2011 Articles

Improving the Performance of Accredited Social Health Activists in India

Dholakia, Ravindra H.; Bajpai, Nirupam

The Accredited Social Health Activist (ASHA) represents the pivotal part in the whole design and strategy of the National Rural Health Mission (NRHM), which, in turn, is a critical initiative of the central government to fulfil its promise on inclusive growth. The performance of ASHAs is, therefore, crucial for the success of NRHM and hence of the inclusive growth strategy of the government in India. In the primary healthcare sector, NRHM is the principal programme of the government to achieve the health related millennium development goals such as infant mortality rate (IMR), maternal mortality rate (MMR); as well as control of specific diseases, and improvement of nutrition status of children and mothers. NRHM was introduced in the year 2005 in the 18 high focus states in India and has been expanding in its coverage ever since. Several mid-term appraisals of NRHM have been carried out, the last one having been done by the present team (2009). The present paper is devoted to identifying and suggesting ways in the short to medium term to improve performance of ASHAs under NRHM in India. The purpose of this investigation is not to question the strategy based on ASHAs in the rural setting but to explore and evaluate alternatives. We believe that under the given circumstances it is not only prudent but also most practical and meaningful to concentrate on improving the performance of ASHAs. The present paper, therefore, examines the whole question in terms of current and potential provisions of the recruitment, training and deployment of ASHAs in India. Our paper presents data collected through written questionnaires with ASHAs in Bihar, Chhattisgarh, Rajasthan, and UP. Where appropriate, we have also provided key qualitative insights from the state of Assam, where we conducted a focus group discussion with 25 ASHAs and 4 ASHA facilitators. All mid-term appraisals of NRHM in India have expressed concerns about role and performance of ASHAs. There is considerable literature and international experience in this regard. A brief review of the literature and international experiences is presented in the second section. The third section discusses current profile of ASHAs in the five selected states and their selection procedure. Further sections then consider the following five questions: a. Is the recruitment process for ASHAs appropriate to ensure proper selection? b. Are the roles and responsibilities assigned to ASHAs easily understood and appropriate? Are new responsibilities for ASHAs envisaged? c. Is the training that ASHAs receive adequate, appropriate for knowledge retention, and of high quality? d. Are ASHAs' current incentives and compensation structure consistent and adequate for them to perform as per expectations of NRHM? e. Are supervisory structures currently in place in the rural areas sufficiently detailed and do they effective monitor/track ASHA performance? The last section summarizes recommendations for the consideration of the International Advisory Panel. A quick sample survey of ASHAs, potential/actual beneficiaries (young mothers) and government officials was carried out during March-May, 2010 in selected states to get an idea about the ground reality for ASHA's role, training, incentives, supervision, effectiveness, etc. details about the sample survey are given in the appendix.