Role of ASHA and ANM

One of the key components of the National Rural Health Mission is to provide every village in the country with a trained female community health activist  'ASHA'  or Accredited Social Health Activist. Selected from the village itself and accountable to it, the ASHA will be trained to work as an interface between the community and the public health system. Following are the key components of ASHA: 

• ASHA must primarily be a woman resident of the village  married/ widowed/ divorced, preferably in the age group of 25 to 45 years.
• She should be a literate woman with formal education up to class eight. This may be relaxed only if no suitable person with this qualification is available.
• ASHA will be chosen through a rigorous process of selection involving various community groups, self-help groups, Anganwadi Institutions, the Block Nodal officer, District Nodal officer, the village Health Committee and the Gram Sabha.
• Capacity building of ASHA is being seen as a continuous process. ASHA will have to undergo series of training episodes to acquire the necessary knowledge, skills and confidence for performing her spelled out roles.
• The ASHAs will receive performance-based incentives for promoting universal immunization, referral and escort services for Reproductive & Child Health (RCH) and other healthcare programmes, and construction of household toilets.
• Empowered with knowledge and a drug-kit to deliver first-contact healthcare, every ASHA is expected to be a fountainhead of community participation in public health programmes in her village.
• ASHA will be the first port of call for any health related demands of deprived sections of the population, especially women and children, who find it difficult to access health services.
• ASHA will be a health activist in the community who will create awareness on health and its social determinants and mobilise the community towards local health planning and increased utilisation and accountability of the existing health services.
• She would be a promoter of good health practices and will also provide a minimum package of curative care as appropriate and feasible for that level and make timely referrals.
• ASHA will provide information to the community on determinants  of health such as nutrition, basic sanitation & hygienic practices, healthy living and working conditions, information on existing health services and the need for timely utilisation of health & family welfare services.
• She will counsel women on birth preparedness, importance of safe delivery, breast-feeding and complementary feeding, immunization, contraception and prevention of common infections including Reproductive Tract Infection/Sexually Transmitted Infections (RTIs/STIs) and care of the young child.
• ASHA will mobilise the community and facilitate them in accessing health and health related services available at the Anganwadi/sub-centre/primary health centers, such as immunisation, Ante Natal Check-up (ANC), Post Natal Check-up supplementary nutrition, sanitation and other services being provided by the government.
• She will act as a depot older for essential provisions being made available to all habitations like Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet(IFA), chloroquine, Disposable Delivery Kits (DDK), Oral Pills & Condoms, etc.
• At the village level it is recognised that ASHA cannot function without adequate institutional support. Women's committees (like self-help groups or women's health committees), village Health & Sanitation Committee of the Gram Panchayat, peripheral health workers especially ANMs and Anganwadi workers, and the trainers of ASHA and in-service periodic training would be a major source of support to ASHA.

Support Mechanism for ASHA 

• The Government of India has set up an ASHA Mentoring Group comprising of leading NGOs and well known experts on community health. Similar mentoring groups at the State/District/Block levels could be set up by the States to provide guidance and advise on matter relating to selection, training and support for ASHA.
• As ASHA will be in the village on a permanent basis, she should be selected carefully through the process laid down in the first set of ASHA guidelines. 
• The guidelines already issued on ASHA envisage a total period of 23 days training in five episodes. 
• Now, that ASHAs have been selected, the next step would be to familiarize her with the health status of the villagers and facilitate her adoption to the village conditions. 
• The Gram Panchayat will be involved in supporting ASHAs in her work. 
• A village health register is maintained by the AWW which is not always complete.
• All State Governments are presently organizing monthly Health and Nutrition day in every village (Anganwadi centers) with the help of AWW/ANM. ASHA along with AWW should mobilize women, children and vulnerable population for the monthly health day activities like immunization, careful assessment of nutritional status of pregnant/lactating women, newborn & children, ANC/PNC and other health check-ups of women and children, taking weight of babies and pregnant women etc. and all range of other health activities. 
• ASHA would be required to interact with SHG Groups, if available in the villages, along with AWW, so that a work force of women will be available in all the villages. 
• ANM should have a monthly meeting with the ASHAs stationed (5-6 ASHAs) in the villages of her work area at the Anganwadi Centre during the monthly Health and Nutrition Day to assess the quality of their work and provide them guidance.
• The Medical Officer In-charge of the PHC will hold a monthly meeting which would be attended by ANM and ASHAs, LHVs and Block Facilitator. 
• A meeting of ASHA could be organized on the day monthly meetings are organized at the PHC level to avoid unnecessary travel expenditure and wastage of time.
• In addition to monthly meetings at PHC, periodic retraining of ASHAs may be held for two days once in every alternate month where interactive sessions will be held to help then to refresh and upgrade their knowledge and skills, as provided for in the original guidelines for ASHA.
• At the block level, the BMO will be in overall charge of ASHA related activities.
• Officials in the ICDS should be fully involved in ASHAs activities and their support should be provided for at every level i.e. PHCs, CHCs, District Society etc. 
• Periodic surveys are envisaged under NHM in every village to assess the improvement brought about by ASHA and other interventions. 
• The District Health Mission in its meetings will specially assess the progress of selection of ASHAs, their training and orientation, usefulness to the villages etc. 
• The success of NHM to great extent depends on performance of ASHA and her linkage with functional health system. 
• The States may take appropriate steps to locally adopt these guidelines and make the ASHA scheme a complete success.

ROLE of  Auxilliary Nurse Midwives (ANM)

• Holding weekly / fortnightly meeting with ASHA to discuss the activities undertaken during the week/fortnight.
• Acting as a resource person, along with Anganwadi Worker (AWW), for the training of ASHA.
• Informing ASHA about date and time of the outreach session and also guiding her to bring the prospective beneficiaries to the outreach session.
• Participating and guiding in organising Health Days at Anganwadi Centre.
• Taking help of ASHA in updating eligible couples register of the village concerned.
• Utilising ASHA in motivating the pregnant women for coming to Sub-Centre for initial check-ups.
• ASHA helps ANMs in bringing married couples to Sub-Centres for adopting family planning.
• Guiding ASHA in motivating pregnant women for taking full course of iron folic acid (IFA) tablets and TT injections, etc.
• Orienting ASHA on the dose schedule and side affects of oral pills.
• Educating ASHA on danger signs of pregnancy and labour so that she can timely identify and help beneficiary in getting further treatment.
• Informing ASHA about date, time and place for initial and periodic training schedule. ANM would also ensure that during the training ASHA gets the compensation for performance and also TA/DA for attending the training.....

The NRHM  seeks to provide minimum two ANMs (against one at present) at each Sub-Centre, as one ANM at a sub-centre has not been found adequate to attend to the complete needs of maternal and child care in any village. The Government of India would support the second ANM for appointment on contract basis and apart from fulfilling the other criteria she must be a resident of a village falling under the jurisdiction of the Sub-Centre. The intention is to improve accountability at the local level..

The second ANM would not be transferred before completion of 10 years at the same Sub-Centre and would not be a substitute for Male Health Worker (MHW). An untied fund of Rs.10,000/- per Sub-Centre per annum is being provided by opening a joint account of the ANM and Sarpanch, to meet the emergency type expenditures and to ensure that lack of drugs and other consumables is not an issue.