Since May 20^th, we have been in Lucknow participating in the ‘PAHELI’ workshop organized by PRATHAM. ‘PAHELI’- People’s Audit for Health, Education and Livelihood, is a rapid assessment of the prevailing status of human development in a district. The highlights of PAHELI are its participatory approach, focus on basic indicators, simple tools and easily replicable processes for collecting primary data. It combines activities, observations and questions, and uses pictorial tools wherever possible. In 2006, PAHELI focused on obtaining information about life and livelihood (availability of food, assets, loans, migration), water and sanitation (sources of water, time spent in collecting water etc.), maternal and child health (antenatal and post-natal care, immunization) and finally, education and literacy.

In this round of ‘PAHELI’, elements of the ‘PAISA’ have been added to the ‘PAHELI’ tool kit. More specifically, we are trying to collect data about  funds flow in various central government schemes which are closely related to the above mentioned points.

One simple example is ‘Janani Suraksha Yojna’, a cash transfer scheme which pays Rs. 1400 to the pregnant mother who delivers her baby in a government medical facility. ASHA- a new cadre of community health workers, are supposed to play an important role in the implementation of this scheme and receive a total of Rs.600 as incentive consisting of a component for arranging transportation, staying with the pregnant mother and thirdly a general cash incentive for her role in the safe delivery. (Details of the scheme can be found here). We are in the process of developing questionnaires. We have been piloting these tools in the nearby villages.

The following observations are based on these pilots and are hence very sketchy. Nevertheless they tell us something.

1)      Awareness: Everybody knows that the beneficiary gets Rs. 1400 if she delivers the baby in a government hospital. However, awareness levels are very low amongst the ASHAs and the beneficiary (mothers) about the accredited private institutions. One possible reason for this could be that there are no accredited private institutions in the area or very few.

Even amongst the ASHA’s, there was no clear idea about the break-up of the payment- how much is meant for transport, how much for staying with pregnant women and how much is the incentive component. The ASHA’s were only aware of the fact that they get a total of Rs. 600 as incentive.

2)      Training: ASHAs are supposed to receive 23 days of induction training within 12 months of joining and then periodic training of 2 days every alternate month. But that does not seem to be happening. With the exception of one ASHA, none of the ASHAs reported receiving training as per the norms.

3)      ASHA Incentives: Our thinking was that an ASHA would be reimbursed for whatever expenses she incurs in facilitating the delivery of the pregnant women. But that does not seem to be the case. From what we gathered from some of the ASHAs, they get Rs. 600 (which is as per the rule) but no reimbursement. Hence in quite a few cases, the ASHAs reported spending money from their own pocket. A natural question that then arises is, why would anybody want to be an ASHA in such a situation. This might also, to some extent explain why they are taking money from the beneficiaries.

4)      Delay in ASHA Payments: In nearly all cases, the ASHA’s reported not receiving their incentives on time. In one village, the ASHA had still not received her payment of a delivery conducted in March 2011. In others, they had not received their incentive payment even 4-6 months after delivery. ASHAs reported having to  always keep aside some of her own personal household expenditure for arranging transport and other services.

5)      Payment Mechanism and Grievance Redressal Mechanism:

Once an ASHA facilitates a delivery, she takes the signature of the doctor and the ANM and submits her application for incentive, which is then forwarded to the Community Health Centre. The application is processed and then the money is sent directly to the ASHA’s account. Earlier the ANM used to pay the ASHA but now the ANM is completely bypassed. So if there is any grievance regarding money not reaching in time or not receiving the full amount, even an ANM does not know anything.  The ASHAs have to approach the Medical Officer of the PHC/CHC ( and in fact, it is the CHC) to get the the exact information.  The ASHAs we interacted with complained about the distances to the CHCs and having to go multiple times and reported getting very rude responses from these officers.

6)      Leakages and Corruption:

In some cases, it was found that ASHAs has taken money from the beneficiary. The impression we got was that mothers thought it as a legitimate payment while as per the guidelines, the mothers are not supposed to pay any amount to ASHAs. In another instance, it was also found that ASHA’s who were supposed to receive Rs.600 as their incentive, had to pay Rs. 100 to the Community Health Centre (CHC) officer. What exactly this means is not very clear.