MAA-Movement Against AIDS Perception on ASHAs in rural Bihar A Rapid Assessment Study Report from District Muzaffarpur, Bihar In association with University of Washington & CHSJ Delhi Researcher Dr. Alok Lodh Bihar, India

Background Context 1 January 2019 BIHAR One of the EAG states in India Maternal mortality rate is high at 371 Maternal care indicators very poor Only 5.8%women received recommended ANC SRS 2001-03 Only 34.1 % women had at least one ANC visit SRS 2001-03 MUZAFFARPUR Antenatal deliveries are limited to 19.3% DLHS-RCH round –II Only 8.4% women ever used Govt. health facilities DLHS-RCH round –II Only 2.5% women are ever contacted by the ANM IIPS Mumbai, Key indicators: RCH Data 2002-2004 Context NRHM has provided for an ASHA at every Revenue Village with certain Service Guarantees in the provisioning of Ante Natal care 1 January 2019

Objective Study wanted to gain an insight into the current status of functionality of the ASHA with regard to provisioning of Ante Natal Care services Rapid Assessment was aimed to yield valuable information for designing mid term course corrections to the implementers and policy makers of NRHM Research Question: What are the Perceptions and Experiences of women among different Social groups, ANMs & AWWs about the “Roles and Performances” of ASHAs regarding provisioning of Antenatal Care in the Muzaffarpur district of Bihar, India 1 January 2019

About the study Study limited to selected 10 villages in Muraul block where at least 20 percent of the population was from SC category Time frame of 2 months (October 2008 to November 2008) Stakeholders were 12 ANMS, 16 AWWS, 15 ASHAS and 234 Women belonging to Reproductive Age Gp. (15-45yrs) Survey of Women, In-depth Interviews of ASHA, ANM & AWW,FGD of women from General Caste compared to SC population 1 January 2019

Limitations & Ethics Limited to few selected villages from one block Did not take into account extraneous factors such as flooding, socio-political situations, radical naxalism etc. which are affecting service prov. Could cover only 234 out of a possible 300 women beneficiaries due to migration & refusal mostly from upper class responders Standard ethical guidelines maintained 1 January 2019

Profile of the ASHA All ASHAs were Hindus unlike women who belonged to various religious groups Seven ASHAs belonged to the General Caste; Three belonged to the SC & Four to the OBCs, while One belonged to the ST 1 January 2019

Comparison of service delivery by ASHA between GC & SC 1 January 2019

Findings- Incorrect Perception Most of the ANMs & AWWs perceive the ASHA as one who has the primary duty to- identify the women in the village, register her through them, help her in the immunisation, look after her nutrition and take her to the hospital whenever required Most of the ASHAs perceive their duties to include assisting women for immunisation, supplementary nutrition, Counseling her on eating nutritious food, maintaining cleanliness & Escorting her for delivery at the PHC The primary role of registration and encouraging the women for availing Institutional Delivery is largely missed by the ASHA 1 January 2019

Findings-In adequate functioning The ASHA did not receive significant support from the ANM/AWW The ASHAs are largely unsatisfied with their monetary benefits. This is supported in view by some of the ANMs and AWWs None of the ASHAs are aware about the Village Health & Sanitation Committee whereas some of the ANMs and the AWWs have heard of the concept No one is generally satisfied with the knowledge & quality of training of the ASHAs including the ASHA herself 1 January 2019

Challenges faced-ASHA No compensation for services other than ID Poor reimbursement policy-Delayed payments Lack of good training including methodology & information Social & personal security esp. during odd hours Poor infrastructure/ transport support for ID (including ASHA kits) Lack of support from PHC staff due to indirect expenses Poor clarity in ANC function at community level and In adequate operational/ functional relationship with ANM & AWW while providing ANC services 1 January 2019

Conclusions Gratifying to note that NRHM has been partially successful in sensitising the public health machinery towards ID, generating awareness, providing an alternative to home delivery and creating a cadre of functional frontline workers Though the NRHM focuses on reducing the maternal morbidity and mortality, creation of functional infrastructures and up gradation of services, it is time that the actual community availing the services is placed at the center of focus and mid term planning There is significant social exclusion in service provisioning among lower castes ASHA has not been able to establish a significant relationship with her own community esp. with lower castes/ marginalised communities ANC service provisioning has serious limitations with quality & coverage Front line workers does not have clarity about roles esp. the ASHA 1 January 2019

Recommendations There is a need to reestablish the presence of the ASHA within her community Developing community-based mechanisms to ensure adequate provisioning There is a need for advocacy at the policy level Ensuring that social exclusion is minimised 1 January 2019