techniques of Data Collection

Table 5 Tools & Techniques of Data Collection Respondents Methods of data collection Techniques Tools ASHA , AWW, ANM Survey Method Individual Interview Structured Interview and ASHA Schedule Coordinator Page | 20 Pregnant & Lactating Group Meetings / Focussed Group Checklists women and other Discussions Discussion beneficiaries

1.8.4 IT Enabling of Data and Reporting

The study used required software packages for data computerization and analysis. Data outputs for each variable were presented in the report in charts and tabular forms with frequencies, percentages and averages. Besides, Preparation Error multi‐vitiate tables of data entry Data Entry Detection in structure Data Entry were also generated and presented based on the study requirements. Generation of Data Data Unlike quantitative Data Analysis Tables (single and multi‐ Validation & using SPSS analysis, the qualitative variate tables) Traingulation analysis of information was also carried out and presented in the form of qualitative data tables / matrixes.

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Chapter – II

2. INCENTIVE PROVISION FOR ASHA

2.1 Payment Provision and System in Orissa Page | 21

The incentive Table 6 Incentive Provision for ASHA in Orissa package of ASHA is Sl. Activities Incentive Provision (in Rs.) presented in Table 6. No. As far as payment is 1. Janani Surakhsya Yozana (JSY) 600/‐ (250/‐ for transportation) concerned, the State 2. Assistance in Immunization 150/‐ (per session) 3. Treatment of TB through DOTS 250/‐ (per case) has adopted a more 4. Female Sterilization 150/‐ (per case) transparent system 5. Male Sterilization 200/‐ (per case) of making payment 6. Pulse Polio Program 75/‐ (per day) through Bank 7 Blood Sample Collection 10/‐ (per slide) Account or Postal 8 Participation in Training Program 100/‐ (per training day) Passbooks to ASHAs. 9 Participation in Sector Meeting 100/‐ (per meeting) 10 Gaon Kalyan Samiti Meeting 50/‐ (per meeting) So far, 89.4% ASHAs 11 Village Health and Nutrition Day 50/‐ (per VHND) in the State (87.3% in Source: NRHM, Orissa KBK region) have opened their Bank Account (by end of November 2009). To further strengthen the payment system and more particularly for quick transfer of funds, recently the Government has introduced E‐ Payment system to ASHA. A brief outline of the payment processes is presented in the box (for more details, refer the ASHA Incentive Payment guideline, NRHM, Orissa).

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2.2 Comparative Picture of Incentives Provision in Orissa and Other States

Table 7 Comparison of Incentive Provision for ASHA in Orissa and other EAG States Orissa EAG States a) JSY ‐ 600/‐ (250/‐ for transp.) a) JSY – Rs. 600/‐ (Madhya Pradesh, Rajasthan, Uttarakhand, b) Treatment of TB through DOTS ‐ 250/‐ (for Jharkhand, Uttar Pradesh, Bihar, Chhatishgarh) Page | 22 every case) b) Blood Sample Collection: @ Rs. 5/‐per case subject to a c) Assistance in Immunization150/‐ (per maximum of Rs. 50/‐p.m. (Madhya Pradesh) session) c) Participation in Training Program: 100/‐ (per day) (Madhya d) Female Sterilization150/‐ (for every case) Pradesh, Rajasthan, Uttarakhand) e) Male Sterilization200/‐ (for every case) d) Participation in Sector Meeting Rs. 100/‐per day (Rajasthan, f) Pulse Polio Program75/‐ (per program) Uttarakhand) g) Blood Sample Collection10/‐ (for each e) Village Health and Nutrition Day Rs. 150/‐per session slide) (Rajastahn); Rs. 25/‐per session (UttaraKhand); Rs. 150/‐ h) Participation in Training Program100/‐ per session (Jharkhand) (per day) f) Cataract Surgery Rs. 175/‐per case(Rajasthan, Uttarakhand, i) Participation in Sector Meeting100/‐ (for and Jharkhand) every meeting) Gaon Kalyan Samiti g) Motivating families for sanitary toilets Rs. 30/‐per toilet for Meeting50/‐ (per meeting) APL and Rs. 20/‐for BPL families & Rs. 10/‐for regular usage j) Village Health and Nutrition Day50/‐ (per for 6 months only (Rajasthan), Rs. 50/‐per family VHND) (Uttarakhand) Payment Modality: E‐Payment (earlier paid by Payment Modality: By Cheque (Rajasthan); By Cheque Cheque) (Uttarakhand and Jharkhand); By Account Payee Cheque (Uttar Pradesh); By Cash: (Bihar)

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Chapter – III

3. STUDY FINDINGS ON FACTORS AFFECTING ASHA ROLES AND INCENTIVES Page | 23 The Chapter analyses primary data collected through the survey of ASHA and other health service providers such as ANM and AWW in the four selected districts viz. Rayagada, Nabarangpur, Bolangir and Kalahandi of KBK region and one Non‐KBK (coastal) district i.e. Balasore. The findings have been broadly structured into two key sections viz. Roles and responsibilities undertaken by ASHA; and Incentives received by ASHA with focus on different factors affecting their roles and incentives.

3.1 Background Information about Study Respondents

3.1.1 ASHA

A comparative picture of the background characteristics of ASHAs between KBK and Non‐KBK District is presented below:

Table 8 Background Information about ASHAs Indicators KBK Districts Non‐KBK district No. of ASHAs interviewed 120 30 Education 8th standard or above: 56.7% 8th standard or above: 100% 5th to 7th standard: 37.5% Intermediate and above: 6.7% Prescribed Qualification: 8th standard (if not available, may be relaxed up to Class‐V or ability to read and write) Marital Status Married: 93.3% Married: 96.7% Widows, divorcee and deserted women: Widows, divorcee and deserted Norm: Married/ 6.7% women: 3.3% Widow/Divorced Age 25 to 45yrs: 83.3% 25 to 45yrs: 96.7% 18 to 24yrs: 16.7% 18 to 24yrs: 3.3% Norm: 25 to 45 years Caste ST: 35%; SC: 35.8%; OBC: 24.2%; and OBC: 50%; General Castes: 40%; General Castes: 5% SC: 6.7% and ST: 3.3% Occupation 20% of ASHAs are engaged in Only 6.7% (2 out of 30 ASHAs) agriculture, petty business, tailoring, are engaged in other craft, animal husbandry etc. for earning occupations apart from the an income. ASHA activity Average Annual Earnings: Rs. 6,067/‐ Average Annual Earning: Rs. In tribal region, both the male and 6,600/‐ female are soldering the responsibility of earning their livelihood.

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Table 8 Background Information about ASHAs Indicators KBK Districts Non‐KBK district Economic Status of ASHA As stated by ASHAs, 53.3% belong to 76.7% belong to family having families family having BPL Card. BPL card. Average Annual Family Income: Rs. Average Annual Family Income: 33,733/‐ Rs. 52,647/‐ Factors motivated to Social service was opined by majority of 80% attributed their family Page | 24 become ASHA ASHAs (75.7%) as the key motivating interest as key motivating factor factor for them to join ASHA. to become an ASHA. Training Received by ASHA Induction Training attended: 100% Induction & Thematic Training Thematic Training attended: 98.3% attended: 100% None has undergone First Aid Training. None has undergone First Aid Training Drug kits and Uniform 100% 100% received by ASHA Bank Account opened by 96.7% of ASHAs each in KBK districts and Non‐KBK district have opened their ASHAs Bank Account.

The following key inferences could be drawn from the findings presented in the above table:

Both in social (education, caste, etc.) and economic front (income), the ASHAs in KBK districts are less privileged than Non‐KBK district covered in the study.

In KBK districts, social service is stated as the key driving force to become an ASHA. While in Non‐ KBK district, most of them joined as ASHA because of their family interest.

3.1.2 ANM and AWW

Table 9 Background Information about ANMs and AWWs KBK Districts Balasore (Non‐KBK) District ANM AWW ANM AWW Education 10th Standard or 10th Standard or 10th Standard or 10th Standard or above: 90% above: 65% above: 100% above: 100% Castes SC & ST: 45% SC & ST: 50% OBC and General OBC and General OBC and General OBC and General Castes: 100% Castes: 100% Castes: 55% Castes: 50% Age Average Age: Average Age: Average Age: 44yrs Average Age: 39yrs 36yrs of AWW 42yrs

3.2 Physical and Demographic Setting of the Operational Area of ASHA

In general, the KBK region is characterized by full of dense forests; hilly tracts and long terrains; and cut‐ off or inaccessible zones. Dominated by Scheduled Castes and Scheduled Tribes, people in KBK region generally live in scattered pockets or hamlets. The population density of the region is quite low as compared to coastal region of the State.

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According to the findings of the study, the maximum number of hamlets covered by an ASHA in KBK districts is 6 as against 4 hamlets covered in Non‐KBK district. In other words, people in KBK live in more dispersed or scattered pockets than Non‐KBK district. It can be also substantiated from the fact that an ASHA in KBK region has to cover a maximum distance of 8kms as against 3kms covered in Non‐KBK district to visit a hamlet.

Page | 25 Table 10 Average households covered by an ASHA The average number of households Region Category of Village Mean HH Valid N covered by an ASHA in KBK districts KBK Compact Village 184 N=40 is only 201 as compared to 275 covered in Non‐KBK district. Districts Village with one Hamlet 197 N=40 Irrespective of KBK and Non‐KBK Village with two or more Hamlet 222 N=40 district, the ASHAs who are engaged Group Total 201 N=120 in villages with more than two Balasore Compact Village 266 N=10 hamlets have to cover more (Non‐ Village with one Hamlet 273 N=10 KBK households (222 HH in KBK and 285 district) Village with two or more Hamlet 285 N=10 HH in Non‐KBK) as compared to Group Total 275 N=30 ASHAs positioned in one compact village (184 HH in KBK and 266 HH in Non‐KBK district).

Like number of households Table 11 Average population covered by an ASHA covered, the average Region Mean Minimum Maximum Valid N population covered by an KBK Districts 970 191 2363 N=120 ASHA in KBK region (970) is Balasore (Non‐KBK district) 1296 478 2270 N=30 also lesser than the Non‐KBK district (1296). In KBK districts, the lowest number of households covered by an ASHA is 50 and lowest population covered is 191 only. Particularly in Thuamul Rampur Block, ASHAs have been positioned in villages having much lesser population than the prescribed norm due to low density and scattered inhabitations. In some exceptional cases ASHAs have to cover two villages (particularly in case of non‐ selection of ASHA in the neighboring village), which is the reason behind an ASHA in KBK region has to cover a maximum population of 2363.

Table 12 Health facilities visited by ASHA during Sep and Oct 2009 Health Facilities KBK Districts Non‐KBK District % of ASHAs Visited Maximum Distance % of ASHAs Visited Maximum Distance AWC 100.0 5 100.0 5 Sub‐centre 100.0 15 100.0 7 New PHC 5.8 40 10.0 7 PHC 97.5 55 56.7 16 CHC 61.7 60 53.3 15 DHH 100.0 120 100.0 125

Apart from covering distant hamlets in their operational area, often ASHAs have to visit various health facilities by covering long distances. Both in KBK and Non‐KBK districts cent percentage of ASHAs were

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A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa found visiting AWC, Sub‐centre and DHH. Health facility like PHC is visited by majority of ASHAs in KBK (97.5%) than Non‐KBK district (56.7%). According to Table 13, the maximum distance that an ASHA have to cover for visiting health facilities like Sub‐centre, New PHC, PHC and CHC in KBK districts is significantly higher to that of Non‐KBK district (Table 13).

In order to get a better idea about the distance covered by an ASHA in KBK region, two case studies of Page | 26 ASHA located in one distant (Thuamul Rampur Block of Kalahandi) and nearest (Sadar Block of Nabarangpur district) Blocks from the district headquarter are presented hereunder:

Thuamul Rampur Block ASHA AWC

UPARCHABRI VILLAGE H1 H3 20kms Bhavanipatna kms Forest Route DHH H2 7 Forest Route 75kms by 3kms Bus Route Forest 25kms by TH Rampur Route 15kms by Mahulapatna Bus Route Bus Route Sub‐Centrre CHC

Bus Route / Pucca Road

Nabarangpur SANUGUDA (Sadar) Block VILLAGE ASHA AWC

9km

Urdi Sub‐ Kuchha Road Centre (3km) Walking/Cycle Bus Stop Route Kukuda Bari Jamuguda New PHC No Road, Electricity 11kms Bus Route Bus Stop 14kms Bus Route 1.5kms Nabarangpur Walking DHH Route Sanamasinga PHC

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3.3 Roles and Responsibilities Undertaken by ASHA

3.3.1 Knowledge about her own Roles and Responsibilities

Table 14 presents the knowledge of ASHAs on their roles and responsibilities in KBK and Non‐KBK districts. According to the table, majority of ASHAs in KBK region have knowledge on most of their roles Page | 27 and responsibilities than Non‐KBK district.

Table 13 Knowledge of ASHA about her own roles and responsibilities Percentage KBK Districts Non‐KBK District of ASHA More than Awareness on basic sanitation, hygienic Awareness on nutrition 80% ASHAs practices and nutrition Birth preparedness, inst. delivery and have Counseling on birth preparedness, inst. Immunization knowledge delivery, immunization and contraceptive use Work in GKS Mobilization to access services in sub center, Accompany needy patients and delivery on: PHC, CHC and DHH cases to health institution Accompany needy patients and delivery cases Primary medical care for fever, first‐aid for to health institution minor injuries, diarrhoea, etc. Primary health care for fever and first‐aid for Provider for DOTS minor injuries, diarrhoea, etc. Depot Holder for ORS, IFA, condoms, etc. Provider for DOTS Inform Births, deaths and disease out break Depot Holder for ORS, IFA, condoms, etc. 70% to 80% Awareness on health & family welfare services Timely utilization of health & family welfare have Timely utilization of health services services knowledge Work in GKS Counseling on breast feeding on: Inform births, deaths and outbreak of diseases Care of new born and management of Promote construction of household toilets common ailments < 50% have Awareness on prevention of RTI/STI & other Awareness on prevention of RTI/STI; basic knowledge RCH issues sanitation, health & family welfare services on: Counseling on contraception Promote construction of household toilets

3.3.2 Activities Undertaken and Time Spent by ASHA in KBK region

Broadly, an ASHA has been entrusted with following six key job responsibilities viz. i) Health Planning; ii) Awareness and Counseling; iii) Mobilization and Follow‐up visits; iv) Participation in Health Events; Trainings and Meetings; v) Escort and Accompany; and vi) Primary Medical Health Care. Under each of the said job responsibilities, the study made an attempt to map the time spent by ASHA during two months preceding the survey.

As presented in Table 15, ASHAs in KBK districts spent maximum of their time (28hrs in October and 27hrs in September) on escorting and accompanying different people e.g. delivery cases, needy patients, etc. to the hospital which includes the time spent on travel. Among the different people accompanied, the time consumed by ASHA for accompanying pregnant woman to the health facility is highest i.e. 44hrs in KBK districts. The next highest time was spent on creating awareness and counseling (i.e. 21hrs

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A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa in October and 20hrs in September); out of which maximum time (i.e. 6hrs) was devoted by ASHA on home visits both in the month of October and September 2009. Participation in health events, meeting and training consumed next highest time of an ASHA (i.e. an average of 18hrs in October and 15hrs in September). On an average, an ASHA devoted 4 to 5hrs of time on health events like immunization day and VHND and 6hrs on Sector meeting (including the time for mobility).

Followed by awareness generation and counseling, ASHAs in KBK districts spent on an average 13hrs Page | 28 towards mobilizing people for immunization day, VHND, DOTS treatment, malaria treatment, etc. in the month of October. ASHA’s engagement in preparation of work plan consumed next highest time in October (6hrs) and September (5hrs) 2009. Among the various activities undertaken by ASHA, the least average time spent (3hrs per month) was on distribution of medicines and other items like ORS, Oral Pills, IFA, etc.

The average total time spent by an ASHA in October and September was 88.6hrs and 87hrs respectively which come to around 3hrs of time spent per day (7days a week) including the time spent on travel.

Table 14 Average time spent by ASHA in KBK districts (including time spent on mobility) Sl. Activities Undertaken October 2009 September 2009 No. No. of % Average No. of % Average ASHAs Time spent ASHAs Time spent undertook (in hrs) undertook (in hrs) A. Work Plan 1 Village Health Plan 103 85.8 3 81 67.5 3 2 Planning with AWW 116 96.7 3 114 95.0 3 Sub Total 120 100.0 6 120 100.0 5 B. Awareness and Counseling 3 Village awareness meeting 120 100.0 4 120 100.0 4 4 Group awareness meeting 108 90.0 4 105 87.5 4 5 Individual awareness meeting 105 87.5 5 101 84.2 5 6 Home visits for awareness 118 98.3 6 115 95.8 6 7 Counseling 103 85.8 3 96 80.0 4 Sub Total 120 100.0 21 120 100.0 20 C. Mobilization and Follow‐up visits 8 Immunization Day 120 100.0 5 120 100.0 5 9 Village Health & Nutrition Day 112 93.3 4 89 74.2 4 10 Pulse Polio Day 0 0.0 . 0 0.0 . 11 TB Treatment/DOTS Provider 28 23.3 4 23 19.2 4 12 Malaria Treatment 61 50.8 4 56 46.7 4 13 Leprosy Treatment 4 3.3 3 2 1.7 2 14 Promote Toilet Construction 71 59.2 4 62 51.7 4 Sub Total 120 100.0 13 120 100.0 12 D. Participation in Health Events, Meetings and Trainings 15 Immunization Day 120 100.0 4 120 100.0 5 16 Village Health & Nutrition Day 115 95.8 4 87 72.5 4 17 Pulse Polio Day 0 0.0 . 0 0.0 . 18 Sector Meeting 113 94.2 6 112 93.3 5 19 GKS Meeting 84 70.0 3 59 49.2 3 20 Trainings 47 39.2 6 11 9.2 7 21 ASHA Diwas 12 10.0 4 13 10.8 4

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Table 14 Average time spent by ASHA in KBK districts (including time spent on mobility) Sl. Activities Undertaken October 2009 September 2009 No. No. of % Average No. of % Average ASHAs Time spent ASHAs Time spent undertook (in hrs) undertook (in hrs) Sub Total 120 100.0 18 120 100.0 15 E. Escort & Accompany Page | 29 22 Escorted pregnant woman for 64 53.3 44 65 54.2 46 institutional delivery 23 Escorted other patients to 42 35.0 10 19 15.8 5 health facility 24 Escorted for ANC, TT, PNC 54 45.0 2 39 32.5 4 and Immunization Sub Total 120 100.0 28 120 100.0 27 F. Primary and Medical Health Care 25 Medicine distribution for 101 84.2 2 98 81.7 2 minor ailments 26 Depot Holder for ORS, IFA, etc 113 94.2 2 107 89.2 2 Sub Total 120 100.0 3 120 100.0 3 Grand Total 120 100.0 88.6 120 100.0 87.0

Apart from time spent, Table 15 also brings out the percentage of ASHAs undertaking various activities in KBK districts. As evident from the table, least percentages of ASHAs in KBK region were engaged in activities like leprosy treatment (4, 3.3%); observing ASHA Diwas (12, 10%); DOTS treatment (28, 23.3%); and escorting patients (other than delivery cases) to health facility (42, 35%) during October 2009.

3.3.3 Convergence of ASHA Role with ANM and AWW in KBK region

Table 16 presents the various activities jointly undertaken by ASHA in convergence with ANM and AWW.

Table 15 Activities undertaken by ASHA in convergence with ANM and AWW in KBK districts ANM AWW Activities Cases Col % Activities Cases Col % Immunization 115 95.8% Immunization 52 43.3% VHND 68 56.7% VHND 62 51.7% Home Visit 53 44.2% Home Visit 25 20.8% ANC 39 32.5% Growth Monitoring 64 53.3% Polio Program 18 15.0% THR 53 44.2% PNC 31 25.8% GKS 33 27.5% GKS 12 10.0% Awareness Creation 8 6.7% Sector Meeting 23 19.2% Distribution of Medicine 12 10.0% Distribution of medicines 8 6.7% Total 120 100.0 Total 120 100.0%

Highest percentages of ASHAs jointly undertook activities such as immunization (85.8%), VHND (56.7%), home visit (44.2%) and ANC (32.5%) with the ANM. Similarly, the activities like growth monitoring

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(53.3%), VHND (51.7%), THR (44.2%), immunization (43.3%), etc. were undertaken by maximum of ASHAs in convergence with AWW.

In KBK districts, 37.5% and 29.2% of ASHAs reported lack of cooperation or support from ANM and AWW respectively for jointly undertaking the above activities.

Page | 30 Table 16 Support expected by ASHAs from ANM and AWW in KBK districts ANM AWW Activities Cases Col % Activities Cases Col % Help in slide collection 2 3.70% Home visit by ANM 4 12.12% Provide more medicine 5 9.26% Training on Growth Monitoring 3 9.09% Home visit by ANM 35 64.81% Help in record maintenance 2 6.06% Training on Immunization 6 11.11% Home visit by AWW 24 72.73% Help in record maintenance 2 3.70% Information on type of medicine 4 7.41% Total 54 100.0% Total 33 100.0%

Thus to perform her roles and responsibilities effectively, the various supports expected by ASHA from ANM and AWW are presented in Table 17. Out of the responses received in this regard, maximum of ASHAs expected ANM (i.e. 64.8%) and AWW (72.7%) to support them for taking joint home visit in their village (Table 17).

On the other side, the ANMs expected ASHA to give more effort on creating awareness in the village (76%); and build good rapport with the villagers (24%). Apart from this, 44% of ANMs also expected ASHA to properly maintain her own documents and records.

Table 17 Support expected by ANM and AWW from ASHA in KBK districts ANM AWW Expectations Responses Col % Expectations Responses Col % More effort in creating 19 76.0% More effort in motivating people 3 12.0% awareness among villagers Maintaining own register 11 44.0% Frequent meeting with villagers 3 12.0% Preparation of beneficiary list 3 12.0% Creating awareness on health 3 12.0% care services Submit report / information in 1 4.0% More involvement in health plan 3 12.0% time Creating good rapport with 6 24.0% Devoting more time 3 12.0% villagers Giving more emphasis to left 2 8.0% Knowledge and skill 7 28.0% out and drop outs enhancement (training) of ASHA for delivering her role effectively Informing villagers in time 1 4.0% Importance to Nutrition services 1 4.0% Regular Home visit 4 16.0% Importance to breast feeding 1 4.0% Personal Involvement of ASHA 2 8.0% Proper maintenance of register 3 12.0%

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Table 17 Support expected by ANM and AWW from ASHA in KBK districts ANM AWW Expectations Responses Col % Expectations Responses Col % Knowledge on use of medicines 2 8.0% Creating awareness on family 3 12.0% planning Total 25 100.0% Total 25 100.0% Page | 31

The other convergence related issues that came out during the time of interview with ASHA, AWW and ANM are as presented below:

Non‐functioning of GKS hampers convergence: At the community level, initiatives have been taken to form GKS in each village so that the AWW and ASHA along with other key members of the community can plan and review the health, nutrition and sanitation related activities in the village. Although GKS has been formed in majority of study areas, it is yet to be functional effectively. Lack of coordination between ASHA and AWW and their awareness on the role of GKS hamper execution of the same. During the survey, the study also came to know that some ASHAs were not informed by AWW about their role in GKS; and funds available in GKS account.

Conflict of interest on incentives: ASHAs in KBK districts opined that the incentives to AWW for sterilization and DOTS treatment hamper their chances of earning more. Apart from this, there was also conflict of interest found between ASHA and AWW due to differential incentive paid to them for GKS. According to the information, AWW is paid Rs. 100/‐ which is double the amount paid to ASHA (Rs. 50/‐ only). The conflict of interest between ASHA and AWW could be also clearly judged from the fact that majority of AWWs at the time of interview demanded incentives for all those activities that an ASHA is entitled to get.

Issues over fixation of immunization point: Many of the ASHAs expressed their discontentment during the survey over fixation of immunization point. It was found that two to three villages in study areas are clubbed together to have one immunization point. In that case, ASHA of some villages found lot of difficulty to motivate people (especially pregnant woman, nursing mothers and children) for immunization, ANC, PNC, etc. held in other village. Sometimes, the delay made by ANM in reaching at the immunization point creates difficulty for ASHA to retain the interest and motivation of people.

Apart from the above, ASHAs due to their low education, social strata (castes) and other factors find difficulty especially in mobilizing and creating awareness among people for availing various health care services. In this regard, the support extended by ANM to ASHA was less evident. Paucity of time and communication problems was reported by ANMs as the reasons for the same. Physiographic factors like dense forest, cut‐off areas, hilly tracts, river/water reservoirs, etc. are other factors that hamper coordination and effective convergence between ANM and ASHA.

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3.3.4 Factors Adversely Affecting ASHA Roles and Responsibilities in KBK region

Personal Factors

Education: Some ASHAs in inaccessible and tribal areas of KBK region due to their low education find difficulty to read the names of medicines; and maintain records / documents. Some of them are even unable to understand and remember the medicinal terms and instructions given for Page | 32 distribution of medicines (as reported by ANMs interviewed in Thuamul Rampur Block). Low education also affects their level of confidence while interacting with service providers like staff nurses and doctors in the health facilities. Age: ASHAs due to pregnancy or having small children (particularly those who below 25yrs) find difficulty in performing their roles and responsibilities. Motivation and communication Skill: ASHAs of ST and SC communities are relatively shy or less expressive in comparison to other communities, which creates problem for them while motivating and mobilizing people. On the other side, people due to low education and less exposure also do not give adequate importance or heed to the messages and services provided by ASHA. Other economic activities: Engagement of some ASHAs in other income generating activities like agriculture; collection and selling of firewood, forest produces; etc. impedes their performance. Dependence on family members: Majority of ASHAs does not know bi‐cycle riding, so either they walk or depend on family members to visit the distant hamlets and sub‐centre. Movement of ASHA in the night: Being a female, her movement gets restricted in the night to attend emergency cases. Superstition of ASHA: After delivery, ASHA does not touch the new born as she has to take bath and change her Saree. Thus, she leaves the hospital immediately after admitting the pregnant women and processing their JSY papers (Thuamul Rampur block).

Community / Demand Side Factors:

Traditional Belief, culture and practices: The following are some of the traditional culture and practices of tribal people which pose problems for ASHA in delivering her roles & responsibilities: Approaching ‘Jani’ (village priest) or ‘Disari’ to offer prayers to village deity (god) for getting cured from any disease. Dependence on local quack as a first choice of getting any health care. Dependence on TBA or ‘Dhai’ for conducting delivery across all districts. The study covered a village named Medinipur in Bhawanipatna block where people prefer local “Dhai” instead of visiting the DHH (only 7 km away from the village) for delivery. Non‐preference of Tribal women to conduct delivery by male doctor in the health facility. They think, their dignity would be lost if delivery is conducted by a male doctor. Tribal people hesitate for institutional delivery as they would not be allowed to bath the baby immediately after birth. They also do not like their new born to be touched by any outsiders including health providers (Thuamul Rampur Block). As a common practice, women in Nabarangpur (Sadar) Block move to maternal home during their pregnancy which in the midway discontinues the services provided by ASHA.

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People think that after sterilization they would suffer from back pain and feel weak to perform any physical labour. Therefore, male sterilization is less preferred among people; instead people depend on ‘Cherimuli” or local Ayurvedics for contraception. Due to caste feeling, ASHA from ST community is not preferred to visit the homes of SCs and other castes and vice versa.

Ignorance / Lack of awareness of people in the community: Page | 33 Some people are unaware of the benefits of immunization, thus they do not turn up on immunization day in‐spite of prior information given to them by ASHA. They fear of fever and swelling of limbs of their children after the immunization. Women especially from ST and SC communities do not consume IFA tablet, instead, say that their baby would be fat / overweight for which normal delivery would not be possible. People, mostly from SC and ST communities are still unaware of the fact that delivery at health institutions would be safer for both mother and newborn. People have a common apprehension that the doctor will operate them while conducting delivery at health facility (Nabarangpur district). Some ASHAs also reported that doctors insist for cesarean delivery in order to get informal payment from people. People think that weighing would affect baby’s weight and overall health status. People do not have confidence on ASHA collecting blood sample. They repose more trust on ANM for the same. People have common perception that the medicines distributed by ASHA are not effective.

Cost / Economic Factors: People think that having more children would help them in earning more income for which they show less interest for sterilization. Sometimes, people do not inform ASHA while going to health institutions for delivery as they have to meet food expenses of her during their stay in the hospital. People located near to Borda CHC in Kalahandi prefer delivery by a private “Bengali Doctor” which incurs less cost to them than CHC. People find JSY incentive is not sufficient to meet the expenses at health facilities. Due to non‐availability of delivery facility, people located near Pujariguda PHC has to hire private vehicle by paying high amount (Rs.700/‐) to visit the Umarkote area hospital. In Tureikela block, people migrate to Hyderabad and Chhatisgarh state for five to six months in a year in search of earning their livelihood. The health services e.g. immunization, awareness generation, counseling, etc. provided to people get discontinued.

Geographical & Communication Factors:

Hilly Tracts and High terrains: Villages in Thuamul Rampur, Tureikela and Gunupur Blocks are located in hilly areas which pose problem for ASHA to move from one hamlet to other. Due to undulating landscape and dense forest, it becomes impossible for her to attend emergency cases during night.

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Distant hamlets and health facilities: Due to long distance, ASHA has to take less frequent visits to hamlets which poses problem for her to mobilize community for VHND and immunization; and to keep track of the delivery cases, TB cases, etc. (Deogaon, Tureikela, Rayagada ‐ Sadar and Thuamul Rampur Block). Therefore, ASHAs operating in one compact village are in advantageous position than villages with more than one hamlet. Page | 34 In Deogaon Block, ASHAs reported about their problem of not being able to make direct observations of patients in distant hamlets for DOTS treatment. Apart from hamlets, ASHAs in KBK region have to also cover long distances to reach at the health facilities which increases the time spent and cost incurred towards mobility. ASHAs in Thuamul Rampur and Tureikela Blocks reported about incurring high travel cost to withdraw money from the Bank located at the Block Headquarter.

Transportation and communication: In Thuamul Rampur and Gunpur Blocks, many villages do not have road communication. Vehicle cannot even come to the villages which creates problem for ASHA to accompany delivery cases and patients to the health facility. In turn, it affects the institutional deliveries in those villages. Due to swelling of rivers and nallas during rainy season, some villages remain completely cut‐off for at least three to four months in a year. In almost all the Blocks covered in the study, the infrequent availability of public transportation pose serious problem for ASHAs to accompany delivery cases and patients to health facilities. Due to lack of any transportation, ASHA herself finds lot of difficulties for attending sector meeting and training programs conducted at sub‐centre and PHC / block head quarters. Sometimes she has to walk down to sub‐centre and PHC due to lack of any public transportation (Thuamul Rampur and Umerkote Blocks). Some PHCs and New PHCs are located in inaccessible areas having no proper road communication and transportation facility. The New PHC located at Jamunguda and the PHC located at Pujariguda in Nabarangpur district are some glaring examples of the same. People of inaccessible and interior pockets of Kalahandi, Raygada and Nabarangpur districts have no access to mobile phones. That affects communication between ANM / other health providers and ASHA. In Thuamul Rampur block, ASHAs due to poor transportation facility find difficulty to send the Blood Samples to PHC for examination.

Work facilities and Environment:

Manpower and Infrastructure in the health facilities: The PHC located at Pujariguda does not have delivery facility. So people based at Pujariguda or in the adjacent area prefer home delivery assisted by ANM and ‘Dhai’ instead of visiting the Umarkote area hospital located at 22kms distance from the PHC. Due to lack of skilled manpower and infrastructures in the PHC at Tureikela and Thuamul Rampur, the difficult and cesarean delivery cases; and patients suffering from major ailments are referred to Patnagarh SDH (60kms) and Bhawanipatna DHH (75kms) respectively. Thus,

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people show less interest to visit the PHC apprehending that they would be referred to other health facility. Lack of adequate beds for delivery cases and staying arrangements for attendants in the health facility are the other reasons for which people give less preference to institutional delivery. There is also no staying arrangement for ASHAs in the health facility. So, she has to manage on the veranda outside the maternity ward. Page | 35 In the PHC at Tureikela, sterilization is not performed for which people are taken to Patnagarh SDH which is 60kms away from the Block Headquarter. Due to long distance, people hesitate to visit the Patnagarh SDH for sterilization. In Patnagarh SDH, the beneficiaries are asked to purchase medicines and gloves for sterilization. In the night, the doctors and other medical staffs do not stay in the Deogaon PHC for which people have to go to DHH at Bolangir for delivery. ASHAs need to go to PHC for collecting drug kits / medicines and thereby, incur high travel costs for the same. Medicines are not supplied to them at their door step. Late submission of blood test report from PHC creates problem for ASHA to provide primary health care to patients. People in turn also put pressure on ASHA to get the same on time.

Behavior of service providers in health facilities: ASHAs of Borda and Umerkote areas reported of not being behaved properly by service providers like ANM, Staff Nurse and Doctors in the health facilities. Also, ASHAs in Deogaon and Bhawaniptna blocks reported that they are not allowed by Staff Nurses to wear chhapal / shoes inside the ward and stay with pregnant woman in the labour room during delivery. But, ASHAs feel that they can counsel and make the pregnant woman feel comfort during labor.

Medicines Supply and Storage: Most of the ASHAs are residing in single room thatched house so they lack proper and adequate space to store the medicines supplied to them in the drug kit. Limited medicines are supplied to ASHA for which she often runs short of medicines particularly during rainy and winter season when more people are falling sick. But surprisingly in some places, the medicines supplied to ASHA were not used or distributed. In Deogaon block, it was noticed that ASHAs were supplied with fungal infected medicines which people do not want to take. According to ASHAs, medicines are stored in the PHC and are not supplied to them until the new stock comes to the PHC.

Payment of incentives: According to the current practice, Rs.150/‐ is deducted from the JSY package of ASHA in case of BCG not administered to the baby in time. Non‐administration of BCG after delivery in the health facility and lack of interest of people (after returning to village) to immunize the newborn are cited by ASHAs as the reasons for same. Rs. 150/‐ is also deducted in case of still birth. ASHAs after providing six to seven months of services to pregnant woman feels de‐motivated due to the deduction from their incentives. Some AWWs do not provide required support to ASHA as they are not paid incentives for JSY, Immunization, etc. D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

On the other side, ASHAs also complain of being paid less incentive than AWW for GKS which adds to the conflicts between ASHA and AWW over payment of incentives. ASHA does not get adequate cases for providing DOTS treatment as the same is also being provided by ANM and AWW. That affects the chances of ASHA earning more incentives and creates competition among ASHA, AWW and ANM. For cesarean or difficult delivery cases, ASHA has to stay more days with the mother in the Page | 36 health facility than for normal delivery. But she is not paid any extra incentive to meet her food and other expenses. ASHAs have been asked to open account in the same bank where BPMU has its account. As a result, some ASHAs instead of opening account in nearby Bank has opened in distant banks which takes more travel time and costs for depositing and withdrawal of money. Few ASHAs are yet to open their bank account. Coverage of less population affects the income of ASHA. In Kadabeda village of Tureikela block, ASHA covers only 542 people (100 households) as a result the chances of getting JSY, Sterilization and TB cases become less which in turn affects her income. Many such cases of covering less population were found in Thuamul Rampur Block of Kalahandi district.

Informal Payment: Staff Nurses and Doctors demand informal payment from people for delivery of pregnant woman in Nabarangpur and Bolangir districts. Staff Nurses particularly in Deogaon PHC demand informal payment for delivery, so people prefer home delivery instead of visiting the PHC. ANM in Nabarangpur demand informal payment from ASHA for filling‐up of JSY card and doing other paper works.

Other support facilities to ASHA: Uniform: ASHA is provided with only one set of uniform which creates difficulty for her to manage particularly during her stay with delivery cases and needy patients in the health facility. Some ASHAs have demanded for by‐cycle and mobile phones to establish contacts with people and health care providers.

3.4 Incentives Earned by ASHA

3.4.1 Knowledge of ASHA about the Incentive Provisions

Table 18 Knowledge of ASHAs about the incentive provisions Incentive Provision KBK Districts Non‐KBK District Count Col % Count Col % Assistance in Immunization 150/‐ (per session) 120 100.00% 30 100.00% Participation in Training Program 100/‐ (per training day) 119 99.20% 11 36.70% Janani Surakhsya Yozana (JSY) 600/‐ (250/‐ for transportation) 117 97.50% 30 100.00% Participation in Sector Meeting 100/‐ (per meeting) 117 97.50% 30 100.00% Female Sterilization 150/‐ (per case) 110 91.70% 30 100.00% Gaon Kalyan Samiti Meeting 50/‐ (per meeting) 103 85.80% 30 100.00% Village Health and Nutrition Day 50/‐ (for every meeting) 100 83.30% 30 100.00% Treatment of TB through DOTS 250/‐ (per case) 95 79.20% 25 83.30%

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Table 18 Knowledge of ASHAs about the incentive provisions Incentive Provision KBK Districts Non‐KBK District Count Col % Count Col % Pulse Polio Program 75/‐ (per day) 89 74.20% 16 53.30% Blood Sample Collection 10/‐ (for each slide) 65 54.20% 3 10.00% Male Sterilization 200/‐ (per case) 50 41.70% 3 10.00% Total 120 100.0% 30 100.0% Page | 37

Table 19 shows, 90 to 100% of ASHAs in KBK region know their incentive packages for JSY, immunization, female sterilization, attending training and sector meeting. About 70 to 90% of ASHAs are aware of the provisions for DOTS treatment, GKS and VHND. But as high as 58.3% and 43.8% of ASHAs did not know their incentive packages for male sterilization and blood sample collection respectively. The training of ASHAs on blood sample collection is in progress in many of the areas of KBK region, which could be the reason for which less percentage of ASHAs knowing the same. But when the State is putting more thrust on male sterilization, it is surprising to find that more than half of ASHAs were not aware of the same. Even more surprising to find, 90% of ASHAs in Non‐KBK district did not know the incentive provisions for male sterilization and blood sample collection.

3.5 Expected Annual Earning by an ASHA in Orissa

Before getting into the actual incentives earned, an attempt has been made here to estimate the incentives that an ASHA can earn in a year. The current rates of births, ailments like TB, Malaria, etc. are taken into account to find out the probable number of beneficiaries in a year that one ASHA would come across within one thousand populations. Apart from the same, the number of training days, meetings, health events, etc. that an ASHA have to attend is also taken to arrive at the total amount of incentives she would get according to the incentive package fixed for ASHAs in the State.

Table 19 Expected Annual Earning by an ASHA in Orissa Sl. Activities Incentive Estimated Case / Estimated Assumptions No. Provision (in Rs.) Work load per year Amount 1. JSY 600/‐ (per inst. 22 13,200/‐ Birth Rate ‐ 21.5 per 1000 (22.4 in delivery) rural) as per year 2007 2. Immunization 150/‐ (per session) 12 1,800/‐ At least one session per month in 1000 population covered by ASHA 3. DOTS Provider 250/‐ (per case) 2 500/‐ 1.70 TB case per 1000 people22 per year in 2004 4. Female Sterilization 150/‐ (per case) 8 1200/‐ Taken as per National Calculation 5. Male Sterilization 200/‐ (per case) 4 800/‐ Taken as per National Calculation 6. Pulse Polio Program 75/‐ (per day) 6 450/‐ Two programs per year (3 days per program) 7 Blood Sample 10/‐ (per slide) 13 120/‐ Slides of 12.4% (4,904,259) people were collected in 2008 (taken projected population of 2008 i.e. 39,655,000)

22 Shashidhara AN, Chadha VK, Jagannatha PS, Ray TK, Mania RN.: The annual risk of tuberculosis infection in Orissa State, India. Int J Tuberc Lung Dis. 2004 May;8(5):545‐51. D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

Table 19 Expected Annual Earning by an ASHA in Orissa Sl. Activities Incentive Estimated Case / Estimated Assumptions No. Provision (in Rs.) Work load per year Amount 8 Training Program 100/‐ (per day) 10 1,000/‐ An average of 10 days of training in a year (refresher & new trainings) 9 Sector Meeting 100/‐ (per 12 1,200/‐ One meeting per month Page | 38 meeting) 10 GKS meeting 50/‐ (per meeting) 12 600/‐ One meeting per month 11 VHND 50/‐ (per meeting) 12 600/‐ One VHND per month Total: 21,470/‐ p.a. 1,800/‐ p.m. approx.

3.5.1 Variance in Incentives Earned by ASHA

3.5.1.1 Monthly Incentive Earned by ASHA

Before analyzing the variance, an attempt has been made here to work out the average monthly incentive earned by an ASHA in KBK and Non‐KBK District (Table 20).

Table 20 Monthly income earned by ASHA from May to September 2009 KBK Districts Balasore (Non‐KBK District) Mean Mode Max. Min. Valid N Mean Mode Max. Min. Valid N Monthly Total Entitled Income 954 830 2,480 225 N=120 1,122 375 2,340 375 N=30 Monthly Total Incentive Received 721 460 2,400 140 N=120 1,048 1,480 1,980 355 N=30 Assumptions: Entitled Income: (Cases done/meeting/sessions attended) x Entitled Incentive (Note: The incentive for JSY case is taken Rs. 600/‐, irrespective of cases) Incentive Received: Actual Incentive Received by ASHA during the reporting period

In KBK districts, the monthly average entitled income of an ASHA was Rs.954/‐ in comparison to Rs.1,273/‐ in Non‐KBK. The income of ASHA in KBK was at least Rs. 168/‐ lesser than the Non‐KBK. Table 20 also shows, the ‘modal’ monthly entitled income (Rs.830/‐) (the average income earned by most of ASHAs) was lesser than the ‘mean’ entitled income of ASHAs in KBK districts, which reflects variance in Figure 3 Income of ASHAs by Range the income earned among ASHAs.

0.0% 20.0% 40.0% 60.0% 80.0% 100.0% Among the ASHAs in KBK, highest 15.0% i.e. 47.5% earned incentives ranging < Rs.500/‐ 3.3% from Rs. 501/‐ to 1,000/‐ followed 47.5% Rs. 501‐1000/‐ 43.3% by 27.5% earned Rs 1,001/‐ to 1,500/‐ pm. More importantly, 15% 27.5% Rs. 1001‐1500/‐ 33.3% in KBK earned below Rs. 500/‐ pm in

5.0% comparison to only 3.3% in Non‐ Rs. 1501‐2000/‐ 13.3% KBK. In total, 90% of ASHAs in KBK 5.0% earned below Rs. 1,500/‐ pm in Rs. 2001‐2500/‐ 6.7% KBK Districts Non‐KBK District comparison to 80% in Non‐KBK. That means, the rest 20% of ASHAs in D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

Non‐KBK could earn more than Rs. 1,501/‐ pm, whereas only 10% of ASHAs in KBK could manage to earn so (Figure 3). An attempt has been made here to know the reasons why some ASHAs could earn better incentives (>Rs. 1,501/‐ pm) than the majority.

KBK (Reasons for Non‐KBK (Reasons for KBK (Reasons for Non‐KBK (Reasons for >1501pm) >1501pm) <1500pm) <1500pm) Page | 39 Avg. Population: Avg. Population: Avg. Population: Avg. Population: 1233 1422 897 1257 Avg. JSY Cases: 13 Avg. JSY Cases: 15 Avg. JSY Cases: 3 in Avg. JSY Cases: 7 in in 5months in 5months 5months 5months

Two key factors (viz. total population covered and number of JSY cases dealt by an ASHA in a month) influenced the amount of incentives earned by an ASHA. As evident from the above figures that ASHAs whose income was >Rs.1,501/‐ pm covers much higher population (i.e. 1233 people per ASHA) than ASHA having income Rs.1,501/‐ pm dealt more institutional deliveries (13 cases in prior 5months) than ASHAs whose income was

3.5.1.2 Scheme wise variance in Income of ASHA

The scheme wise monthly income earned by an ASHA is presented in Table 21. Among the different schemes, the average monthly entitled income of an ASHA in KBK districts from JSY is highest i.e. 671/‐ followed by Rs. 147/‐ from immunization, Rs. 94/‐ from sector meeting, Rs. 90/‐ from DOTS cases, Rs. 64/‐ from training and Rs. 57/‐ from female sterilization. Rest of the schemes fetched a monthly entitled income of below Rs. 50/‐ to ASHAs in KBK region. Incentive provisions under a scheme and number of cases dealt by an ASHA are the two key reasons behind scheme wise wide variance marked in the income of ASHA.

Table 21 Scheme wise monthly income earned by ASHA KBK Districts Non‐KBK District Mean Valid N Mean Valid N JSY Cases Assisted by ASHA (5 month) 6 N=113 8 N=30 Monthly Entitled Income (JSY) 671 N=113 774 N=30 Monthly Incentive Received (JSY) 565 N=112 706 N=30 Immunization Sessions Att.(5 month) 5 N=120 5 N=30 Monthly Entitled Income (Immunization) 147 N=120 124 N=30 Monthly Incentive Received (Immunization) 114 N=60 124 N=30 TB Cases provided DOTS treatment (5month) 2 N=10 Monthly Entitled Income (DOTS) 90 N=10 Monthly Incentive Received (DOTS) 50 N=1 Female Sterilizations (5month) 2 N=9 2 N=4

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Table 21 Scheme wise monthly income earned by ASHA KBK Districts Non‐KBK District Mean Valid N Mean Valid N Monthly Entitled Income (Female Sterilization) 57 N=9 60 N=4 Monthly Incentive Received (Female Sterilization) 56 N=8 60 N=4 Male Sterilizations (5month) Page | 40 Pulse Polio Days attended (5month) Blood Samples Collected (5month) 12 N=12 28 N=2 Monthly Entitled Income (Blood Samples) 24 N=12 55 N=2 Monthly Incentive Received (Blood Samples) Training Days attended (5month) 3 N=24 Monthly Entitled Income (Training) 64 N=24 Monthly Incentive Received (Training) 68 N=22 Sector Meetings attended (5month) 5 N=119 5 N=30 Monthly Entitled Income (Sector Meeting) 94 N=119 98 N=30 Monthly Incentive Received (Sector Meeting) 93 N=119 96 N=30 GKS Meeting attended (5month) 3 N=74 6 N=29 Monthly Entitled Income (GKS) 31 N=74 64 N=29 Monthly Incentive Received (GKS) 35 N=48 64 N=29 VHND attended (5month) 5 N=89 5 N=30 Monthly Entitled Income (VHND) 49 N=89 52 N=30 Monthly Incentive Received (VHND) 39 N=43 52 N=30

Table 21 also brings out that none of the ASHAs in both the regions could earn incentive for male sterilization. Similarly, there was no incentive earned by ASHAs for pulse polio program. In fact, not a single pulse polio program was held during five months (i.e. May to September 2009) prior survey.

The scheme wise segregated income also shows that ASHAs in Non‐KBK districts earned better incentive than KBK districts in almost all schemes except income from DOTS treatment and female sterilization.

Apart from inter‐scheme variance, the study findings also reveal intra‐scheme variance in the incentives paid to ASHA for immunization and JSY (institutional deliveries). According to the current practice, the incentive amount (i.e. Rs. 150/‐) fixed per immunization session is equally divided among all the ASHAs who attend the session for which the minimum incentive received by an ASHA comes down to Rs.50/‐ per session (as 3 ASHAs attending one session). But, some ASHAs could get the full amount of Rs. 150/‐ as they do not have to share with other ASHAs. Some ASHAs even managed to get Rs.300/‐ because of attending two immunization sessions in a month as the selection of ASHA in neighboring village was not done.

The reasons of variance in incentive received by ASHA under JSY are as follows:

Non‐payment of transportation cost (Rs. 250/‐) to ASHA, if Janani Express is availed by the pregnant woman for delivery at the health facility. Deduction of Rs. 150/‐ from the total JSY package for ASHA in case of still birth or non‐ administration of BCG.

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3.5.1.3 Spatial Variance

Table 22 and Figure 4 &5 bring out the geographic or spatial variance in the income earned by ASHAs.

Figure 4 Average Monthly Entitled Income of Figure 5 Average Monthly Entitled Income ASHA in Nearest & Distant Block in KBK of ASHA in Nearest & Distant Block in Non‐ districts KBK districts Page | 41

KBK Non‐KBK

Distant, Distant, Nearest, 881/‐ 832/‐ Nearest, 1016/‐ 1411/‐

As evident from Figures 4 and 5, the earning of ASHAs interviewed in nearest Blocks (from the district head quarter) is found to be only Rs. 125/‐ more than the distant Blocks in KBK districts. Interestingly in Nabarangpur and Rayagada districts, ASHAs in distant Blocks could earn slightly higher income to that of nearest Blocks. The distant Block covered (Umerkote) in Nabarangpur district has more than forty villages inhabited by Bengali refugees who are relatively more educated and economically advanced to that of tribal dominated Nabarangpur (Sadar) Block which could be the reason behind ASHAs able to earn more incentives. Unlike Nabarangpur, the nearest Block in Rayagada (Sadar Block) due to dense forest and river has at least eight to ten Gram Panchayats in inaccessible zones. Thus, in spite of nearest location to the district headquarter the income earned by ASHA of the Sadar Block in Rayagada district is lesser than to that of the distant Block.

But except Kalahandi, there is no significant difference found between the income of ASHAs operating in nearest and distant Blocks of KBK districts. In other words, the distant and nearest blocks do not have much impact on the amount of incentives earned by an ASHA in KBK districts. Only in Kalahandi, ASHAs of nearest Block (Bhawanipatna) earned Rs. 504/‐ more than the distant Block (Thuamul Rampur, where ASHAs on an average could manage only Rs. 789/‐ pm).

However in Non‐KBK district, ASHAs operating in nearest Block (Rs. 1411/‐) earned significantly higher income of Rs. 579/‐ than those in distant Block (Rs. 832/‐). But the comparison with KBK districts indicates that the income of ASHAs operating in distant Blocks of Non‐KBK is more or less same with KBK districts. That means the ASHAs operating in remotest Block of Non‐KBK were not able to earn better income either.

More details about the district and block wise segregated monthly income of ASHA are presented in Table 22. The reasons or factors affecting ASHA roles and incentives are presented in the next to next section of this chapter. Table 22 District and Block wise monthly income earned by ASHAs District Block Income Particulars Mean Valid N Bolangir Deogaon (Nearest) Monthly Entitled Income 1,112 N=15

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Table 22 District and Block wise monthly income earned by ASHAs District Block Income Particulars Mean Valid N Monthly Incentive Received 836 N=15 Tureikela (Distant) Monthly Entitled Income 934 N=15 Monthly Incentive Received 556 N=15 District Total Monthly Entitled Income 1,023 N=30 Monthly Incentive Received 696 N=30 Page | 42 Kalahandi Bhawanipatna (Nearest) Monthly Entitled Income 1,293 N=15 Monthly Incentive Received 644 N=15 Thuamul Rampur (Distant) Monthly Entitled Income 789 N=15 Monthly Incentive Received 551 N=15 District Total Monthly Entitled Income 1,041 N=30 Monthly Incentive Received 598 N=30 Nabarangpur Nabarangpur (Nearest) Monthly Entitled Income 945 N=15 Monthly Incentive Received 811 N=15 Umerkote (Distant) Monthly Entitled Income 1,079 N=15 Monthly Incentive Received 988 N=15 District Total Monthly Entitled Income 1,012 N=30 Monthly Incentive Received 899 N=30 Rayagada Rayagada (Nearest) Monthly Entitled Income 714 N=15 Monthly Incentive Received 663 N=15 Gunpur (Distant) Monthly Entitled Income 763 N=15 Monthly Incentive Received 722 N=15 District Total Monthly Entitled Income 738 N=30 Monthly Incentive Received 693 N=30 Balasore Remuna (Nearest) Monthly Entitled Income 1,411 N=15 (Non‐KBK) Monthly Incentive Received 1,275 N=15 Bhograi (Distant) Monthly Entitled Income 832 N=15 Monthly Incentive Received 821 N=15 District Total Monthly Entitled Income 1,122 N=30 Monthly Incentive Received 1,048 N=30

The above table also brings out district wise variance with regard to payment made to ASHA for immunization session. In contrary to Rayagada and Nabarangpur districts, ASHAs in Bolangir and Kalahandi districts were not paid for attending immunization session during the reporting period. Lack of fund allocation for immunization was cited by BADAs in Bolangir and Kalahandi districts as the reason for the same. That is why the study reveals, 50% of ASHAs did not receive any incentive for immunization session in KBK districts.

3.5.1.4 Average Income Expected vs. Income Earned by ASHA in KBBK

Average Monthly Income Expected Average Monthly Income Earned

• Rs. 1800/‐ pm / per ASHA •Rs. 954/‐ pm / per ASHA

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3.5.1.5 Perception of ASHA on Payment System and Procedures

Apart from knowing the amount of incentive earned by an ASHA, the study also made an attempt to know the payment mode and procedures adopted for making payments to ASHA.

Mode/Procedure of Payment Maximum of ASHAs were made payment during August to September 2009 (notice served by government for clearing backlogs). Page | 43 All the three different modes of payment viz. Cash, Cheque and E‐Payment were evident in KBK districts. Increase in the E‐Payment transactions was reported from May to October 2009. On the spot cash payments were made for GKS, Sterilization and Training in all the four districts covered in KBK region. Except Bolangir, the payment to ASHA for sector meeting in rest of the three KBK districts was made though cash payments. In Non‐KBK districts, the payments to ASHA were made through E‐Payment system only except sterilization. On the spot cash payment was made to ASHAs for sterilization.

Problems encountered Delay in paying the incentive to ASHA for immunization in Bolangir and Kalahandi districts (delay in fund allocation to BADA). Unequal payment of incentive to ASHA for immunization. Except Rayagada, ASHAs in Nabarangpur, Bolangir and Kalahandi districts were not paid any incentives for VHND. More time is consumed for transfer of incentive to ASHA due to multiple Bank accounts used by BADA/BPMU. ASHAs have to cover long distance to withdraw money as majority of their accounts are in the Block headquarter. It is important to mention here that ASHAs are asked to open Bank Account in the same place where the BPMU / BADA has account. Due to low economic status, ASHAs are finding difficulty to maintain the minimum savings balance of Rs. 500/‐ in the Bank account opened by them. As a result, ASHAs have to pay monetary penalty to the Bank. Some ASHAs reported about informal payments made by them for getting the incentives.

Prospects of E‐Payment Table 23 Prospects of E‐payment Advantages Disadvantages After the introduction of E‐Payment system, ASHAs no more have to go ASHAs are unable to know how to Banks for depositing cheque. much incentive has been They need not have to meet and request BADA for payment of incentives. deposited under which head. Particularly, those ASHAs having low education find E‐payment as the ASHAs are unable to know when much easier mode of depositing incentive. They need not have to fill‐up the money was deposited. the forms and maintain other formalities for depositing the money. The transaction cost of ASHA ASHAs are able to save more money in the Bank because of e‐payment increases for updating their Bank system. Some ASHAs with an intention to increase their savings account and for withdrawing the knowingly do not go to bank for withdrawing incentive. money. It becomes two fold in

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Table 23 Prospects of E‐payment Advantages Disadvantages As reported by ASHAs, the informal payment has been reduced due to places like Thuamul Rampur introduction of E‐Payment. where ASHAs have to cover long The transaction cost and time of BADA have been also reduced. distances to reach at the Banks.

3.5.1.6 Backlogs (during May to September 2009) Page | 44

The Region, District, Block and Scheme wise break‐up of backlog amounts to ASHA are presented in Table 24, 25 and 26 respectively. Irrespective of backlog clearance and E‐Payment during May to September 2009, the average backlogs per ASHA works out to be Rs. 1,171/‐ in KBK and Rs. 789/‐ in Non‐KBK district. The maximum backlog amount that an ASHA to be paid in KBK districts is Rs. 7,420/‐.

Table 24 Backlog payments to be made to ASHA during May to September 2009 Region Mean Maximum Minimum Sum Valid N KBK Districts 1,171 7,420 100 139,335 N=119 Non‐KBK District 789 3,000 100 11,050 N=14 Assumptions: (Backlog Amount= Entitled Incentive – Amount Paid / Received)

The highest amount of backlog was in Bhawanipatna Block (Rs. 3,245/‐) of Kalahandi district and lowest (Rs. 203/‐) in Gunupur Block of Rayagada district. The district wise calculation of backlog amount puts Kalahandi district on the top with an average of Rs. 2,217/‐per ASHA during the reporting period.

Table 25 District and Block wise backlog payments to be made to ASHA during May to Sep 2009 Districts Block Mean Maximum Minimum Sum Valid N Balasore Bhograi 170 340 100 850 N=5 Remuna 1,133 3,000 600 10,200 N=9 District Total 789 3,000 100 11,050 N=14 Bolangir Deogaon 1,380 4,600 750 20,700 N=15 Tureikela 1,890 4,950 750 28,350 N=15 District Total 1,635 4,950 750 49,050 N=30 Kalahandi Bhawanipatna 3,245 7,420 860 48,680 N=15 TH Rampur 1,189 1,750 1,000 17,830 N=15 District Total 2,217 7,420 860 66,510 N=30 Nabarangpur Nabrangpur 670 1,600 400 10,050 N=15 Umerkot 457 900 300 6,850 N=15 District Total 563 1,600 300 16,900 N=30 Raygada Rayagada 273 800 125 3,825 N=14 Gunupur 203 500 100 3,050 N=15 District Total 237 800 100 6,875 N=29

Scheme wise backlogs presented in Table 26 shows that highest i.e. 119 out of 120 ASHAs interviewed in KBK had backlogs for immunization followed by 80 ASHAs for VHND, 35 for JSY and 27 for GKS. But amount wise, highest i.e. 1,800/‐ was to be paid to ASHA under JSY for the reporting period (May to September 2009).

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Table 26 Scheme wise backlog payments to be made to ASHA during May to September 2009 Schemes KBK Districts Non‐KBK District Mean Max. Min. Sum Valid N Mean Max. Min. Sum Valid N JSY 1,800 6,000 600 63,000 N=35 1,133 3,000 600 10,200 N=9 Immunization 451 750 50 53,675 N=119 Sterilization (female) 300 300 300 300 N=1 DOTS 425 500 250 4,250 N=10 Page | 45 Blood Collection 118 310 10 1,410 N=12 275 340 210 550 N=2 Training 100 100 100 200 N=2 Sector Meeting 200 200 200 200 N=1 100 100 100 300 N=3 GKS 111 250 50 3,000 N=27 VHND 166 500 50 13,300 N=80 Total 1,171 7,420 100 139,335 N=119 789 3,000 100 11,050 N=14

3.5.2 Factors Affecting ASHA Incentives

The factors affecting ASHA role and incentives are inextricably linked with each other. In the earlier section, the study brought out various factors adversely affecting ASHA roles and responsibilities which in turn also affect her chances of earning more. In this section, an attempt has been made to summarize all those factors which have direct linkage with the incentives earned by ASHA in the KBK region.

Table 27 Factors adversely affecting ASHA incentives in KBK region Category Factors affecting the ASHA Incentives Personal Factors Low education and lack of exposure creates difficulty for ASHA to convince and motivate people for institutional delivery, blood slide collection, DOTS, etc. Some ASHAs due to small children and pregnancy are unable to devote more time for mobilization and awareness generation which affects her incentives Involvement in other economic activities by ASHA particularly from tribal community restricts her engagement. Needs to depend on others for visiting hamlets and contacting TB and Malaria patients and pregnant woman; that affects the number of cases handled by her and in turn also affects her incentives Problem of moving in night and unable to escort pregnant woman to the hospital that ultimately leads to home delivery. So, no payment to ASHA in spite of providing six to seven months of service to pregnant woman Community Non‐preference of women to conduct delivery in the hands of male doctors; traditional Factors practice of conducting delivery with the assistance of Dhai; more trust on private practitioner; and various other blind belief and superstations affects inst. delivery. Some people without informing ASHA visit the health facility for delivery. Some pregnant woman moving to their maternal home for delivery. Due to ignorance of people, the EDD could not be calculated correctly. So, the delivery takes place at home due to un‐preparedness of people. Dhais and private practioners motivate people to conduct delivery by them in less cost. People generally feel that the medicines provided by ASHA are of poor quality which de‐ motivates the TB patients to take treatment from ASHA. People hesitate to give blood samples to ASHA. Migration of people in major part of the year affects their chances of getting more cases. Coverage of less population also affects their chances of getting more cases.

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Table 27 Factors adversely affecting ASHA incentives in KBK region Some people in the village do not like to visit ASHA because of caste feelings. People believe that they will be weak and develop back‐pain after sterilization. Less people show interest for the same. Less acceptance of ASHA as health provider as she belongs to their own community. Geographic and Due to hilly terrains and dense forest, people do not prefer to visit the health facilities. Communication Lack of transportation also de‐motivates people to visit the health facility. Page | 46 factors Long distance between hamlets and health facilities also creates problem for ASHA (ASHA is unable to visit the hamlets for identifying cases and providing health services) There are many such in‐accessible pockets in KBK districts where vehicle cannot reach. Due to communication problem, the movement of ANM gets restricted for which immunization and VHND could not be observed. High transportation cost de‐motivates people to visit the health facilities. Due to distance and expenses, people show less interest for sterilization. Work facilities Lack of manpower & infrastructures like doctors, staff nurses, logistic facilities, un‐ and cleanliness of hospital, etc. de‐motivates people for institutional delivery. environment Delay in submission of blood test report discourages people to further conduct blood tests by ASHA. Pathological test for TB cases requires patients to visit the hospital for more number of times for which patients do not show interest. Absence of health providers also discourages people to visit the heath facility. Money demanded by health providers also affects the work of ASHA. Transportation expenses paid to ASHA is diverted for Janani Express. A part of incentive is deducted from JSY package of ASHA in case of still birth non‐ administration of BCG. Due to lack of proper facility, cases are referred from PHC to DHH. So people prefer not to visit the PHC. Due to less number of immunization point, the incentive fixed per session is shared among the ASHAs. Apart from ASHA, the AWW and ANM are also given the responsibility for DOTS and sterilization. That reduces the number of cases handled by ASHA. In many places, the GKS is not functional. ASHAs are not aware about GKS. There is also no coordination between ASHA and AWW to conduct GKS meeting, which affects the incentive earned by ASHA from GKS. The number of training programs has come down, so income from the same has been reduced. Many of the ASHAs are not aware of the different incentive provisions.

3.5.3 Factors Feasible to Address

Among the various factors mentioned above, an attempt has been made here to identify those factors which are under the control of health system and can be addressed effectively. a) Training and exposure to ASHA for improving their communication and mobilization skills b) Provision of by‐cycles to ASHA for movement within the villages and visiting the sub‐centre c) Fixation of immunization point in every 1000 population

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d) Distribution of medicines for all common minor ailments and timely replenishment. Facility to ASHA for proper storage of medicines. e) Focused IEC and BCC intervention to dispel the myths, misconceptions, blind beliefs, etc. of people.

Page | 47 f) Provision of cash in hand with ASHA for dealing emergency delivery cases and patients g) Orientation of doctors and staff nurse for properly dealing with ASHA and beneficiaries h) Timely allocation of funds to BPMU and release of incentives to ASHA account i) Adequate manpower and infrastructure facility in PHC and New PHCs j) Submission of pathological reports by PHC in time k) Organizing sterilization camps in the PHC / Block headquarter l) Avoiding duplication of roles & responsibilities of ASHA with other providers (e.g. ANM and AWW apart from ASHA are also engaged for providing DOTS, motivating people for sterilization, etc.) m) Home visit and facilitation by ANM for establishing good rapport of ASHA with villagers. n) Effective convergence between AWW and ASHA o) Opening up of zero balance savings bank account of ASHA

***

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Chapter – IV

4. SCOPE OF EXPANSION OF ASHA ROLES AND POSSIBLE CHANGES IN ASHA PACKAGE Page | 48

The scope of expanding ASHA role largely depends on the following few factors:

Extent to which ASHA is able to perform her current roles and responsibilities; The various other community health needs which remain unaddressed; Time currently devoted by ASHA; and her willingness to devote more time and take‐up additional responsibilities; and Capacity of ASHA to deliver additional responsibilities

4.1 Community health needs addressed by ASHA

Table 28 Contribution of ASHA in addressing community health needs Community Health Problems Specific Contribution of ASHA in Gaps & Needs addressing the health needs Common / Minor ailments ASHA distributes medicines for the Insufficient medicines with ASHA like fever, cold & cough, common ailments (for cold, fever, body aches, etc.) worm, etc ; and expensive Accompanies pregnant women and Medicines and ointments for skin and improper treatment by patients to health facilities diseases are not given by ASHA. Quacks & Village priests Before ASHA, patients were visiting the No medicines provided for (Nabarangpur, Gunupur, quacks. indigestion Rayagada, Thuamul Rampur, No provision of dressing of Tureikela blocks) wounds. Wide prevalence of ASHA distributes medicines & ORS Many people are not aware of the Diahhorea cases among packets health care provided by ASHA, so children and adults they do not approach ASHA for (Rayagada, Thuamul Rampur, the same. Deogaon, Tureikela, Nabarangpur blocks) Wide prevalence of Malaria Provides chloroquine tablets Most of the villagers do not use (all districts) Counsels families to use mosquito nets mosquito nets (due to the habit Mobilizes community for DDT spray of not using the same and high cost of purchasing the same) Majority of ASHAs do not collect Blood Samples (their training on the same is not done). Existence of anemia among Mobilizes community on Mamata Divas Many of the pregnant women do pregnant women and ASHA distributes and motivates pregnant not consume IFA tablets. children woman for IFA consumption Escorts referral cases to PHC on Pustikar Divas

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Table 28 Contribution of ASHA in addressing community health needs Community Health Problems Specific Contribution of ASHA in Gaps & Needs addressing the health needs Distant location of PHC / Sub Undertakes home visits High transportation and medicine Centre , occasional visit of Identifies and registers pregnant women costs ANM / health personnel for Motivates them for ANC & TT Less visit of ANM to the village. identification & care of Counsels pregnant woman and their No provision of cash in hand for Page | 49 pregnant women (all blocks) relatives for institutional delivery emergency delivery or other Lack of interest to go to Informs on financial benefits provided cases. health facilities (no delivery under JSY Large segment of people do not facility near to the village) Arranges vehicle with support from listen to ASHA and conduct family members and villagers delivery with local Dhai. Accompanies pregnant women to health Lack of staying arrangement for facilities, stays with them and assists attendants in the health facility. them in getting JSY benefits Some ASHAs return back home Across all places, people admire ASHA for without accompanying the accompanying delivery cases to hospital. nursing mother and new born. Engagement of ASHA has helped villagers to interface with staff nurses and doctors in the health facility Number of institutional deliveries have increased than before Post delivery complications Does home visits and mobilizes for PNC Less home visits by ANM for In case of complications, informs ANM PNC Major ailments like TB, Identifies TB suspect and send sputum to People having TB symptoms do Jaundice, Typhoid, health facilities for test not report to ASHA Gastroenteritis, Fids, Provides DOTS to the patients & does TB Cases in distant pockets are Cataract, Leprosy, STI/RTI, follow up left without treatment Chicken Pox, Measles, Occasionally escorts needy patients to Discontinue of medicines by TB Cholera, Bone fractures, hospitals patients (ASHA finds difficulty for Dental Problems, Mouth direct observation) Ulcers, Appendicitis, Stomach Except TB, ASHA does not provide pain, Snake bite, etc. services for other major ailments. Unclean village environment Only few ASHAs create awareness on Negligible involvement of ASHA village sanitation and safe drinking water on the same Informs members to attend GKS meeting People do not listen to ASHA for the same Lack of coordination between ASHA and AWW for GKS

4.2 Willingness of ASHA to take up Additional Responsibilities

During the interview with ASHAs, 100% of them expressed their willingness to take‐up additional responsibilities but, wanted enhancement in the scope and amount of incentives paid to them. Even, some ASHAs also demanded for fixed salary instead of incentives paid to them.

4.3 Expansion of ASHA Role and Responsibilities

While ASHAs interviewed in KBK districts are willing to take up more responsibilities and have also time for the same, it is essential for the state to address all those feasible factors which are adversely

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So the first option that emerges is to retain the same role of ASHA with various constraints addressed and increasing the amount of her current incentives, which would not only help her in effectively delivering the current responsibilities but also enable her to earn more incentives. The second option could be to add more individual services (e.g. first‐aid, distribution of medicines for minor illness, etc.) in Page | 50 the existing basket of ASHA package which would help to cater the increasing demand for health care of the community. The last option could be to add more group services (e.g. school health program, greater involvement in GKS, working with women’s groups / SHGs) into her existing roles and responsibilities which would make her more effective in community actions, awareness generation, mobilization, etc.

4.4 Suggested Changes in ASHA Incentive Package for Discussion

Keeping into account the amount of incentives earned by ASHAs, payment system and procedures; and health care needs of people, an attempt has been made here to work out the changes in the overall ASHA package for the KBK region of Orissa. But in view of diverse work conditions and environment between and within regions, the State may consider for introducing inter and intra region differential incentive package for ASHAs in Orissa. ASHAs in KBK may be given higher incentives than especially those working in other regions with better work conditions. Even within the KBK region, ASHAs located in the most difficult pockets may be paid higher incentives than those positioned in areas having relatively better communication and physiographic conditions. Thus, mapping and identification of the difficult areas in KBK region is essential before introducing a differential package.

The study irrespective of intra‐regional differences of work conditions has suggested here a consolidated package for ASHAs operating in KBK region. Table 29 presented below brings out the changes suggested in the current package of ASHA and Table 30 presents the additional package suggested for ASHA in KBK region. But, the application and effectiveness of the package more specifically the additional package suggested here will depend on following few factors:

Capacity building of ASHAs on areas such as: (i) identification and care of leprosy patients; (ii) identification and motivation of patients for cataract surgery and (iii) IUD insertion; (iv) group facilitation; (v) school health program; (vi) processing up of birth & death registration form; and (vii) Health Survey, documentation and reporting Monitoring and supervision at different levels Cost factor (i.e. the additional cost implications that the State will have if this package is executed) Additional time that an ASHA can devote (i.e. time implications to ASHA if new responsibilities are entrusted to her) and case load on ASHA Work load on other service providers (viz. BADA, BPO, ANM, etc.)

Thus keeping all the above factors into account, the feasibility of the whole package suggested here requires further exploration and discussion with various stakeholders associated with ASHA intervention.

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A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

Table 29 Changes suggested in current ASHA package Schemes Break‐up Changes Suggested Incentive Expected Cases Expected Amount / Sessions / Annual Income Meetings pa (minimum) JSY: 600/‐ (250/‐ Antenatal Care Registration, 3 ANC, 2 TT (300/‐) 350/‐ 22 16,500/‐ for transport.) IFA (50/‐) Peri and Post Natal Accompanying for Inst. Delivery 200/‐ to Page | 51 Care (Normal: Rs. 150/‐ per 2 days; 350/‐ CS: Rs.300/‐ for 4 days) 2 Post‐Natal Home Visits within 15days: Rs. 50/‐ Immunization of New BCG and Zero Dose Polio (Rs. 50/‐ Born 50/‐) Transportation Rs. 350/‐ (Deduction of Rs.250/‐ 150/‐ to if Janani Express is availed) 350/‐ Sub‐Total 750/‐ to 22 16,500/‐ 1100/‐ Immunization: Mobilization Rs. 75/‐ for pre Immunization 75/‐ 12 2,700/‐ 150/‐ (per Mobilization session) Immunization Day Rs. 75/‐ for attending 75/‐ Immunization Follow‐up Rs. 75/‐ for follow‐up 75/‐ Sub‐Total 225/‐ 12 2,700/‐ DOTS: 250/‐ (per Identification & Rs. 100/‐ (on approval of ANM 100/‐ 2 1000/‐ case) accompanying patient for accompanying patient) for test Confirmation of TB Rs. 100/‐ after confirmation 100/‐ (after 2nd testing) and Collection of DOTS medicine Providing DOTS for 3 Rs. 150/‐ 1st Phase DOTS 150/‐ months and 1st Testing treatment report after 3 months of DOTS Providing DOTS for Rs. 150/‐ on final confirmation 150/‐ next 3 months and on of cure final confirmation of cure Sub‐Total 500/‐ 2 1000/‐ Pulse Polio: 75/‐ Mobilization Rs. 75/‐ for pre Immunization 75/‐ 2 450/‐ (per day) Mobilization Pulse Polio Booth Day Rs. 75/‐ for attending 75/‐ Immunization Follow‐up (Mop‐up) Rs. 75/‐ for follow‐up (Mop‐up) 75/‐ Sub‐Total 225/‐ 2 450/‐ Female Motivation and 300/‐ per case 300/‐ 8 2,400/‐ Sterilization: Accompany 150/‐ (per case) Male Motivation and 500/‐ per case 500/‐ 4 2,000/‐ Sterilization: Accompany 200/‐ (per case) Malaria and Blood Sample 20/‐ per slide 20/‐ 20 1,000/‐ Filaria: (Blood Collection for Malaria Sample / Filarial and sending Collection: 10/‐ PHC for testing

D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

Table 29 Changes suggested in current ASHA package Schemes Break‐up Changes Suggested Incentive Expected Cases Expected Amount / Sessions / Annual Income Meetings pa (minimum) per slide) Medicine Distribution 30/‐ per case 30/‐ 20 and Ensure cure of the case Sub‐Total 50/‐ 20 1,000/‐ Page | 52 Training (100/‐ Attending Training 100/‐ per day 100/‐ 10 1,000/‐ (per training day) Sector Meeting: Attending Sector 100/‐ per meeting 100/‐ 12 1,200/‐ 100/‐ (per Meeting meeting) GKS 50/‐ (per Managing GKS 100/‐ per GKS 100/‐ 12 1,200/‐ meeting) activities and Fund VHND: 50/‐ (per Mobilization & 100/‐ per VHND 100/‐ 12 1,200/‐ VHND) Attending Pustikar Diwas Accompanying referral 150/‐ per Pustikar Diwas 150/‐ 4 600/‐ case Total (Current Package) 33,050/‐

Table 30 Additional Package for ASHA Schemes Break‐up New Package Incentive Expected Expected Annual Amount Cases / Income Sessions / (minimum) Meetings pa Group Group facilitation in Rs. 100/‐ per hamlet per month 100/‐ 36 (3/pm) 3600/‐ Facilitation of each hamlet women SHG Leprosy Identification and Rs. 100/‐ (on approval of ANM 300/‐ 1 300/‐ Accompanying for test for accompanying patient) Ensure medicine Rs. 200/‐ consumption and Conformation of Cure of Leprosy Cataract Surgery Identifying and Rs. 200/‐ per case 200/‐ 2 400/‐ Accompanying IUD Insertion Motivation and 150/‐ per case 150/‐ 12 1,800/‐ Follow‐up visit Birth & Death Supporting and Rs. 50/‐ per case 50/‐ 30 1,500/‐ Registration Informing ANM for Birth & Death Registration School Health Mobilizing and Rs. 50/‐ per program / per ASHA 50/‐ 4 200/‐ Program Attending Toilet Motivating Beneficiary Rs. 50/‐ per case 50/‐ 4 200/‐ Construction for Toilet Construction Participation in Other Health Events Rs. 100/‐ per event 100/‐ 4 400/‐ any Other Health Events outside the Village Monthly Documentation Rs. 50/‐ per month 50/‐ 12 600/‐ Reporting, Filling‐up of D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

Table 30 Additional Package for ASHA Schemes Break‐up New Package Incentive Expected Expected Annual Amount Cases / Income Sessions / (minimum) Meetings pa ASHA Diary Health Survey Bi‐annual health Rs. 300/‐ 300/‐ 2 600/‐ survey Page | 53 Outbreak of Information to health Rs. 50/‐ 50/‐ 1 50/‐ Epidemic facility on Outbreak of epidemic First Aid Care Dressing of wounds, Rs. 50/‐ per case 50/‐ 30 1,500/‐ cuts, burns Accidents Fracture Major Ailments Accompanying BPL Rs. 100/‐ per case 100/‐ 12 1,200/‐ patients having any major ailments Depot Holder / Managing Depot / Rs. 100/‐ per month 100/‐ 12 1,200/‐ Distribution of Distribution of Medicines medicines Total (Additional Package) 12,050/‐ Grand Total (Current + Additional Package) 45,100/‐

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D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa

Chapter – V

5. SUMMARY AND CONCLUSION

The current study has brought to light some key findings with regard to ASHA roles and incentives in the Page | 54 KBK region.

A reasonable percentage of ASHAs operating in KBK region have poor socio‐economic background. Majority are from ST and SC communities. Non‐availability of suitable candidates could be the reason for which more than forty percent of ASHAs are below eighth standard. About seventeen percent are also below the required age prescribed for selection of ASHA. More than fifty percent belong to BPL category and about twenty percent have to depend on various income generating activities for earning their livelihoods.

Apart from the lower socio‐economic status, ASHAs in the region work in a much difficult physiographic setting than other regions of the State. Hilly tracts, undulating landscapes, dense forests, scattered population, etc. made their movement more difficult both within and outside her operational area. The highest distance that an ASHA has to cover is eight km to reach at a hamlet. Apart from the same, the distance covered by an ASHA to reach various health facilities are stupendously higher in comparison to Non‐KBK districts.

Given the poor socio‐economic background and difficult geographic settings, ASHAs in the region have much better knowledge about their roles and responsibilities in comparison to those in Non‐KBK district covered in the study. However, their knowledge on incentive package requires improvement more specifically on the provisions for male sterilization and blood slide collection.

During two months prior survey, more than eighty percent of ASHAs were involved in health planning; awareness generation; mobilizing beneficiary and attending health events like immunization day and VHND; and distribution of medicines. Lesser percentages of ASHAs were engaged in mobilizing patients for leprosy treatment; DOTS treatment; and escorting patients and delivery cases to health facilities. While less percentage of ASHAs accompanied delivery cases to health facility, the average monthly time spent on the same is highest (almost two days) among the various activities undertaken by ASHA. Awareness generation, counseling and participation in health events consumed the next highest time of ASHA. The least time was spent on distribution of medicines, which she does along with her domestic chores. On an average, an ASHA spent 3hrs of time per day for undertaking various activities.

The average monthly earning of an ASHA was found to be only Rs. 954/‐ in KBK districts which is at least Rs. 168/‐ lesser than the incentives earned by an ASHA in Non‐KBK district. Keeping the current trend of births, diseases, etc. into account, the monthly incentive earned by ASHAs in KBK districts was found to be almost half of the earnings expected from ASHA (Current earnings: Rs. 954/‐pm and Expected earnings: Rs. 1,800/‐pm).

The factors that affect their roles and incentives are varied and pose multi dimensional challenges to

D‐COR Consulting with support from TMST

A Rapid Assessment of Factors Affecting ASHA Roles and Incentives in KBK Region of Orissa overcome. Apart from system related constraints, various personal, community, geographic and communication factors affect her performance.

The personal factors which adversely affect her tasks include low education, lack of exposure, domestic works, engagement in income generation, lack of communication skill, etc. More than her personal factors, ASHAs in KBK districts find lot of difficulties due to blind beliefs, superstitions, caste feelings, traditional health practices and behavior of people in the community. Coupled with personal and Page | 55 community factors, the physiographic and geographic settings (e.g. hilly tracts, dense forests, river, long distance, scattered population, lack of transportation & communication facility, etc.) make her tasks even more difficult.

Besides these above factors, various other constraints relating to work facilities and environment e.g. lack of storing place for medicines; limited and delayed supply of medicines; lack of manpower and infrastructures (beds, doctors, staff nurses, staying arrangements, etc.) in the health facilities also adversely affect her performance.

Eventually, ASHAs in KBK districts end up with mobilizing very less number of institutional deliveries, TB, sterilization cases, etc. which lead to much lesser incentives earned by ASHAs than the earnings expected from them. The parallel scope provided to ANM and AWW (for earning incentives) for sterilization and DOTS further brings down her chances of earning more incentives. As a result, the overall contribution of ASHA in addressing the health needs of people in KBK region has been also affected. While people in the KBK region appreciate the engagement and contribution of ASHA, there is enormous demand among people for providing health care support e.g. distribution of medicines for all types of common ailments, initial care and treatment of major ailments (e.g. jaundice, leprosy, cataract, etc.), provision of cash in hand with ASHA for visiting the health facility at the time of emergency, etc.

Thus, a careful examination of all these findings insinuates following three options which may be considered for strengthening and improving the ASHA intervention in KBK region, viz. i) retaining same role of ASHA with constraints addressed and increased package; and/or ii) adding more individual services e.g. first aid, medicines for minor illness, etc.; and/or iii) adding more group services e.g. school health program, more involvement in GKS, work with women’s groups / SHGs.

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