Dashboard India: Demand Generation Enabling Urban Accredited Social Health Activists

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.

Audience:

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 the video.

The TCI tutorial below features a webinar held in May 2020 introducing urban Accredited Social Health Activists (ASHA) approach to improve contraceptive use among young first-time parents.

Helpful Videos

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

Although ASHAs have undergone initial training, this includes only one session on FP. More in-depth training is required to provide quality FP services to their communities. A two-day training period specifically on FP and informed choice counseling is required for ASHAs.

Job Aids

Providing FP job aids will help ASHAs to deliver more effective interpersonal counseling during the home visits

Mentoring & supportive supervision of ASHAs by Area ANM

Training of the urban ASHA is only the first step in equipping her with the skills she requires to effectively meet the FP needs of the community she serves. Continuous on-the-job mentoring and supervision is required to help the ASHA translate her training into practice

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

Recognizing and rewarding ASHAs who perform well, contributes to maintaining motivation of ASHAs and helps prevent drop-outs.

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
Record-keeping

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

Role	Responsibility
CMHO/CDMO/CMO	Ensure ASHAs are selected and placed as per the approved Record of Proceedings (ROP) Ensure funding for training of ASHAs and for facilitating their work through the Program Implementation Plan (PIP)process (Refer to the TCIHC’s PIP tool) Identify / hire competent trainers with extensive experience in FP to train ASHAs (Refer to the-List of master trainers to be sourced at the time of planning of training from states) Engage NGOs/health partners to facilitate the role ofASHAs as mandated by the NUHM Review the physical (programmatic and financial) progress of the ASHA component, particularly on FP indicators
Nodal Officer-Urban Health and FP	Facilitate training of trainers on FP Provide supplementary FP training forASHAs Provide FP jobaids, IEC materials, commodities and other supplies Ensure supportive supervision of ASHAs Recognize well-performing ASHAs and reward them
District Program Managers	Support CMHO/CDMO/CMO in budgeting for ASHA component Develop strategies and ensure implementation of the ASHA component
District Community Process Manager	Ensure selection and hiring of ASHAs Ensure capacity building of ASHAs on FP methods Provide support in identifying vulnerable population (Refer to TCIHC’s Mapping& Listing Tool) In coordination with MoIC, conduct periodic review of ASHAs’ performance on FP indicators
Medical Officer-In-Charge UPHC	Provide FP job aids, IEC materials, commodities and other supplies to ASHAs Ensure availability of the roster and supplies for UHNDs and outreach camps Conduct overall monitoring and review of the performance of ASHAs on FP indicators Inform ASHAs about the Fixed Day Static (FDS) service schedule As per the defined terms and conditions, release timely payment to ASHAs
ANM (ASHA Facilitators)	Provide mentoring and supportive supervision to ASHAs Ensure timely indenting and supply of FP commodities Inform ASHAs about the Fixed Day Static (FDS) service schedule Ensure that commodities and supplies are provided to ASHAs Collect FP data from ASHAs and collate the same

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.

Cost Elements

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.4.4.1.1	ROP 2016-17, NHM-UP
U-ASHA FP incentives	P.6.1.2.1	ROP 2016-17, NHM-UP
Budget for ‘Reward and Recognition’ of U-ASHAs	B1.1.3.7.1	ROP 2016-17, NHM-UP
Budget for engaging NGOs for supervision and mentoring of U-ASHAs	Not available

Sustainability

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.