What gets measured, gets managed

Moving towards excellence: Capacitating ASHA Sanginis for supportive supervision and performance improvement

ASHA Sanginis are a critical cadre for the success of ASHA program of the National Health Mission. The Training Need Assessment conducted by SIFPSA clearly brought forward training and capacity gaps amongst this new cadre. A customized training plan to systematically address these gaps would go a long way in building skills and confidence amongst the Sanginis for effective monitoring, mentoring, supportive supervision, facilitation and strengthening of ASHAs, with an intent to eventually impact their performance in the community.

Peer supervision usually refers to reciprocal arrangements in which peers work together for mutual benefit where developmental feedback is emphasised and self-directed learning and evaluation is encouraged (Benshoff, J.M. 1992). Some of the benefits of peer supervision include increased access/frequency of supervision, reciprocal learning through the sharing of experiences, increased skills and responsibility for self-assessment and decreased dependency on expert supervisors. Peer supervision can play a valuable role in giving more people, more access to more supervision, which in turn influences the quality of service to clients and community.

Introduction of a new cadre of 'ASHA Sangini' (Facilitator) to oversee, support and supervise ASHAs in an allotted geography, is a step in this direction under National Health Mission program, encouraging peer based supportive supervision of ASHAs. ASHA Sanginis are expected to play a crucial role in providing day to day support and strengthening the work of ASHAs. Based on the principal of first among the equals, ASHA Sanginis are identified amongst the best performing ASHAs with aspiration and potential for career growth.

The process of ASHA Sangini selection was kick-started in Uttar Pradesh with a government order issued in Sept 2013, from the Directorate of Family Welfare, GoUP. The National Health Mission clearly laid down the selection criteria and qualification for Sangini (Facilitator) as per which she must have minimum three years of experience as Asha and should voluntarily be willing to become Asha Sangini. She must be a resident of her cluster/working area and should be an active and experienced Asha and that the Asha database must contain her details. As per the NHM norms, one ASHA Sangini was to be assigned around 20 ASHAs in her cluster to provide peer supervision and support.

To orient and build capacity of this cadre, a handbook was developed by NHSRC, New Delhi and based on it SIFPSA developed a five-day curriculum for orienting ASHA Sanginis of the State with funding from NHM.

SIFPSA was assigned the tasks of training the district-level master trainers, mentoring and monitoring of the district training programs between 2012-2014. In all, 225 district-level trainers representing all seventy-five districts in the state were trained during this period. The training was conducted in a phased manner, with phase one covering 17 districts and phase two 58 districts. ASHA Sanginis of almost all the districts have been oriented on their role & responsibilities.

Like ASHAs, ASHA Sanginis also require continuous capacity building to enhance their supportive supervision of ASHAs working under them. Since they are selected from among the existing ASHAs to play the role of peer based supportive supervisor and help in problem solving of the community and the ASHAs, a platform is required to address their issues at the initial stage, for improved performance. To address this gap, SIFPSA proposed a three-day refresher training to all ASHA Sanginis who had been trained in the first phase in 17 districts.

However, to scientifically assess the training needs and capacity gaps of ASHA Sanginis in the state, SIFPSA undertook a detailed training needs assessment (TNA) study before deciding the content of the refresher training.

To obtain substantial qualitative inputs it was decided to carry out the TNA study in a set of sample districts drawn from the 17 phase one districts where the ASHA Sanginis had a minimum of 6 months of work experience post their induction training. Six districts representing all regions of the state were randomly selected for the study. The selected districts were Saharanpur and Aligarh (Western), Lakhimpur Kheri (Central), Banda (Bundelkhand), Behraich and Siddharth Nagar (Eastern). Two blocks from each of the selected districts were randomly selected for conducting interviews with 60 ASHA Sanginis, BPMs, BHEOs and one nodal officer from the CMO office, using tools developed to capture quantitative and qualitative information. This was an in-house study conducted in May 2016 by six teams, each consisting of one officer from SIFPSA and one from SPMU-NHM.

The key highlights of the TNA study were: The average age of ASHA Sangini was found to be around 34 years. Around 6 out of every 10 (58%) ASHA Sanginis had education upto the intermediate level while remaining 42 percent had received higher education reflecting that young, enthusiastic and educated grass root workers exist at the village level. On an average, each ASHA Sangini had undergone 43 days of training as ASHA, with nearly two-thirds undergoing 41-50 days of training. Besides the above, nearly all the ASHA Sanginis had received the mandatory 5-day ASHA Sangini orientation training provided by SIFPSA in coordination with NHM.

Most ASHA Sanginis were found to be having about 22 ASHAs to support while 20 percent of them had 26 to 33 ASHAs in their allotted geography. When it came to active ASHAs, the average dropped to 19 ASHAs per Sangini, indicating 03 inactive ASHAs on an average under each Sangini in the state.

Majority of ASHA Sanginis reported fixed day of weekly cluster meetings, mostly held either on Tuesdays (31.7%) or Thursdays (25.0%) while one in every six (17%) Sanginis did not have a fixed day for their weekly cluster meeting in their area. Each Sangini is expected to hold a cluster meeting in a month. For the onsite support and handholding of ASHAs, a vast majority (90%) of Sanginis were found to be visiting their ASHAs once in two months.

In terms of work focus and peer supervision, most Sanginis were involved in supporting ASHAs in VHND, in preparation of due list of beneficiaries for VHND, accompanying ASHAs during home visits, particularly to resistant households, checking of client records (VHIR) of ASHAs, counselling ASHAs in areas requiring improvement, participating in cluster meeting of ASHAs and visiting health centres on certain days. Majority (83%) of ASHA Sanginis reported having knowledge on how to calculate number of beneficiaries for different health services in a given geography eg. number of pregnant and lactating women for ANC and PNC, number of infants for vaccination in their area etc. Most Sanginis could estimate/calculate various beneficiaries for a specific geography with defined population correctly. To facilitate field visit, though majority of Sanginis had received sufficient quantity of assessment and reporting formats, about 18 percent reported their shortage. Almost two third (65%) ASHA Sanginis reported facing problems in performing their job, primary reasons being: travel to remote and distant villages to meet the ASHAs of the assigned area, with their own conveyance, without any reimbursement of conveyance expenses. The state government has now decided to provide a cycle to each ASHA. Low honorarium was also one of the grievances reported. A criteria has been developed where minimum honorarium of Sangini will be fixed. Three-fourth ASHA Sanginis reported receiving regular payments for their work as Sanginis, while the rest reported delay in the payment process.

Based on the data analysis, there were several actionable recommendations emerging from the TNA study. The study clearly reflected certain capacity gaps amongst the ASHA Sanginis requiring customised refresher trainings in: supportive supervision skills, counselling and IPC skills, training on community mobilization, technical aspects of routine immunization, their role in identification and referral of high risk pregnancies and HBNC, due list preparation, updating knowledge on family planning counselling on informed choice, their role in epidemic outbreak and disaster management, reorientation on various NHM activities, group communication activities and use of mobile for program reporting.

The block and district level officials interviewed also indicated need for regular hand-holding support mechanism and reorientation on use of ASHA performance assessment and reporting formats. Exposure visit of Sanginis to another area for cross learning was also highly recommended by officials at block and district level.

The ASHA programme is a critical component of the National Health Mission (NHM) and is one of the several processes which aim to actively engage communities in improving health status. ASHA Sanginis are a critical cadre for the success of ASHA program of NHM. The training need assessment study clearly brought forward training and capacity gaps amongst this new cadre of ASHA Sanginis. Customised training plan to systematically address these gaps would go a long way in building skills and confidence of the Sanginis for effective monitoring, mentoring, supportive supervision, facilitation and strengthening of ASHAs and eventually impact their performance in the community.

To achieve the FP2020 goals, SIFPSA is leading the way in capacitating the ASHA Sanginis and block Community Process Managers in family planning counselling skills in the state.

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