India Toolkit: Demand Generation
Enabling Urban Accredited Social Health Activists
Purpose: To aid district health officials in strengthening the role of Urban Accredited Social Health Activists (ASHAs) in facilitating the utilization of Family Planning (FP) services among marginalized and vulnerable populations in urban slums.
- Chief Medical and Health Officers (CMHO/CDMO/CMO)
- Nodal Officer-Urban Health and Family Planning
- Medical Officer-Urban Primary Health Center (UPHC)
- District Program Managers
- District Community Process Managers
- ASHA Facilitators
- NGOs / Health Partners
Background: Urban Accredited Social Health Activists (ASHAs) act as community level care providers with a vital role in reducing preventable child and maternal deaths, by facilitating access to health care services including family planning. They have recently come into existence under the National Urban Health Mission (NUHM).
ASHAs, as per the National Health Mission (NHM), work on the pattern of rural ASHAs and serve as the link between the urban poor and the health services. Similar to the rural ASHAs, the Urban ASHAs make household visits to provide information and counseling on a range of health issues. They are also required to support the Urban Health and Nutrition Days (UHNDs), organize and support monthly meetings of Mahila Aarogya Samitis(MAS) which are community meetings for health awareness, and promote services (for scope of work of ASHAs, refer to Induction Training Module for ASHAs in Urban areas, Section 1, Page no 7 to 13). Their specific activities in regard to FP are listed in the box below:
Scope of ASHA’s Family Planning Work
- Maintain household-wise eligible couple data in Urban Health Index Register (UHIR), or in an equivalent register in states other than Uttar Pradesh
- Undertake post-partum visits and counsel for family planning
- Provide information and counseling on the full range of methods and provide OCPs and condoms at the doorstep to those who desire to use these methods
- Help the couple in deciding the best FP method suited for them and help them in accessing the required contraceptive services
*Refer to Induction Training Module for ASHAs in Urban areas, Section 1, Page no 7 to 13 for detailed roles and responsibilities of ASHA.
Evidence of Impact
Contacts by ASHAs with women / eligible couples increase referrals for FP services and the number of new contraceptive users.
Experience from UHI shows that the ASHA were well accepted and were leaders in promoting FP and other services in their communities. They were an important link between their communities and the health system. Not only did they provide information and counseling, but often escorted women to the service delivery points. Furthermore, women who met with and discussed FP with the ASHAs were significantly more likely to become new acceptors of contraception.
Although the deployment of ASHAs was only one of the several key interventions implemented, these results nonetheless demonstrate their critical contribution.
Data from the end line evaluations of UHI showed that 65% of women reported ever discussing FP with an ASHA and approximately 40% of women met with an ASHA within twelve months following delivery.
Guidance on Enhancing the Urban ASHA’s Capacity as Family Planning Mobilizers
The details of the seven UHI trainings that were effective in strengthening the capacity of providers and staff are mentioned below.
In-depth FP-specific Training
Mentoring & supportive supervision of ASHAs by Area ANM
Guidance on mentoring and supervision of ASHAs is provided in the handbook for ASHA facilitators, and includes a Supervisor field visit checklist and a checklist for feedback. (Refer to the Guidelines for ASHA Facilitators District ASHA Resource Center, Gujarat”, Annexure-I & Annexure-II, from page no. 8 to 10)
Recognize and Reward Performance
Critical Components for ASHA Training:
- Mapping and listing of all households including the most vulnerable population (Refer to the TCIHC’s Mapping & Listing tool)
- Prioritization of household visits to couples and women with the greatest need
- In-depth knowledge of modern contraceptive methods
- Provision of information and counseling on FP to motivate new users, as well as to encourage continuation and switching of methods, if necessary(Refer to the training module on Inter-personal Communication and method-specific training PPTs)
- Follow-up of users’ continuation and tracking of drop-outs
- Follow-up and referral for the management of any side-effects or complications
- Mobilizing the community for UHND and –outreach camps
- Establishment, facilitation and support of MAS
Job-aids for ASHAs:
- Method-specific counseling cards
- Frequently asked questions and their answers
- Handbills listing facilities where FP services are available
- Contraceptive display kits showing different FP methods available
Refer to the materials listed on the following link: http://www.iecrmncha.in/node/102
Roles and Responsibilities
|Nodal Officer-Urban Health and FP||
|District Program Managers||
|District Community Process Manager||
|Medical Officer-In-Charge UPHC||
|ANM (ASHA Facilitators)||
Monitoring of Performance and Outcomes
Auxiliary Nurse Midwives, ASHA Facilitators, the DCM and the Urban Health Coordinator (UHC) monitor the ASHAs on a set of indicators, including ones based on the key tasks undertaken by them. These indicators can be derived from the data in the HMIS, ASHA registers, ASHA facilitator reports and other activity reports, and include the following:
- The number of ASHAs in place compared to the number sanctioned
- The number of ASHAs trained compared to those in place
- The number of ASHAs who received supplementary training on FP
- The number of ASHA monthly meetings compared to those planned
- The percentage of ASHAs receiving supportive supervision from ASHA facilitator
- The number of eligible couples who received services from the ASHA
- The number and percentage of institutional deliveries
- The number and percentage of post-partum family planning service acceptors
- The number of women escorted for deliveries by the ASHA
- The number of new FP acceptors recruited by the ASHA
- The percentage of ASHAs who have stocks of both condoms and pills
- The number of ASHA monthly meetings where FP performance and related issues were discussed
- The percentage of ASHAs who have made a prioritization plan for their household visits to eligible couples and pregnant women
- The percentage of marginalized and vulnerable households visited by ASHAs
In addition, it is important to monitor through the field visits, whether ASHAs have been provided with job aids and IEC materials and whether ASHAs are distributing IEC material to eligible couples.
These indicators can be monitored at the CMHO/CDMO/CMO and UPHC monthly meetings. These meetings serve as a forum for sharing and validation of information related to the performance of ASHAs and for problem-solving.
Strengthening ASHAs’ capacity to facilitate and support family planning requires that the following items are budgeted for. If not budgeted, then the request should be made in the Supplementary PIP and in the next year’s PIP(Refer to the TCIHC’s PIP tool).
This table below is indicative and illustrates the manner in which cost elements are provisioned in a Govt. PIP, thus giving guidance to the audience on where to look for elements related to a particular task, such as strengthening the urban ASHAs.
|Cost Element||FMR Code||Source|
|Training of trainers on FP for cascading training to U-ASHAs||P.3.4||ROP 2016-17, NHM-UP|
Supplementary training on FP for U-ASHAs
|P.3.4||ROP 2016-17, NHM-UP|
|Job-aids, IEC material||P.3.4||ROP 2016-17, NHM-UP|
|Commodities and supplies||P.18.104.22.168||ROP 2016-17, NHM-UP|
|U-ASHA FP incentives||P.22.214.171.124||ROP 2016-17, NHM-UP|
|Budget for ‘Reward and Recognition’ of U-ASHAs||B126.96.36.199.1||ROP 2016-17, NHM-UP|
|Budget for engaging NGOs for supervision and mentoring of U-ASHAs||Not available|
The ASHA component will be sustained under NUHM. However, ensuring the capacity of ASHAs to provide quality FP information and services will require concerted efforts on the part of the CMHO/CDO/CMO to ensure that the costs for hiring, training and supervision/mentoring of ASHAs are included in the PIP.Reward and recognition to well-performing ASHAs can provide motivation for their continued activities.
Disclaimer: This document is based on the learnings collated from Urban Health Initiative, Health of the Urban Poor (supported by USAID) and Expanded Access and Quality (EAQ) to broaden method choice in Uttar Pradesh. This document is not prescriptive in nature but provides overall guidance of how this particular aspect was dealt with in these projects for possible adoption and adaptation.
**This tool is a guidance document for ASHAs specifically on family planning. The downloadable versions of this document are slightly modified to make it state representative for Uttar Pradesh, Madhya Pradesh and Odisha, respectively.
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The role of an ASHA in regards to FP includes:CorrectIncorrect
Contact by ASHA with women/eligible couples increases referrals for FP and the number of new contraceptive services.CorrectIncorrect
In addition to the initial ASHA training, there also needs to be a two-day FP and informed choice counseling training that provides job aids.CorrectIncorrect
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Government of India Resources
- Induction Training Module for ASHAs in Urban areas_English, Section 1, Page No. 7 to 13
- Induction Training Module for ASHAs in Urban Areas_Hindi
- Guidelines for ASHA Facilitators District ASHA Resource Center-Gujarat, Annexure-I & Annexure- II, from page no. 8 to 10
- Flow Chart for ASHA support mechanism
- Contraceptives Display Kit
- Pregnancy screening checklist
- TG Segmentation Matrix
- ROP, 2016-17, NHM-UP
- Method Specific Training PPTs
- Method Specific counseling cards
- Frequently Asked Questions and Answers
- Urban Health Index Register
ASHAs in Action