3 months ago


POLICY WATCH Ray of hope

POLICY WATCH Ray of hope for ASHAworkers in Assam National Health Mission,Assam, Health & Family Welfare Department, Government of Assam, has recently streamlined the compensation of ASHAs in the state by implementing an online payment and monitoring system. Excerpts from a case study Being a service organisation meant for delivery of health services through a force of more than 22000+ employees, employee motivation and retention of both service delivery and allied programme management staff is a priority area. Action plan for ASHAs Accredited Social Health Activists (ASHAs) is the backbone of healthcare system at grass root level. At present 30,619 Rural ASHAs and 1,336 Urban ASHAs are working in the state of Assam. ASHA receives incentive for the activities they performed. Regular enhancement of capacity, proper monitoring of activities and timely payment of incentive are the basis for success of ASHA programme. However, due to various field level as well as systematic issues, ASHA programme was not running smoothly including irregular payment of incentives which resulted grievances among ASHAs and de-motivated them and large sunk of this huge work force became inactive. Most of the ASHAs ASHAs on an imunisation drive were even unaware about their entitlement for various activities. Lack of proper guidelines deprived the ASHAs from their due. Due to absence of structured monitoring system quality of services and capacity building programmes were compromised. Absence of proper monitoring system made it difficult to assess the performance of ASHAs. ASHAs were performing only few activities and most of activities were remained unaddressed which hampered the overall implementation of various programmes under National Health Mission. There was an urgent need to streamline the entire ASHA programme to address the field level issues. After rounds of interaction with ASHAs and other stakeholders and through field visit by state level officials, field level issues related to ASHA programme were listed out and a comprehensive action plan was prepared to streamline the entire ASHA programme. Use of information technology was taken as the platform by implementing single window payment system to streamline the processes in addition to rectification of systematic issues. The processes for this initiative were initiated from April 2015 and the system was implemented from November 2015. Challenges faced before deployment / implementation The following issues hindered proper implementation of ASHA programme in the state: ◗ ASHAs are not aware about the list of activities for which they are entitled for incentives: There are around 48 activities through which ASHAs could claim incentive by performing their duties. But, during round of interactions with ASHAs it was observed that, most of ASHAs were not aware about the activities to be performed. ASHAs were performing only few activities and most of activities remained unaddressed which hampered the overall implementation of various programmes under National Health Mission. ◗ There were no comprehensive guidelines: Absence of comprehensive ASHAs at a training workshop 30 EXPRESS HEALTHCARE February 2018

guidelines on payment of incentives to ASHAs created a lot of confusion. Activity wise guidelines were issued time to time from various programme / components. Even all guidelines were not disseminated to the grass root level. Lack of clarity on guidelines and supporting documents to be submitted along with the claims witnessed diversified system in each block empowering accounts managers to decide the supporting documents to be submitted compromising the overall objective of the programme. Even rate of incentives paid was not uniform as newer guidelines was not peculated down to grass root level. Due to lack of proper guidelines, verification/ validation of claims were also not done properly by respective programme officer which raised question on accountability on the system. ◗ Complex system of incentive claims by implementing multiple claim forms: Incentive claim forms were developed for each activity separately and most of the claim forms were very complex for ASHAs to fill up. Verification of claim forms and documents became tedious and time consumption job for the accounts persons. ◗ No specific time frame for receipt of claim and release of payment resulting irregular and delay in release of payment: Timeframe for submission of claims and release of payment was not specified and accountability was not fixed at any level. Irregular and delay in release of payment was the major cause of grievances of the ASHAs. During field visit by state officials it transpired that neither ASHAs were not submitting claims regularly and timely nor account managers were releasing payments as accountability was not fixed. Home based new born care (HBNC) voucher distribution Home visit by an ASHA ◗ Multiple window payment system: As ASHA incentives were approved under different programmes, so payments were released by different programme officers. ASHAs used to approach each programme officers to submit claim forms, enquire about status of approval and collect separate cheques from each programmes. It was a tedious job for the ASHAs and they have to travel to Block PHCs frequently. Excuse of insufficient fund always resulted prolonged delay in release of genuine entitlement of ASHAs. Due to this complex payment mechanism, ASHAs were not interested to perform activities with smaller amount which compromised the overall performance of the programmes. ◗ Lack of transparency in the payment system: Interaction with ASHAs with the accounting staff was not formal. There were complains regarding issue of red tapping and corruption. In most cases, programme officers were also not involved for verification of claims by ASHAs. ◗ Lack of monitoring system to assess the performance of ASHAs: Manual system was implemented for the entire process. There was no mechanism to assess the performance of ASHAs. It was difficult to find out good performing ASHAs, poor performing ASHAs and non-performing ASHAs. More than 5,000 ASHAs were not involved in any activities which deprived the entire population covered by those ASHAs from healthcare services. Programme officers were unaware about the performance of various activities and due to this reason most of the activities were unaddressed and ASHAs could not earned as per expected level. ◗ Lack of digitised ASHA database: There was no database covering all ASHAs. Only basic information of ASHAs was captured through Mother & Child Tracking System (MCTS) which was also not updated. It leads to improper planning and implementation of the programme. ◗ Quality of ASHA trainings: Though regular trainings were organised for ASHAs as per guidelines provided by Government of India, but question of quality of training and impact of training was always questioned. Proper system for assessment and monitoring of training was not in place. Impact of trainings was also not assessed. Process followed for deployment / implementation ◗ Development of comprehensive guidelines: Comprehensive guidelines on payment of ASHA incentives was developed covering all programmes and all 48 activities were to be performed by ASHAs. The guidelines was developed in consultation with all stakeholders including ASHAs, programme officers, accounts officers etc. Eligibility criteria, claim methods, rate and supporting documents to be submitted for each activity was clearly listed out in the guideline to ensure uniform EXPRESS HEALTHCARE 31 February 2018

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