In a state where infant mortality rate (IMR) is 52 and maternal mortality rate (MMR) is 312, it comes as no surprise to find Bihar lagging behind in development goals. With 36 of Bihar’s 38 districts being categorized backward, it is one of the high focus states under the National Rural Health Mission (NRHM). However, a determined bid is being made by the State Health Society Bihar to improve the lives of women and children by reducing IMR to less than 45 and MMR to 200 and improve the rate of institutional delivery to 70 percent. Further, it hopes to reduce Birth Rate (CBR) from 28.1 (SRS Dec 2011) to 27, Death Rate to 6.7 from 7 and increase contraceptive prevalence rate (CPR) from 29.4 (RCH 3, 2007-08) to 45 so that it can stabilize population by bringing down the total fertility rate. Bihar continues to be the third most populous state in India despite the 3.5 percent decline in the decadal growth of the population (2011 census).
ASHA Resource Center Hold the Key
In order to achieve these goals, the state is concentrating on augmenting support to the Accredited Social Health Activist (ASHA), the key worker responsible for improving availability, accessibility and utilization of reproductive and child health (RCH) services under the NRHM. The recently instituted ASHA Resource Center (ARC) in the state is a big step in this direction. Since the lack of support and supervision has impacted the ASHAs negatively and prevented them from making a huge difference, the ARC has adopted a multi-pronged strategy to help them achieve their potential. Quality training to ASHAs and training of trainers has started after identifying a cadre of trainers at state, district, and block levels with the appropriate skill mix.
Introducing a New Strategy
What has really worked at the ground level has been the excellent strategy of appointing one ASHA facilitator for every 20 ASHAs. This ASHA facilitator not only handholds all the ASHAs, but is also the 21st ASHA. According to Ms. Vasudha Gupta, Team Leader and Member Secretary of the ASHA Resource Centre (ARC), this will help in building and developing the necessary skills required for a community health worker in a sustainable way. “The Block coordinator, medical officer, panchayat and fellow ASHAs select the best ASHA as the facilitator. An ASHA facilitator is responsible for visiting the ASHAs in the villages, providing support, supervision, and on the job training. We have one ASHA facilitator for every 20 ASHA, so there are five ASHA facilitators in a block. Ideally, the facilitator is a graduate in social work or has passed Class XII. So when she visits the ASHA in the field, she can review their records comprising Maternal and Newborn cards, diary and village health register and also conduct home visits. Thus, she monitors at the field level which is very important to assess quality of inputs and identify issues that need to be resolved,” said Ms Gupta.
Impact on the Ground
Just how important constant supervision by ASHA facilitators is was seen at a village health and sanitation (VHSN) meeting in the Semara Harijan hamlet in Mahuawa Kataharawa panchayat, Bagaha-2 block in West Champaran district. When the ASHA and the auxiliary nurse midwife (ANM) were asked when the measles vaccinations should be given to children, both gave different answers. While Rita Devi, the ASHA, contended that the vaccination should be given after the child turned nine months, ANM Prabha Kumari felt it should be administered nine months after the child has been given the BCG shots.
When the block supervisor realized that Rita Devi was very confident of her answer, he asked how she was so sure .On being told that this information was given in her ASHA book, he asked to be shown the appropriate page. Finding the answer given by Rita Devi to be right, he asked the ANM to correct herself and ensure that the measles vaccination was given accordingly. Not only did Prabha Devi thank Rita Devi for correcting her mistake, but she also shared this information with Jamwanti Devi, the ASHA from Kataharawa at the next VHSN meeting.
Facilitating Community Linkages
According to Nawin Kumar, Block Community Mobilizer, (BCM), Bagaha-2, West Champaran, ASHA facilitators have been able to involve local leaders. “At a panchayat level meeting of ASHAs at Nautanwa village, upmukhiya Bachchi Devi was so impressed with the information shared that she expressed the desire to attend all future meetings so that she could also increase her own knowledge,” said Nawin.
In fact, experience sharing is one of the ways the ASHA facilitator uses to motivate the ASHAs. At the Gaunaha primary health center (PHC), ASHA facilitator Meena Devi is using a quiz to test the knowledge of the 20 ASHAs gathered there for their monthly meeting. “This is why we elected Meena as our facilitator. She is able to teach us in an interesting way,” stated Salima Devi. BCM Utpal Kant, in charge of Gaunaha PHC, pointed out that having a facilitator has helped greatly in disseminating information to all the ASHAs. “She helps to break several myths, especially related to family planning, by sharing case studies,” he revealed. According to Rajesh Kumar, district community mobilizer, West Champaran, the states of Orissa, MP and UP have adopted the facilitator initiative.
However, keeping up the motivation levels of the ASHAs is a big challenge as their payments in the form of monetary incentives are always delayed. A majority of the complaints registered in the complaint book instituted to redress their grievances relates to delay in payments. So far, this hasn’t deterred the ASHAs from carrying out their work thanks to their facilitators. Hopefully, the financial problem will be resolved soon and the new initiative will continue to boost healthcare.