Study setting: The urban poor settlements of Delhi.
Study period: September 2011 to December 2013
Study context: In order to make the intervention fit within the context of the implementing organization, which in the present case was the urban community health system catered by primary urban health systems (PUHCs) under the DSHM, its culture and networks were also assessed.
The ANCHUL intervention was envisaged to be an add on to the existing ASHA program. At the time of planning of the ANCHUL intervention, the ongoing model of ASHA program was implemented in various districts of Delhi where new seed PUHCs were being operationalized in addition to the existing ones. One ASHA was supposed to cater to a population of 2000. The vision was to have 1 PUHC catering to a population of 50,000. Hence one PUHC would have 25 ASHAs under it and 2 centres would usually cater to a population of 100,000 with 50 ASHAs. This 100,000 population would comprise of 1 administrative unit. The selection strategy for ASHA for Delhi urban areas entailed a committee comprising of an ANM, Medical officer, area Pradhan, anganwadi supervisor who would collect the nominations for ASHA, and the selection was done at the Unit level. The nominations were then sent to the district for endorsement. The training was conducted at the PUHC and after the first module training, a kit was provided to the ASHAs. At the time of planning of ANCHUL intervention, the ASHAs were providing preventive care. There were various mentor groups at the unit, district and state level. There was however a lack of clarity on the role of these mentor groups. Delhi State had also developed Public Health Standards and Quality Assurance Manuals for the PUHCs, an essential input towards health system strengthening. The incentivisation strategy for ASHAs was also revised in December 2010.We attempted to follow this structural framework of the ASHA program while incorporating specific components in the program to address implementation challenges.
Study population: This included the key stakeholders of the program including the ASHA program implementers, decision makers, program planners, policy makers, academicians, health care providers of public health system and the community living in urban poor settlements.
Study design: The ANCHUL intervention design was informed from data collected by mixed methods i.e. by data from quantitative surveys, qualitative enquiries like in-depth interview, focus group discussions and key informant interviews and desk review.
The intervention was developed in three phases:
Formative phase (Phase 1): This was a combination of community based survey, consultations with the program implementers and decision makers, and a desk review with the goal to identify key gaps in the program and a rapid assessment of the existing MCH needs in urban poor settlements of Delhi. This led to the development of the conceptual framework for our intervention.
Design phase (Phase 2): Based on the conceptual framework, this phase aimed at developing the key components of the ANCHUL intervention that needed to be contextualized within the care provision set up, external environment and the end users of the intervention as identified in Phase 1. The processes of implementing each component of ANCHUL intervention were finalized. This phase also identified key process indicators linked to each component of intervention for the purpose of evaluation.
Evaluation phase (Phase 3): The intervention was rolled out with the goal to test its feasibility, but allowing flexibility of modifying the processes through an iterative rapid feedback mechanism. In this phase we also evaluated the intervention using a pragmatic quasi experimental design.
A schematic presentation of phases is provided in figure 1. In this paper we have focussed on the formative and design phase of the intervention.
In the following section, methodology for each phase along with the results are discussed.
Methods
Formative Phase: (Phase 1)
Desk review: A desk review of the existing ASHA models in various states of India and their evaluations was conducted. Informal meetings with key stakeholders of the ASHA program were also conducted to facilitate understanding their perception regarding factors associated with the success and weaknesses of the program in urban areas.
Community survey: The formative phase included a cross sectional household (HH) survey in three slum clusters namely CPJ, Buland Masjid and Chanderpuri of Seelampur, Gandhinagar and Kailash Nagar Assembly respectively of the north east district of Delhi. Apart from collecting information on cluster level characteristics including vulnerability in terms of infrastructure and access to MCH services, we collected information about family details, socio demographic status, place of childbirth (for women who had given birth in the past 1 year), and maternal and child deaths within households in the past 1 year. All households with pregnant women, recently delivered mothers and randomly selected households with under-5 children, were revisited and detailed information was collected about antenatal care (ANC), child birth, immediate postnatal period, new born care practices, morbidity in children, nutritional status of mothers and children and presence of any community based maternal, neonatal and child health (MNCH) services. Qualitative data were also collected from the community and the service providers in order to assess the MNCH care practices and availability, access and utilization of both community and facility based MNCH services in the study areas.
Development of a conceptual framework: This included listing the key issues/gaps and identifying the key interventions which had the potential to address issues were identified.
A round table consultation: A round table consultation was organized to present the findings of community survey and to take into account the perspectives of the policy makers, MCH experts and researchers, nutritionist, health specialist, representative from Delhi Urban Shelter Improvement Board (DUSIB) and ANCHUL team members. The main objective of the RTC was to obtain inputs of the RTC members on the feasibility, sustainability of the intervention framework, and scalability of the proposed model.
Presentation of ANCHUL intervention to DSHM and permission to conduct the trial: The proposed intervention was presented to DSHM. This exercise was crucial in understanding what was feasible within the decision space of the program implementers and getting their feedback on practical feasibility of proposed processes to address the gaps identified. Following this, formal permissions were obtained to roll out and evaluate the modified components of ASHA program in the intervention area in consultation with DSHM officials and program implementers.
Results
Formative phase (Phase 1)
Desk Review: The desk review revealed various models of the ASHA program that are operational in different states of India. Review of the training modules of ASHAs, highlighted the need for restructuring and to remove some repetitive sections. The document on evaluation of the Delhi ASHA model as part of the 6th Common Review Mission 2013 [10] provided some crucial inputs regarding the need for restructuring with specific focus on the training, supervision and monitoring of ASHAs. Further, recommendations existed on strengthening the ASHA selection process in order to optimize their productivity and consistency of performance [22, 23]. Literature also suggested a consensus that continuous training or refresher training of community health workers is as important as the initial training [24]. Also, there was evidence on the importance of context specific supervision with supportive approaches as crucial factor for worker performance [25].
Informal meetings: Eleven informal discussions were conducted with key policy makers and stakeholders in the health department of both the National and the State Government, Planning Commission of India (currently renamed as Niti Ayog), at a tertiary level medical institute, and in an NGO doing extensive work in MCH. The meetings provided insight into the following:
(1) The felt need for an urban community health worker.
(2) The relevance of ANCHUL project as a very timely initiative as the National Urban Health Mission was a priority in the then proposed 12th five year plan.
(3) A need for a realistic appraisal of the feasibility and likelihood of success of ANCHUL model in urban slums in the context of:
- Optimal utilization of existing infrastructure, exploring a public private partnership in the proposed model
- An ideal worker to population ratio in the urban context
- Clarity about the role definition of the worker with clear-cut strategies on curative and preventive roles of the ASHAs and their supervisors i.e. Auxillary Nurse Midwives (ANMs),
- Life cycle approach to address intergenerational influence on health of mother and child
- Convergence of various sectors related to health
- Optimal utilization of an existing ASHA kit and its synergy with the promising AYUSH department (Ayurveda, Yoga, Unani, Sidhha and Homeopathy);
(4) A need for robust referral component at various levels of the health system with better linkage between the levels of continuum of care
Community survey: A survey that was conducted in 6092 HHs with a median family size of five showed that among the women (n=852) who gave birth in the previous year, 53% (95% CI 49.7 to 56.6) had delivered at home. The predictors of these home births included multiparity, low literacy and migrant status are reported in details elsewhere [26]. In the qualitative enquiries with the community, fear of hospitals, comfort of home and lack of social support for child care emerged as the primary reasons for home births. Almost 80% of the pregnant and recently delivered women who participated in the detailed survey reported receiving some form of ANC but the package was inadequate in terms of the components covered and the quality. The various determinants for non-utilization of ANC included poverty, literacy, migration, duration of stay in the locality and high parity [27].
Just above half (57.3%) of these women availed ANC from a public health facility but only 44% of them made their first ANC visit within the 1st trimester. Prevalence of anaemia in pregnant women across all gestational ages was 85%, and 97.1 % in women who had recently delivered. Among the under five children, 17% did not receive any immunization and amongst those who received immunization, only 58.8% were completely immunized for age. A high prevalence of undernutrition (Z score <-2SD) in terms of underweight (34.9 %), stunting (61.3%) and wasting (10.2%) was observed among under-5 years children. The qualitative enquiries with recently delivered women and mothers of children under 5 years of age showed a clear preference towards the private health care providers in case of illnesses in neonates and children. With respect to CHW (i.e. anganwadi Worker, ASHAs and other voluntary health workers associated with NGO), there was a very nominal presence of any CHW in the slums studied with only 29% of the households being aware about the presence of any CHW in their area. There was however, a felt need by the community for a CHW to serve in their area.
Development of conceptual framework: Based on findings of the formative phase and the existing literature on the evaluation of the ASHA program in different set ups in India, a conceptual framework was developed that informed the ANCHUL intervention (Figure 2).
Improvement in MCH care practices and better healthcare utilization were the core outcomes of the intervention. In order to achieve those, various factors that led to this outcome were identified. The factors identified were categorized into three core areas:
- Quality of community based care provided by ASHAs
- Motivation level of ASHAs
- Knowledge, awareness and practices regarding MNCH care among the community
This was followed by identification of factors that may influence these outcomes. These factors were especially those that could be tackled by addressing the implementation challenges of ASHA program. Better selection of motivated ASHAs, their enhanced work performance which would lead to better awareness in the community, better trust on ASHA workers, and improved referral for MNCH care needs were identified as the key factors. Hence, 4 crucial interventions that could address most of these factors included:
- Selection of ASHAs
- Modified training
- Supportive supervision and monitoring
- Improved job-aids, structured work schedule and data for review
Round table consultation: The community survey findings were presented in a round table meeting along with a proposed ANCHUL intervention model. The RTC ended with a positive note on the proposed model and the experts emphasized the need for trying out the intervention in a real world set up and within the current framework of the program.
Presentation of ANCHUL intervention to DSHM and permission to conduct the trial: The same findings along with the proposed model were also presented to the key officials of DSHM. DSHM was keen on interventions that would motivate the workers to perform their day to day job responsibilities, made them accountable for their work and improve their skills in executing quality work. It was also desirable that none of the process would ideally need additional resources in terms of manpower or financial inputs. The DSHM identified two matched slum settlements under the PUHC of Sangam Vihar (B block) and Lalkuan in the South east district of Delhi and provided formal permission to ANCHUL team to roll out the intervention in one of the settlement while the other was supposed to serve as the control where the standard Government ASHA program was planned to be rolled out.
Methods
Design phase (Phase 2)
Based on a conceptual framework developed and the feedback from the program implementers, the key components of the intervention were developed and the processes to implement the intervention were finalised. The process indicators to monitor the implementation of the ANCHUL intervention and its evaluation were also finalized.
Study team: The intervention development team consisted of the researchers from Indian Institute of Public Health - Delhi, Public Health Foundation of India, All India Institute of Medical Sciences, New Delhi, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA, CARENIDHI, a grass root NGO and the implementers, policy makers and decision makers at the DSHM. At every stage of the development of this intervention, the DSHM provided specific feedback on various concerns in the existing ASHA model and possibility of adaptation of the proposed modifications into the existing framework.
Results
Design Phase (Phase 2)
Components of the ANCHUL intervention
Thr ANCHUL framework was consistent with the ongoing ASHA program but had added components to address impleentation challenges. Figure 3 provides an overview of the salient differences between the ANCHUL intervention and the existing ASHA program. The four components of the intervention included
- A competitive selection process (multi stage selection process)
- Enhanced training (modified training modalities)
- Active monitoring and surveillance (suportive supervision and data driven decision making)
- Effective implementation of the program (use of job aids and active use of data)
Though all these components existed in the Government run program, we incoprorated some simple processes that had the potential to address implementations gaps identfied during formative phase of the study.
Table 1 details out each component of intervention while comparing it with the standard government protocol . We also assessed the readiness of the program implementers (DSHM) for the proposed changes in the program and maintained a continuous dialogue with them. While working on each component of the ANCHUL intervention, we assessed the acceptance of the modifications suggested thus assuring the “the feasibility of modifications suggested”.
ANCHUL intervention was a complex intervention and each of the component was fixed by form but flexible by function. (Table 2) [28]. In other words, the intervention had provision of options for flexible modalities for better adaptation in varied contexts in which it was implemented. This was a crucial component of this entire evolution as it led to identification of processes that were feasible within the limits of the health system.
Processes of implementation of the proposed component: Standard government norms were followed for the coverage area for ASHAs, their activities, reporting mechanism and supervisory structure. The ANCHUL intervention introduced two additional components namely, a real time data entry of the information gathered by the ASHAs. This aided in better supervision and incentive calculation. We also introduced a supervisory cadre similar to the cadre of ASHA facilitator in other states. The cadre provided supportive supervision and assessed the work performance of ASHAs using simple scores like head (knowledge), heart (attitude) and hand (practice) (HHH score) (table 1) and supported them in enhancing the same.
Process indicators for monitoring implementation of the intervention and its evaluation:
Process indicators were identifed for each component of the intervention and data was required to be collected from the records of ASHAs and supervisors and target population like pregnant and recently delivered women and mothers of under 5 children . Table 3 shows the list of process indicators identified.
Methods
Evaluation phase (Phase 3)
A quasi experimental design was used to study the feasibility of this complex intervention. During the roll out of the intervention, its various components and their implementation modalities were tested for feasibility and modified through an iterative process in consultation with implementers of the program. The project was evaluated in catchment areas of two seed PUHCs of south-east district of Delhi namely Sangam Vihar “B Block” (intervention area) and Lalkuan (control areas) that were purposively selected in consultation with DSHM. Both the PUHC did not initially have any ongoing ASHA program. In the control area the Government ASHA program was rolled out as per the established procedures.
Study team consisted of an intervention team and an independent surveillance team. The intervention team consisting of an intervention officers and researchers worked closely with the DSHM and its field functionaries and tested the feasibility of each of the components of intervention while the surveillance team collected data on process indicators from both the intervention and control areas.
Results: The ANCHUL intervention was successfully rolled out in the intervention area while the routine Government ASHA program was rolled out in the control area.