Population Council Research that makes a difference

Based on secondary analysis of data sets from Population Council studies in northern India, this case study examined how the dual-cadre model of mid-level professional auxiliary nurse midwives (ANMs) and accredited social health activists (ASHAs) functions at the community level. It also assessed whether mobile phones have the potential to improve this model.

Observations

• ASHA/ANM roles and responsibilities: Supportive supervision is a major missing link between ANMs and ASHAs. In principle, ANMs supervise ASHAs, reviewing their records and financial claims and refilling their medical kits. However, most ANMs do not view ASHA supervision as being a key responsibility. ANMs and ASHAs usually meet only twice per month, giving ANMs limited opportunity to provide support.
  
  In addition, although ASHAs are expected to stock and distribute items such as condoms and contraceptive pills, few had any of these items in stock at the time of their interviews. ASHAs also had limited training and counseling skills in promoting contraception. While ASHA contraceptive method awareness was very high, correct knowledge of spacing methods was not.
  
  
• Status of the health system: The model is well conceived and accounts for appropriate resources, organizational support, and monitoring inputs for effective implementation. However, implementation and resource provision has varied greatly across different areas of the regions. Clear guidelines for ASHA selection have been provided by the National Rural Health Mission to aid community leaders in identifying and choosing individuals, but this guidance is not strictly followed. Also, when community health workers lack correct contraceptive knowledge, they often share the same misconceptions with the community members they serve. In addition, there is a lack of emphasis on the responsibility of ASHAs to counsel women on a full range of contraceptive methods.
  
  
• Potential for use of mobile phones to provide services: Mobile phone ownership and/or access by ASHAs and ANMs is almost universal, with one study showing that they were used regularly by health workers for information dissemination, client interaction, and supervision. This suggests that mobile phones could be a highly effective tool for providing the workers with accurate information and improved support services.
  
  

Key recommendations

ANMs need the means and incentives to develop supervisory skills, and a job aide to make this oversight more systematic. Both ASHAs and ANMs should be encouraged and enabled to counsel women interested in family planning in the full range of methods so that women can choose a method appropriate to their needs. In addition, given the observed scope in mobile phone access and use, further investigation is recommended to develop methods of using them in continuing the education of ASHAs and ANMs and as a potential outlet for strengthening supervision.

Impact

Through this study, researchers were able to determine where improvements in the dual-cadre model should be made to increase efficiency and responsiveness to the needs of women and families. If adjustments are made to the model and to the training and information given to ANMs, it is possible to improve and enhance the services provided by the more than 825,000 ASHAs they oversee.

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Related project

• Task-sharing between Community Health Workers and Community Mid-level Professionals: Increasing Access to FP and RH Services