In India, the Accredited Social Health Activists (ASHAs) have long played an indispensable role in healthcare for the rural poor, above all in mother-child healthcare. They act as the first link between the health system and the rural community. ASHAs are local women who have been identified, selected and trained to act as health promoters in their communities. They generate health awareness and mobilise communities to engage in local health planning and greater use of healthcare delivery systems. Their practical tasks include encouraging women to give birth in hospitals, bring their children to immunisation clinics and embrace family planning. They administer first aid to treat basic illnesses and injuries and help improve hygiene and village sanitation. The ASHAs also assist with out-patient treatment or admissions by escorting pregnant women and children to the nearest assigned health facility. This would be a primary health centre (PHC) for communities numbering 20,000 to 30,000 or a community health centre (CHC) for populations of 80,000 to 120,000 (covering 4 PHCs) with 30-bed provision.
However, their work is complicated by a wide range of obstacles. Each ASHA has to cover a target population of 1,000 on the plains and 500 in desert, hilly or tribal areas. Only one Auxiliary Nurse Midwife (ANM) is provided for a population of 5,000, which means one ANM usually supervises five ASHAs. She holds a weekly or fortnightly meeting with the ASHAs and gives them on-the-job training. ASHAs can also draw on the support of a village-based Aangan Wari Worker (AWW) under the Integrated Child Development Scheme (ICDS) run by the Ministry of Women and Child Development. Moreover, an ASHA has the daily problem of covering a great deal of difficult terrain, mostly on foot and often loaded down with registers, weighing scale and information, education and communication (IEC) materials needed for interpersonal communication with beneficiaries. No wonder that some ASHAs become less fastidious and the delivery of services suffers, especially the counselling of eligible couples.
With the aid of IEC, ASHAs are required to find out whether a woman is underweight, anaemic or in any way physically unfit and establish who requires medical attention. But due to the practical difficulties they face, they are often unable to communicate effectively. In some cases, too much time passes between identifying an alarming symptom and initiating a medical response. Besides, there are several bottlenecks in the health monitoring system, including:
In order to provide the rural front-line workers with a technology to make their communication with village beneficiaries more effective, the United Nations Children’s Fund (UNICEF) field office for Rajasthan, with the assistance of the Indian Institute of Technology (IIT), Jodhpur, designed an innovative approach called e-ASHA. It consists of tailor-made application software that offers a more efficient way of identifying, tracking and monitoring mother and child health. It was decided to field test the concept and approach in a difficult-to-reach cluster of remote villages with fewer facilities, and with the set of those ASHAs who were comparatively less literate and more deprived of exposure to the outside world. Jasol Village was identified for this purpose. It is located in Balotra Block of Barmer, one of the difficult-to-access desert districts in Rajasthan. Given its tough terrain and hard location, Jasol Village was likely to have a low success rate for any innovation trial. It was believed that if the innovation was found to be successful in such an area, then it could be easily replicated in other less difficult parts of Rajasthan. The test started initially with 25 ASHAs, covering a population of 40,000 individuals in 2013.
Salient features of e-ASHA
The tool was designed to reduce the burden of the rural front-line workers, while also advancing their planning and communication skills. This would eventually improve the quality of counselling and institutional deliveries and ensure regular ante-natal check-ups, timely vaccinations and post-natal care. The salient features of this innovation are as follows:
The Indian Institute of Health Management Research (IIHMR) was involved in capacity building among the front-line health workers. During summer training courses, IIHMR interns at UNICEF worked assiduously with ASHAs in the villages for a month and taught them how to use the technology effectively. They gave both on-job and classroom training to ASHAs and worked upon improving staff communication skills and proficiency with the tablets. ASHAs who were only functionally literate have now become very adept at working with the tablets.
The role of the Government of Rajasthan has been very encouraging here. During the trial the government officials concerned were always kept in loop through formal and informal discussions. From time to time they were updated on the progress being made in the project. The government officials supported the idea and its implementation. At the end of the test phase, the Accredited Social Health Activists were invited to demonstrate their acquired skills and capabilities at the Institute of Technology in Jodhpur to high-ranking politicians, including the President of India, ShriPranab Mukherjee. The policy makers were very impressed with the outcome. The ASHAs showed improvement in their confidence level with effective interpersonal communication, easy and assured data entry skills and the ability to automatically generate reminders to facilitate an action plan. The ICT tool ensures that no child or mother goes untracked, makes register entries much easier and allows ASHAs to carry less weight.
Of course, in spite of the positive examples, some problems were revealed in the course of implementation:
As a result of the presentation at the Institute of Technology in Jodhpur, the politicians concluded that the Government of Rajasthan should adopt this innovation and initiate a phased roll-out in other rural areas. Whether this actually happens will depend on the policies to be adopted by the newly elected state government.
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