Ray of hope for ASHA workers in Assam

National Health Mission, Assam, Health & Family Welfare Department, Government of Assam, has recently streamlined the compensation of ASHAs in the state by implementing an online payment and monitoring system. Excerpts from a case study

Being a service organisation meant for delivery of health services through a force of more than 22000+ employees, employee motivation and retention of both service delivery and allied programme management staff is a priority area.

Action plan for ASHAs

Accredited Social Health Activists (ASHAs) is the backbone of healthcare system at grass root level. At present 30,619 Rural ASHAs and 1,336 Urban ASHAs are working in the state of Assam. ASHA receives incentive for the activities they performed. Regular enhancement of capacity, proper monitoring of activities and timely payment of incentive are the basis for success of ASHA programme.

However, due to various field level as well as systematic issues, ASHA programme was not running smoothly including irregular payment of incentives which resulted grievances among ASHAs and de-motivated them and large sunk of this huge work force became inactive. Most of the ASHAs were even unaware about their entitlement for various activities. Lack of proper guidelines deprived the ASHAs from their due. Due to absence of structured monitoring system quality of services and capacity building programmes were compromised. Absence of proper monitoring system made it difficult to assess the performance of ASHAs. ASHAs were performing only few activities and most of activities were remained unaddressed which hampered the overall implementation of various programmes under National Health Mission. There was an urgent need to streamline the entire ASHA programme to address the field level issues. After rounds of interaction with ASHAs and other stakeholders and through field visit by state level officials, field level issues related to ASHA programme were listed out and a comprehensive action plan was prepared to streamline the entire ASHA programme. Use of information technology was taken as the platform by implementing single window payment system to streamline the processes in addition to rectification of systematic issues. The processes for this initiative were initiated from April 2015 and the system was implemented from November 2015.

Challenges faced before deployment/ implementation

The following issues hindered proper implementation of ASHA programme in the state:

• ASHAs are not aware about the list of activities for which they are entitled for incentives: There are around 48 activities through which ASHAs could claim incentive by performing their duties. But, during round of interactions with ASHAs it was observed that, most of ASHAs were not aware about the activities to be performed. ASHAs were performing only few activities and most of activities remained unaddressed which hampered the overall implementation of various programmes under National Health Mission.
• There were no comprehensive guidelines: Absence of comprehensive guidelines on payment of incentives to ASHAs created a lot of confusion. Activity wise guidelines were issued time to time from various programme/ components. Even all guidelines were not disseminated to the grass root level. Lack of clarity on guidelines and supporting documents to be submitted along with the claims witnessed diversified system in each block empowering accounts managers to decide the supporting documents to be submitted compromising the overall objective of the programme. Even rate of incentives paid was not uniform as newer guidelines was not peculated down to grass root level. Due to lack of proper guidelines, verification/ validation of claims were also not done properly by respective programme officer which raised question on accountability on the system.
• Complex system of incentive claims by implementing multiple claim forms:  Incentive claim forms were developed for each activity separately and most of the claim forms were very complex for ASHAs to fill up. Verification of claim forms and documents became tedious and time consumption job for the accounts persons.
• No specific time frame for receipt of claim and release of payment resulting irregular and delay in release of payment: Timeframe for submission of claims and release of payment was not specified and accountability was not fixed at any level. Irregular and delay in release of payment was the major cause of grievances of the ASHAs. During field visit by state officials it transpired that neither ASHAs were not submitting claims regularly and timely nor account managers were releasing payments as accountability was not fixed.
• Multiple window payment system: As ASHA incentives were approved under different programmes, so payments were released by different programme officers. ASHAs used to approach each programme officers to submit claim forms, enquire about status of approval and collect separate cheques from each programmes. It was a tedious job for the ASHAs and they have to travel to Block PHCs frequently. Excuse of insufficient fund always resulted prolonged delay in release of genuine entitlement of ASHAs. Due to this complex payment mechanism, ASHAs were not interested to perform activities with smaller amount which compromised the overall performance of the programmes.
• Lack of transparency in the payment system: Interaction with ASHAs with the accounting staff was not formal. There were complains regarding issue of red tapping and corruption. In most cases, programme officers were also not involved for verification of claims by ASHAs.
• Lack of monitoring system to assess the performance of ASHAs: Manual system was implemented for the entire process. There was no mechanism to assess the performance of ASHAs. It was difficult to find out good performing ASHAs, poor performing ASHAs and non-performing ASHAs. More than 5,000 ASHAs were not involved in any activities which deprived the entire population covered by those ASHAs from healthcare services. Programme officers were unaware about the performance of various activities and due to this reason most of the activities were unaddressed and ASHAs could not earned as per expected level.
• Lack of digitised ASHA database: There was no database covering all ASHAs. Only basic information of ASHAs was captured through Mother & Child Tracking System (MCTS) which was also not updated. It leads to improper planning and implementation of the programme.
• Quality of ASHA trainings: Though regular trainings were organised for ASHAs as per guidelines provided by Government of India, but question of quality of training and impact of training was always questioned. Proper system for assessment and monitoring of training was not in place. Impact of trainings was also not assessed.

Process followed for deployment/ implementation

• Development of comprehensive guidelines: Comprehensive guidelines on payment of ASHA incentives was developed covering all programmes and all 48 activities were to be performed by ASHAs. The guidelines was developed in consultation with all stakeholders including ASHAs, programme officers, accounts officers etc. Eligibility criteria, claim methods, rate and supporting documents to be submitted for each activity was clearly listed out in the guideline to ensure uniform system throughout the state. Guidelines were translated in all local languages like Assamese, Bengali, Hindi, Bodo and English and ensured that it is made available with all ASHAs, all accounts persons and all programme officers. Distribution mechanism of the guidelines up to ASHA level was properly monitored and documented. All old guidelines were inactivated by issuing order to avoid conflict.
• Implementation of master claim forms: Master claim form was developed covering all activities which simplified the claim process. It was also translated in all local languages and made available in sufficient quantity. ASHAs found it simple to fill up the claim form as only number of claims to be mentioned. Name of the activities and rate were pre-printed which reduces the work and minimised mistakes. Implementation of Master Claim form also simplified the work of accounts persons and streamlined the entire process.
• Implementation of single window system for all claims: Single window system for submission of claims was introduced so that ASHAs need not require approaching each programme officers separately for submission of claims. ASHAs need to submit all claims in the Master Claim Form and submit it to Accounts Manager.
• Fixation of accountability for verification of claims: After receipt of the claims through single window system, the claims are verified by the respective programme officers. It raised accountability and ownership of the programme officers on their respective programme and to ensure proper verification and validation of claims.
• Fixation of time frame for submission of claim and release of payment: Fixed time frame was defined and notified for submission of claim, verification of claims and release of payment. The objective was to ensure timely and regular release of payment to ASHAs. Timeframe was finalised and notified after due consultation with all stakeholders.
• Opening of bank account of all ASHAs: It was ensured that, bank accounts of all ASHAs are opened and registered and validated through Public Financial Management System (PFMS) to ensure authenticity.
• Development of online ASHA payment and monitoring system: Online ASHA Payment and Monitoring System was developed in open source platform using the in-house capacity of National Health Mission, Assam. The system was developed under ‘Health Services Monitoring System’ and hosted in the NHM, Assam server. The objective was to use the power of information technology to create comprehensive ASHA database and streamline ASHA payment and monitoring system. Claims submitted by the ASHAs are captured in the system and acknowledgements are sent to ASHAs through SMS. Information of approval and release of payment through DBT is also communicated to ASHAs through SMS. This transparent system streamlined the ASHA payment system by ensuring timely release of payment and ASHAs are relived to visit accounts persons. The system also identified good performing, poor performing and non performing ASHAs. Activity wise report up to ASHA level helped the programme officers for proper monitoring and implementation of the programmes. The system was integrated with PFMS portal for release of payment to ASHAs through DBT.
• Monitoring of quality of ASHA trainings: ASHA database was created with all vital information of ASHAs along with bank account information, mobile number, photographs etc. The system is also used for monitoring of capacity building workshops of ASHAs. Pre-assessment and post assessment findings of each ASHA is monitored through the system to evaluate quality of trainings.

Innovative aspects of your project/ activity

• Implementation of single window payment system: one of the major objectives of this approach is to implement hassle free single window ASHA claim system. Development of comprehensive guidelines covering all programmes and implementation of innovative Master Claim form simplified and made the system hassle free.
• 100 per cent Direct Bank Transfer (DBT) mode payment: One of the major strategies of the system is to implement 100 per cent DBT mode payment. The ASHA Payment system was integrated with PFMS to ensure 100 per cent DBT mode payment to ensure transparency in the system and ASHAs need not required visiting accounts managers and standing in queue for collection of cheque.
• Use of power of Information Technology for development of ASHA Payment System: IT-based online system empowered proper monitoring of claim and release of payment. Now, account managers cannot keep the payments pending which is reflected in the dashboard. Activity wise performance could be monitored and tracked at all level (state, district, block, sectoral, SC and ASHA level) by click of a mouse. The system also generates alarm if payments are made more than normal level allowing the higher level authorities for proper monitoring of the system. Dashboard and different analytical reports helped programme officers for proper implementation of the programme.
• SMS-based alarms: The system send automatic SMS to ASHAs during receipt of claim, approval and release of payment to ensure transparency in the system.
• Categorisation of ASHAs based on performance: ASHAs are categorised as good performing, poor performing and non-performing based on claims submitted. It helped to identify the good performing ASHAs for nomination of awards. Similarly, non performing ASHAs were identified, motivated, re-oriented to improve performance.
• Categorisation of activities based on performance: Activities were categorised based on performance by ASHAs. Low performing activities were identified and causes of poor performance was analysed and necessary strategies adopted to improve performance.

Solution/ technologies implemented

ASHA payment and monitoring system was developed using open source technology. The system has been developed and implemented using in-house capacity of NHM, Assam and hosted in the NHM Server. The system is developed under secured user login and role-based user access is provided to the different users. Following modules are implemented: i) ASHA Master Database: ASHA database was created with all vital information of ASHAs along with Bank Account information, mobile number, photographs etc.

• Incentive claim: Information of incentive claims by ASHAs is captured through this module. Automatic SMS is delivered to ASHAs on submission of claims in the system.
• Approval of claim: Information of approval of claims is captured through the system. automatic SMS is delivered to ASHAs on updating of approval.
• Payment process: After approval of the claims, payment process is generated to enable payment through PFMS in DBT mode. Automatic SMS is delivered ASHAs after release of payment.
• Monitoring of ASHA trainings: The system is also used for monitoring of capacity building workshops of ASHAs. Pre-assessment and post assessment findings of each ASHA is monitored through the system to evaluate quality of trainings.
• Dashboard: Dashboard to highlight the ASHA payment system.
• Analytical reports: Different customised analytical reports are generated from the system. State, district, block, sectoral, sub centre and ASHA wise reports can be generated. There is option of generation of drill down reports from state level to ASHA for each activity. Activity wise performance reports are also available. Report of good performing, poor performing and non performing ASHAs can be generated in mouse click.

Comparison of the pre-deployment with post-deployment scenario

Highlighted comparison of pre-development with post-development scenario of the system: i) Before implementation of the system in 2014-15, average monthly income per ASHA was Rs 1188 in 2014-15. After implementation of the system it has increased to Rs 4326 in 2016-17.

• Before implementation of the system, ASHAs were not aware about the list of activities for which they are entitled for incentives. Now all ASHAs are aware about the list of activities for which they are entitled for incentives.
• Multiple forms used for claiming incentives for different schemes before implementation of the system. Now, single Master Claim form is used for all activities.
• Before implementation of the system, multiple window payment system was followed, i.e., ASHAs used to approach each programme officers to submit claim forms, enquire about status of approval and collect separate cheques from each programmes. But, after implementation of the new system, ‘Single Window System’ has been implemented. Now, ASHAs submit all claims together using single master claim form and need not visit to any person as the amount is directly transferred to bank account.
• There was no system to track good performing, poor performing and non performing ASHAs. Now, list of good performing, poor performing and non performing ASHAs could be generated in a mouse click.
• There was no method for analysis of activity wise performance. Now, activity wise performance can be analysed automatically from the system.
• There was no method to check over payment to ASHAs. Now, alert messages appears for doubtful payment cases.
• Before implementation of the system, there was no fixed time frame for receipt of claim and release of payment. After implementation of the system, fixed time frame developed for receipt of claim and release of payment followed.
• Issue of regular non payment was major concern before implementation of the system. Now, payment is regular throughout the state.
• Interaction with ASHAs with the accounting staff was not formal. Now transparent system implemented by sending automatic SMS to ASHAs.
• Issue of red tapping and corruption offend complained. Now, after implementation of the transparent system, it has reduced substantially.

Benefits derived from the solution implemented

• Increase of income of ASHAs: Exceptional outcome of this initiative witnessed sharp increase of average monthly income of ASHAs from Rs 1188 in 2014-15 to Rs 4326 in 2016-17.
• Timely payment of ASHAs: ASHA payment system has been streamlined and monthly payment is released to ASHAs as per fixed time frame. All backlog payments were identified and cleared within three months from the date of implementation of the system. Now, there is no complaint of delay of payment. Now, ASHAs used to submit claim on time as non submission of claim by ASHAs are also categorised as non performer.
• 100 per cent DBT mode payment: Now, 100 per cent payment is made to bank account of ASHAs through Direct Benefit Transfer only. More than Rs 150 crore payment has been released to ASHAs through this system.
• Free from non performer: Around 5000 non-performing ASHAs were identified and converted to zero non performer within two years through motivation, reorientation and replacement. It could be achieved through monthly follow up of non performing ASHAs from the report generated from the system.
• Transparency in the system: The major achievement of the system is to establish transparency and accountability in the system. Interaction of ASHAs with accounts persons minimised by implementing single window system. Substantial reduction in issue of red tapping and corruption.
• Structured monitoring: Using the alerts and reports, now the administrators and programme officers are more empowered for monitoring. Using the analysis reports and alerts, instances of overpayment to ASHAs were tracked and those were recovered after thorough investigation.

Potential for replicability arising from the success of your project/ activity

• Cost effectiveness: The initiative is cost effective. The entire project was managed from the available fund and existing human resources without any hassle. The system was developed using in-house capacity of National Health Mission, Assam using open source technology and it is hosted in the NHM Assam server, so no extra cost was involved.
• Customised solution: The system was developed within reasonable time of three months despite several technical issues like integration with PFMS, validation of bank accounts etc. As the system is developed in-house, so it is easy to customised and include new features without any problem. New customised reports could be included as per requirement.
• Utilisation of PFMS platform for DBT payment: As PFMS portal is utilised for payment to ASHAs through so there was no cost involved. As PFMS is used by all State and Central Government agencies so it is easily replicable.
• DBT payment: Establishing a DBT Payment System in the pursuit of a sustainable development and economic growth is very important. ASHA Payment System develops the e-payment system by transforming traditional payment process to electronic payment practices which has broken new grounds and has taken a global dimension.
• Motivate ASHA, develop their economic growth and improve health services: After payment to ASHA become regular, it motivates the ASHA in performing their activities regularly. It also helps in the economic growth of them and helped improvement of health of the community.
• Transparency: Using the new system, the payment process to ASHAs became very transparent. All the data can be viewed anytime using the web-based system.

(Source: National Health Mission, Ministry of Health and Family Welfare, Government of Assam)